• How can CBTI be adapted for delivery to older adults?

• CBTI is a very flexible protocol that has been adapted for delivery in many different populations, including older adults. Insomnia often remains unrecognized and untreated in older adults, possibly because it is presumed that insomnia is just an inevitable consequence of aging. Although changes in sleep are a normative part of aging, insomnia is not normative at any age and can and should be treated. Indeed, most of the early research validating CBTI was done in older adults. Depending on the patient, modifications can be made to the typical course of CBTI that still provide the effective ingredients to produce meaningful change in a patient’s sleep as well as indirect benefits on comorbid medical and psychological conditions. First, older adults often have a degree of advanced circadian phase, meaning they are biologically compelled to go to bed earlier and wake up earlier than younger adults. Thus, it is always important to assess for circadian rhythm sleep-wake disorder, advanced type. Advanced circadian phase can be addressed with chronotherapy after successfully consolidating and regularizing the sleep schedule (with sleep restriction and stimulus control) as described in the training. In other words, first get the sleep to a consistent quality and quantity, and then adjust the timing gradually. A pattern of advanced sleep phase will be fairly obvious, with patients typically falling asleep before 9pm and waking up before 5-6am. Second, it is wise to prioritize the treatment components that have the strongest evidence. At a minimum, you should include stimulus control instructions that are tailored to the patient’s specific sleep pattern as indicated by the sleep diary. Alternatively, counter control may be appropriate if fall risk during getting out of bed in the night is a concern. Some sleep psychoeducation should also be provided, as it may increase understanding of the stimulus control or counter control recommendations. If appropriate based on the case conceptualization, other treatment components should also be added. For example, if you are sure the patient is not suffering from excessive daytime sleepiness, sleep restriction is the component most often added to stimulus control. Alternatively, sleep compression may be considered as a “gentler” form of sleep restriction, though it has been found to be less effective than sleep restriction. Third, progressive muscle relaxation techniques may be more difficult for older adult patients who are physically impaired because it can cause prevent muscle spasms or arthritic pain. In these cases, it is recommended to eliminate the instruction to contract or tense the muscles and instead have the patient focus on passively releasing muscle tension (Lichstein & Johnson, 1993). Alternatively, another relaxation technique can be selected (e.g., guided imagery). Fourth, it is important to be cognizant of polypharmacy (e.g., statins, antidepressants, anticholinergics, antihypertensives, diuretics, gabapentin). Many drugs can cause difficulty sleeping and generally little is known about the interactions between drugs. We find it useful to review all of the patient’s medicines on an ongoing basis to make sure none might be causing sleeplessness or daytime symptoms (e.g., fatigue, sleepiness). If the list is long and unfamiliar, the patient can ask that their pharmacist do a review (https://hmsa.com/portal/provider/PRC_Guide_COA_Medication_Review.pdf). Finally, it is good to always provide older patients, who may have more difficulty with memory, with written take-home materials that summarize the treatment instructions and provide educational information. It is also sometimes useful to have them repeat the instructions in session and/or bring a caregiver with them to session.

• References:

• Lichstein, K. L., & Johnson, R. S. (1993). Relaxation for insomnia and hypnotic medication use in older women. Psychology and Aging, 8, 103–111. Lichstein, K. L., & Morin, C. M. (Eds.). (2000). Treatment of late-life insomnia. Sage.

• For group CBT-I, it is generally recommended to include 6-8 patients per group or 10-12 if it is possible to have a group co-leader. CBT-I groups generally consist of 6-8 sessions that last 60-90 minutes each. There is no need to adjust the content of CBT-I protocols for group, although additional benefits may be offered by utilizing the group process to provide group members with peer support and encouragement. For example, the group leader may ask group members to reflect on their experiences implementing a particular technique and encourage other group members to help troubleshoot any difficulties. 

The primary challenge for implementing group CBT-I is managing multiple sleep diaries to ensure that sleep diary entries and calculations for sleep parameters (i.e., total sleep time [TST], time in bed [TIB], sleep efficiency [SE]) are done correctly in order to titrate sleep schedules accurately. There are several methods that can work well for completing sleep diary calculations:

•  First, if your group is relatively high-functioning, you can teach them to conduct their own sleep diary calculations (e.g., using the provided Excel spreadsheet, the VA app CBT-I Coach, or by hand), and include these calculations as an expectation of completion of the sleep diary. You can ask group members to arrive to group 15-20 minutes early to ensure these calculations are completed. This method has the added benefit that patients are capable of completing their own calculations after the group has ended, which increases their autonomy and mastery over managing sleep over time. 

• An alternative approach works best if you have a co-leader. One co-leader can collect sleep diaries at the beginning of session and complete calculations while the other co-leader begins the group. 

• Finally, an “analog” sleep diary can be used to help approximate sleep efficiency if calculations are not possible. This type of sleep diary has boxes that represent each hour of the day that are shaded in by the patient to indicate hours slept. Then, the TST and SE can be calculated by adding up the shaded boxes for each night (TST) and dividing that number by the total number of hours indicated for TIB (SE). This type of sleep diary is included in the resources. 

Regardless of the method selected to complete sleep diary calculations, it is recommended that at the first 2-4 sessions of sleep restriction, when the sleep schedule is being adjusted, that the group leader(s) spend 5-10 minutes with each patient individually at each session to develop the new sleep plan for the upcoming week. Although most troubleshooting of stimulus control, relaxation, sleep hygiene, and cognitive elements can be completed as a group, sleep restriction should be reviewed individually in order to tailor recommendations specifically for each patient’s sleep schedule and ensure that the sleep restriction is working properly. 

If a patient misses a session, the patient should continue to complete a sleep diary. Then, the most recent sleep diary can be used for titrating the sleep schedule at the next session. 

• References:

• Koffel, E. A., Koffel, J. B., & Gehrman, P. R. (2015). A meta-analysis of group cognitive behavioral therapy for insomnia. Sleep Medicine Reviews, 19, 6-16. doi:10.1016/j.smrv.2014.05.001

• How can CBTI be adapted for delivery in primary care?

• CBTI is a very flexible protocol that has been adapted for delivery in many non-traditional settings including primary care. Depending on the restraints of the setting, modifications can be made to the typical course of CBTI that still provide the effective ingredients to produce meaningful change in a patient’s sleep. Ultimately there is no single “right way” to adapt CBTI in a primary care setting. However, there are some principles that should be considered. First, tracking sleep via sleep diary is key. It is preferable if patients can begin tracking sleep prior to the initial appointment with the therapist in order to reduce the necessary number of appointments with the therapist. Second, it is wise to prioritize the treatment components that have the strongest evidence. At a minimum, you should include stimulus control instructions that are tailored to the patient’s specific sleep pattern as indicated by the sleep diary. Some sleep psychoeducation should also be provided, as it may increase understanding of the stimulus control and sleep restriction recommendations. However, it can be abbreviated based on the patient’s needs. If time allows, other treatment components may be selected based on the case conceptualization. For example, if you are reasonably sure the patient will return for additional titration sessions, sleep restriction is the component most often added to stimulus control in primary care settings. In addition, if the patient has high physiological arousal at bedtime, relaxation strategies may be prioritized. Alternatively, if the patient demonstrates very strong cognitive distortions related to sleep, cognitive therapy may be an important component. One modification that is often necessary in a primary care setting is a reduction in the number of contacts or the length of each visit. A study by Edinger and Sampson (2003) gives an example of how that might be achieved. In this study, an abbreviated version of CBT-I was delivered in person with a therapist located in a primary care clinic across two 25-minute sessions two weeks apart. In the first session, the therapist reviewed the sleep log, provided sleep psychoeducation, and developed a sleep plan that used sleep restriction and stimulus control instructions. In the second session, the therapist reviewed the previous instructions, addressed treatment adherence problems, modified the sleep plan based on the sleep diary information, and provided brief relapse prevention information. Patients were also provided with written and audio take-home materials that summarized behavioral recommendations and provided educational information. The results of this study demonstrated that about half of the patients treated with abbreviated CBT-I demonstrated a significant improvement in their insomnia symptoms. Another example of CBT-I delivered across 3 sessions is given by Goodie, Isler, Hunter, & Peterson (2009). CBT-I can also be delivered in a group format in primary care. For more information, please see our FAQ on group-delivered CBT-I. Additionally, articles by Davidson, Dawson & Krsmanovic (2019) and Sandlund, Hetta, Nilsson, Ekstedt & Westman (2017) outline their approaches to this topic. For more detailed information on ideas for adapting CBT-I in primary care, please review a guide developed by Goodie & Hunter (2014). 

• References: 

• Davidson, J. R., Dawson, S., & Krsmanovic, A. (2019). Effectiveness of group Cognitive Behavioral Therapy for Insomnia (CBT-I) in a primary care setting. Behavioral Sleep Medicine, 17(2), 191-201.

• Edinger, J. D., & Sampson, W. S. (2003). A primary care “friendly” cognitive behavioral insomnia therapy. Sleep, 26(2), 177-182

• Goodie, J. L., & Hunter, C. L. (2014). Practical guidance for targeting insomnia in primary care settings. Cognitive and Behavioral Practice, 21(3), 261-268.

• Goodie, J. L., Isler, W. C., Hunter, C., & Peterson, A. L. (2009). Using behavioral health consultants to treat insomnia in primary care: A clinical case series. Journal of Clinical Psychology, 65(3), 294-304. 

• Sandlund, C., Hetta, J., Nilsson, G. H., Ekstedt, M., & Westman, J. (2017). Improving insomnia in primary care patients: a randomized controlled trial of nurse-led group treatment. International Journal of Nursing Studies, 72, 30-41.

• There are many aspects of military culture that impact sleep and insomnia and having an understanding and appreciation of military culture can be an important part of working with patients. We have attempted to address many of these aspects throughout this training. In the resources section, we have also included a manuscript titled “Special considerations in the adaptation of cognitive behavioral therapy for insomnia with active-duty U.S. Army personnel” (Pruiksma et al., 2018) that goes into more detail. 

• For providers who see active duty miltiary personnel or veterans, it is improtant to increase competency pertaining to miltiary culture. In the resources section, we have included “Military Rank Charts,” and powerpoint slides pertaining to “Military Culture Vital Signs.” However, we encourage providers to learn more through the Center for Deployment Psychology’s excellent resources pertaining to military culture at  https://deploymentpsych.org/military-culture

• There are a number of excellent books and treatment manuals available. We have listed only a selection of resources here. This list is not meant to be comprehensive. 

• Books:

• Carney, C. (2020). Goodnight mind for teens: Skills to help you quiet noisy thoughts and get the sleep you need. New Harbinger: Oakland, CA. 

• Carney, C. & Manber, R. (2009). Quiet your mind and get to sleep: Solutions to insomnia for those with depression, anxiety or chronic pain. New Harbinger: Oakland, CA.

• Edinger, J. D., & Carney C. E. (2014). Overcoming insomnia: A cognitive-behavioral therapy approach: Therapist guide. New York, NY: Oxford University Press.

• Kryger, M. H., Roth, T., & Dement, W. C. (Eds.). (2005). Principles and practice of sleep medicine (4th ed.). Philadelphia, PA: Elsevier/Saunders. 

• Morin, C. M., & Espie, C. A. (Eds.). (2003). Insomnia: A clinician's guide to assessment and treatment. New York, NY: Springer.

• Manber, R., & Carney C. E. (2015). Treatment plans and interventions for insomnia: A case formulation approach. New York, NY: Guilford Publications.

• Perlis, M. L., Aloia, M., & Kuhn, B. (2011). Behavioral treatments for sleep disorders: A comprehensive primer of behavioral sleep medicine interventions. Burlington, MA: Academic Press.

• Taylor, D.J., Peterson, A.L., Goodie, J.L., Grieser, E., Hryshko-Mullen, A.S., Rowan, A., Wilkerson, A., Pruiksma, K.E., Dietch, J.R., Hall-Clark, B., & Fina, B. (2019). Cognitive-Behavioral Therapy for Insomnia in the military: Therapist guide. Retrieved from http://insomnia.arizona.edu/CBTI-M

• Taylor, D.J., Peterson, A.L., Goodie, J.L., Grieser, E., Hryshko-Mullen, A.S., Rowan, A., Wilkerson, A., Pruiksma, K.E., Dietch, J.R., Hall-Clark, B., & Fina, B. (2019). Cognitive-Behavioral Therapy for Insomnia in the military: Patient guide. Retrieved from http://insomnia.arizona.edu/CBTI-M

• Taylor, D.J., Wilkerson, A., Hryshko-Mullen, A.S., & Goodie, J.L. (2019). Cognitive-Behavioral Therapy for Insomnia in the military: Rating scales. Retrieved from http://insomnia.arizona.edu/CBTI-M

• Vermetten, E., Germain, A., & Neylan, T. C. (Eds.). (2018). Sleep and combat-related post traumatic stress disorder. Springer New York.

• Websites/Trainings:

• The Society of Behavioral Sleep Medicine Website www.behavioralsleep.org 

• The American Academy of Sleep Medicine Website www.aasmnet.org 

• The Center for Deployment Psychology Website www.deploymentpsych.org

• University of Arizona www.sleephealthresearch.com/seminar.html 

• Defense Centers of Excellence Wellness Resources for the Military Community: afterdeployment.dcoe.mil/topics-sleep 

• University of Pennsylvania CBT-I Conference Website: www.med.upenn.edu/cbti/index.html 

• To date, studies have found CBTI to be effective in active duty military populations. One retrospective cohort study of 98 service members (94% in the U.S. Army) treated in a military sleep disorder clinic found improvements on sleep diary-assessed sleep variables and self-reported insomnia severity, particularly among service members who received four or more sessions of CBTi (Lee et al., 2019). A randomized clinical trial compared in-person CBTi (n = 34) to Internet CBTi (n = 33) and to a waitlist control (n = 33) in a U.S. Army population (Taylor, et al., 2017). Internet and in-person CBTI performed significantly better than the minimal contact control on sleep diary-assessed sleep variables, self-reported insomnia severity, and dysfunctional beliefs and attitudes about sleep. In-person CBTI was more effective than Internet CBTI on self-reported sleep quality and dysfunctional beliefs and attitudes about sleep. A follow-on study that continued to recruit active duty service members into in-person CBTI (n = 75) and the waitlist control (n = 76) also found that CBTI significantly reduced mental fatigue, nicotine use, and caffeine use and improved activity, motivation, and general mental health (Taylor et al., 2018). Contrary to hypotheses, there were not reductions in symptoms of depression, anxiety, PTSD, or hypnotic medication use. There have not been any studies comparing the efficacy of CBTI for military compared to civilians or veterans. 

• References:

• Lee, M. R., Breitstein, J., Hoyt, T., Stolee, J., Baxter, T., Kwon, H., & Mysliwiec, V. (2019). Cognitive behavioral therapy for insomnia among active duty military personnel. Psychological Services. Advance online publication. http://dx.doi.org/10.1037/ser0000340

• Pruiksma, K. E., Fina, B., Dietch, J. R., Dondanville, K. A., Williams, J., Wright, E. C., . . . Taylor, D. J.; for the STRONG STAR Consortium. (2018). Special considerations in the adaptation of cognitive behavioral therapy for insomnia with active-duty U.S. Army personnel. Cognitive and Behavioral Practice, 25, 515-530. https://doi.org/10.1016/j.cbpra.2017.12.007

• Taylor, D. J., Peterson, A. L., Pruiksma, K. E., Hale, W. J., Young-McCaughan, S., Wilkerson, A., . . . Mintz, J.; on behalf of the STRONG STAR Consortium. (2018). Impact of cognitive behavioral therapy for insomnia disorder on sleep and comorbid symptoms in military personnel: A randomized clinical trial. Sleep, 41(6). https://doi.org/10.1093/sleep/zsy069

• Taylor, D. J., Peterson, A. L., Pruiksma, K. E., Young-McCaughan, S., Nicholson, K., Mintz, J.; 

• The accuracy of consumer-grade wearable devices is mixed, though recent research shows that some of these devices are comparable to or outperform research-grade actigraphy devices (de Zambotti et al., 2020). However, like actigraphy, the accuracy of consumer-grade wearables is reduced in populations with sleep disorders, particularly in those with insomnia. This is because a wrist-worn device is unable to distinguish between quiescent wakefulness and sleep. Wearables may be helpful for individuals with generally healthy sleep who are seeking to ensure they are obtaining sufficient quality and quantity of sleep on a daily basis. However, in the context of insomnia, they may do more harm than good. Importantly, sleep staging data from wearables is likely to be inaccurate and misleading, because sleep staging is determined based on brain activity and the wrist cannot provide said brain signals. So, any estimate of sleep staging from wrist wearables should not be relied upon at this time (Danzig et al., 2020). 

• For patients who bring up wearable data in their CBT-I assessment or treatment sessions, there are several strategies you might try:

• For patients who are merely curious or do not hold a strong attachment to their wearable data, we recommend that they turn off or do not look at the sleep data on the wearable during the course of CBT-I. As rationale for this, you can discuss how insomnia diagnosis and symptomatology is based on their own internal experience, and that as the therapist you are most interested in hearing from them about how their insomnia is progressing. You can introduce the sleep diary and highlight the importance of this tool for monitoring progress in CBT-I. Additionally, you can add that almost all research on CBT-I has used sleep diary data to track progress. At the very least, it’s important to emphasize that patients should NOT use the wearable data to complete their sleep diary under any circumstance!

• It may also be helpful to discuss how wearables are best used for tracking overall sleep patterns and sleep duration. You can discuss how wearables cannot differentiate from being asleep and lying quietly in bed, which is something that occurs frequently in insomnia! Additionally, wearables do not capture things like how well you feel you slept or how rested you feel in the morning. These dimensions, rather than sleep quantity, are the focus of CBT-I (remember, you’d rather have a solid 6-inch pizza than an 8-inch pizza full of holes and thin patches!)

• If the patient is insistent on the importance of the sleep tracker data, consider reviewing the patient’s sleep tracker data with them. This can be important for building rapport and validating the patient’s concerns. At the same time, gently correct misconceptions as they arise. Encourage them to separately collect sleep diary data, not based on the wearable (i.e., fill it out before they look at the wearable data for the night). Emphasize that it is important to consider multiple sources of information, and that you will be basing recommendations for the therapy on their sleep diary data, which crucially must be based on their own self-reported estimate. 

• It might be helpful to suggest that patients use the wearable data to test strongly held beliefs using behavioral experiments. For example, a patient can track their daytime performance compared against their wearable data, and see if the relationship is as close as they believe. They can also consider going one week with the wearable data, and one week without it to determine whether using the wearable has an impact on their stress level, performance, or sleep. 

• References:

• Baron, K. G., Abbott, S., Jao, N., Manalo, N., & Mullen, R. (2017). Orthosomnia: are some patients taking the quantified self too far? Journal of Clinical Sleep Medicine, 13(2), 351-354.

• Baron, K.G., Culnan, E., Duffecy, J., Berendson, M., Cheung Mason, I., Lattie, E., & Manalo, N. (2021). How are Consumer Sleep Technology Data Being Used to Deliver Behavioral Sleep Medicine Interventions? A Systematic Review. Behavioral Sleep Medicine, 1-15.

• Danzig, R., Wang, M., Shah, A., & Trotti, L. M. (2020). The wrist is not the brain: Estimation of sleep by clinical and consumer wearable actigraphy devices is impacted by multiple patient‐and device‐specific factors. Journal of Sleep Research, 29(1), e12926.

• Disparities in sleep based on socioeconomic advantage and ethnic/racial groups are highly prevalent, though the nuances of these differences and how to best tailor treatment as a result have not been studied in great detail. Generally, women, African Americans, Hispanics, and adults over 65 have worse sleep than other groups. Unsurprisingly, those in lower income areas have increased environmental disadvantages to overcome, including safety concerns, overcrowding/room sharing, lack of temperature and light control. It is important to first assess safety and adequacy of a bedroom environment before attempting to implement any CBTI strategies taught in CBTIweb.

• Another important component to understand is bedsharing. Though the most common bed sharing practice is with that of a partner/significant other, bedsharing may also occur out of overcrowding or parental beliefs about co-sleeping. This is important to address and troubleshoot in treatment. For instance, implementing sleep restriction that would have the patient staying awake much longer than someone else in the bed may disturb the sleep of others in the home and thus cause more problems even if it improves insomnia. If sleep restriction is disturbing the schedule of others, separating rooms briefly may be a potential solution. If this is not an option then activities in the bed may be allowed as long as they are not too activating, with a discussion that not strictly following stimulus control in this way may slow the pace of treatment gains.

• Unfortunately, little work has been done with CBTI targeting ethnic/racial groups, though what has been done to date indicates it is effective across groups. Similarly, measures in various languages are lacking, though we are trying to keep those that do exist compiled in the Resources section of CBTIweb. 

• References and further reading:

• Gentry, R. (2020). Cultural Considerations and Sleep. In Handbook of Cultural Factors in Behavioral Health (pp. 323-329). Springer, Cham.

• Grandner, M.  A., Patel, N.  P., Gehrman, P.  R., Xie, D., Sha, D., Weaver, T., & Gooneratne, N. (2010). Who gets the best sleep? Ethnic and socioeconomic factors related to sleep disturbance. Sleep Medicine, 11, 470–479.

• There are varying opinions on whether patients should completely withdraw from medications before, during or after CBT-I. Several studies (Sweetman et al., 2020 for review) have shown that simply treating insomnia alone, without discussion of CBT-I, results in some degree of hypnotic withdrawal. That said, others believe that it does not make sense to treat insomnia with CBT-I while they are on medication, because a) they will have rebound insomnia later when trying to withdraw from the medications, and b) there is evidence that being on medications results in patients not following CBT-I protocols as closely and thus gaining less long-term benefit. Our general approach is to recommend the patient speak with their prescribing physician about withdrawing, provide a withdrawal schedule (See FAQ Hypnotic Medication Withdrawal), and then treating the patient with CBT-I. Given our clinical work is not limited by a set number of therapy sessions or timeframe, like most clinical trials, we have more flexibility of giving booster sessions, etc. if withdrawal should take longer than CBT-I.

• Evidence

•  No evidence currently exists to suggest one approach of gradual dose reduction over any other.

• References

• Sweetman, A., Putland, S., Lack, L., McEvoy, R. D., Adams, R., Grunstein, R., ... & Lovato, N. (2020). The effect of cognitive behavioural therapy for insomnia on sedative-hypnotic use: A narrative review. Sleep medicine reviews, 101404.

• The accuracy of consumer-grade wearable devices is mixed, though recent research shows that some of these devices are comparable to or outperform research-grade actigraphy devices (de Zambotti et al., 2020). However, like actigraphy, the accuracy of consumer-grade wearables is reduced in populations with sleep disorders, particularly in those with insomnia. This is because a wrist-worn device is unable to distinguish between quiescent wakefulness and sleep. Wearables may be helpful for individuals with generally healthy sleep who are seeking to ensure they are obtaining sufficient quality and quantity of sleep on a daily basis. However, in the context of insomnia, they may do more harm than good. Importantly, sleep staging data from wearables is likely to be inaccurate and misleading, because sleep staging is determined based on brain activity and the wrist cannot provide said brain signals. So, any estimate of sleep staging from wrist wearables should not be relied upon at this time (Danzig et al., 2020). 

• Although telehealth clearly presents substantial benefits, it is also accompanied by various disadvantages to be considered. These disadvantages include an added layer of separation between the client and the clinician, the loss of body language cues that can often be observed and used to assess the client’s affect and/or distress, and the increased likelihood of issues due to technological problems. 

• As with most CBT-based therapies, one of the primary challenges in delivering CBT-I via telehealth is the transfer of materials (e.g., sleep diaries) between therapist and patient. If you are equipped to send electronic messages (e.g., secure email, MyHealtheVet), this can be a good means for sharing data. The therapist can send materials to the patient ahead of time, and the patient can return the materials by scanning them (e.g., using a smart phone scanner app like Genius Scan), taking a smartphone camera picture of them, or even holding them up to the camera during session. Electronic sleep diaries may be particularly useful for telehealth and can be collected via the CBTi Coach app (available for free for Android and iOS), exported as a PDF, and emailed to the clinician. 

• Given the potential disadvantages of telehealth and the special considerations implicated (e.g., ensuring use of a HIPAA-compliant telecommunication technology), we recommend you thoroughly review the APA’s Guidelines for the Practice of Telepsychology (American Psychological Association, 2013).

• References

• Angley, G. P., Schnittker, J. A., & Tharpe, A. M. (2017). Remote hearing aid support: The next frontier. Journal of the American Academy of Audiology, 28(10), 893-900.

• American Psychological Association. (2013). Guidelines for the practice of telepsychology.

• Gehrman, P., Shah, M. T., Miles, A., Kuna, S., & Godleski, L. (2016). Feasibility of group cognitive-behavioral treatment of insomnia delivered by clinical video telehealth. Telemedicine and e-Health, 22(12), 1041-1046.

• Horrigan, J. B. (2008). Home broadband adoption 2008: Adoption stalls for low-income Americans even as many broadband users opt for premium services that give them more speed. Pew Internet & American Life Project. Retrieved from http://www.pewinternet.org/pdfs/ PIP_Broadband_2008.pdf

• Lichstein, K. L., Scogin, F., Thomas, S. J., DiNapoli, E. A., Dillon, H. R., & McFadden, A. (2013). Telehealth cognitive behavior therapy for co‐occurring insomnia and depression symptoms in older adults. Journal of Clinical Psychology, 69(10), 1056-1065.

• Martin-Khan, M., Fatehi, F., Kezilas, M., Lucas, K., Gray, L. C., & Smith, A. C. (2015). Establishing a centralised telepsychology service increases telepsychology activity at a tertiary hospital. BMC health services research, 15(1), 534.

• Pong, R. W., & Hogenbirk, J. C. (2002). Licensing physicians for telepsychology practice: issues and policy options. Centre for Rural and Northern Health Research.

• Poropatich, R., Lai, E., McVeigh, F., & Bashshur, R. (2013). The US Army Telemedicine and m-Health Program: making a difference at home and abroad. Telemedicine and e-Health, 19(5), 380-386.

• van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin, C. M., & Lancee, J. (2018). Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis. Sleep Medicine Reviews, 38, 3-16.

• Yellowlees, P., Marks, S., Hilty, D., & Shore, J. H. (2008). Using e-health to enable culturally appropriate mental healthcare in rural areas. Telemedicine and e-Health, 14(5), 486-492.

• Zickuhr, K. (2011). Generations and their gadgets. Pew Internet & American Life Project. Retrieved from http://pewinternet.org/Reports/2011/ Generations-and-gadgets.aspx

• There are several web-based treatment programs for insomnia. Descriptions and links to these programs are provided below. Please note that the descriptions for each program are based on the information made available from each program’s website and may not be complete or up-to-date.

• Product: Sleepio

• Link: https://www.sleepio.com/

• Status: Currently available to research participants

• Description: Sleepio is a web-based, cognitive-behavioral treatment program for a variety of sleep problems based on the CBT-I treatment model. Users begin by setting treatment goals and completing an in-depth questionnaire battery. From there, a treatment program is developed which includes weekly 20-minutes sessions with a virtual sleep expert targeting the following sleep-related areas: 1) thoughts and worries about sleep, 2) nighttime sleep schedules, 3) lifestyles, and 4) the bedroom. Users also have access to a moderated social/network community of users. 

• Evidence: One randomized clinical trial has been published on the Sleepio program. Sleepio was compared to Imagery Relief Therapy, and treatment as usual. Sleepio resulted in significantly better improvements in sleep efficiency and sleep-wake functioning from baseline to post-treatment. 

• References: 

• Espie CA, Kyle SD, Williams C, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012;35(6):769-81.

• Product: SHUTi

• Link: https://app.shuti.me

• Statues: Currently available to research participants

• Description: SHUTi is a web-based, cognitive-behavioral treatment program for insomnia based on the Cognitive Behavioral Therapy for Insomnia treatment model. SHUTi begins with an overview of educational information on sleep problems and an evaluation of patients’ sleep problems and treatment goals. Users then participate in five, weekly, 45- to 60-minute modules focused on specific methods for improving quantity and quality of sleep. After each module, users spend a week practicing what they have learned in their daily routines. These include exercises designed to help develop new sleep habits and skills. Users also complete a daily Sleep Diary which allow SHUTi to make personalized treatment recommendations.

• Evidence: One randomized controlled trial comparing SHUTi to a waitlist control found that SHUTi resulted in significantly improved scores on the Insomnia Severity Index and sleep efficiency, and that treatment gains were maintained at 6-month follow-up (Ritterband, Thorndike et al., 2009). Follow-up analyses found significant improvements in psychological symptoms, mental health quality of life, and fatigue (Thorndike, Ritterband et al., 2013)). Another trial with cancer survivors with insomnia comparing SHUTi to a waitlist control found significant improvement in insomnia severity, sleep efficiency, sleep onset latency, soundness of sleep, restored feeling upon wakening, and general fatigue (Ritterband, bailey et al., 2012). Another randomized controlled trial with patients with insomnia and depression symptoms found that SHUTi, compared to an interactive, attention-matched, internet-based placebo control program resulted in significantly improved depression symptoms at post-treatment and 6-month post-treatment (Christensen et al., 2016).

• References: 

• Ritterband LM, Thorndike FP, Gonder-frederick LA, et al. Efficacy of an Internet-based behavioral intervention for adults with insomnia. Arch Gen Psychiatry. 2009;66(7):692-8. 

• Ritterband LM, Bailey ET, Thorndike FP, Lord HR, Farrell-carnahan L, Baum LD. Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. Psychooncology. 2012;21(7):695-705.

• Thorndike FP, Ritterband LM, Gonder-frederick LA, Lord HR, Ingersoll KS, Morin CM. A randomized controlled trial of an internet intervention for adults with insomnia: effects on comorbid psychological and fatigue symptoms. J Clin Psychol. 2013;69(10):1078-93.

• Christensen H, Batterham PJ, Gosling JA, et al. Effectiveness of an online insomnia program (SHUTi) for prevention of depressive episodes (the GoodNight Study): a randomised controlled trial. Lancet Psychiatry. 2016;3(4):333-41.

• Product: The Conquering Insomnia Program

• Link: https://www.cbtforinsomnia.com/

• Status: Currently available to consumers

• Description: The Conquering Insomnia program is a web-based program based on the CBT-I treatment model. Users participate in five sessions provided sequentially over five weeks and are delivered in a PDF format. These sessions include: 1) basic facts about sleep and an insomnia assessment; 2) sleep scheduling and stimulus control techniques; 3) cognitive restructuring and sleep medication tapering techniques; 4) daytime relaxation techniques and developing stress-reducing, sleep enhancing attitudes and beliefs; and 5) bedtime relaxation techniques and lifestyle habits that improve sleep. Users also complete a weekly sleep diary that can be emailed to the program developer, Dr. Gregg Jacobs, who provides individualized guidelines and feedback on CBT-I techniques based on the sleep diary results. Lastly, the program offers weekly summaries of goals and tips for meeting goals and articles and blogs on insomnia. 

• Evidence: This web-based program was developed based on a randomized controlled trial of CBT-I compared to sleep medication, a combination of CBT-I and sleep medication, and a pill placebo. CBT-I resulted in the largest changes in sleep-onset latency and sleep efficiency and fewer insomnia diagnoses at post-treatment, and treatment gains were maintained at long-term follow-up. Thus far, no trials have been conducted on the web-based delivery of this program. 

• References:

• Jacobs GD, Pace-Schott E, Stickgold R, Otto M. Cognitive-behavioral therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med.2004;164:1888-96.

• Product: Path to Better Sleep course

• Link: https://www.veterantraining.va.gov/insomnia/index.asp

• Status: Currently available to consumers

• Description: The Path to Better Sleep course was developed by the Department of Veteran Affairs but is available to all users. The program begins with a “sleep check up,” or an insomnia questionnaire. The course is designed to be completed over six weeks and is delivered using an interactive user interface with video guides on the following topics: 1) an overview of CBT-I; 2) sleep scheduling; 3) stimulus control; 4) controlling worries; 5) challenging thoughts; and 6) relapse prevention. The course also includes videos of real veterans who recovered from insomnia, a learning log, and weekly sleep diary entries.

• Evidence: According to the VA website, this course is based on the self-help guide, “Improve your Sleep: A Self-Guided Approach for Veterans with Insomnia.” No additional research particular to this program has been found at this point in time.

• References: 

• Ulmer CS, Farrell-Carnahan L, Hughes JM, Manber R, Leggett MK, Tatum J, and the MidAtlantic (VISN 6) Mental Illness Research, Education and Clinical Center (MIRECC). (2018). Improve your Sleep: A Self-Guided Approach for Veterans with Insomnia (Self-Help Workbook)

• Product: Cobalt Therapeutics RESTORE CBT for Insomnia and Sleep / The Online Program for Insomnia

• Link: http://www.cobalttx.com/Products/restore.html / https://www.return2sleep.com/

• Status: Does not appear to be available to consumers

• Description: : RESTORE is a web-based program based on the CBT-I treatment model. The program includes the following seven sessions delivered over five weeks: 1) introduction and psychoeducation; 2) applied relaxation; 3) stimulus control; 4) impactful thoughts; 5) sleep hygiene; 6) mindfulness; and 7) a closing session. 

• Evidence: The initial randomized controlled trial compared the program to a waitlist control and found that the program resulted in improved sleep quality, insomnia severity, daytime fatigue, pre-sleep cognitive arousal, and dysfunctional beliefs about sleep. Since this trial, there have been numerous publications about the program (see below).

• References:

• Vincent, N., & Lewycky, S. (2009). Logging in for Better Sleep: A randomized controlled trial of the effectiveness of online treatment for chronic insomnia. Sleep, 32, 807-815. 

• Beaulac, J., Vincent, N., & Walsh, K. (2014). Dissemination of an Internet-Based Treatment for Chronic Insomnia Into Primary Care. Behavioral Sleep Medicine,12, 1–16 

• Holmqvist, M., Vincent, N., & Walsh, K. (2013). Web-based vs telehealth-based delivery of CBTI: A randomized controlled trial. Sleep Medicine, 15, 187-195.

• Vincent, N., Walsh, K., & Lewycky, S. (2013). Determinants of success for computerized CBT: Examination of an insomnia program. Behavioral Sleep Medicine, 11, 1-13.

• Vincent, N., Walsh, K., & Lewycky, S. (2010). Sleep locus of control and computerized cognitive behavioural therapy (cCBT). Behaviour Research and Therapy, 48, 779-783.

• Vincent, N., Lewycky, S., Hart Swain, K., & Holmqvist, M. (2009). Logging on for Nodding off: Empowering patients through the use of computerized cognitive behavioural therapy (cCBT). The Behavior Therapist. 32,123-126.

• Sleep diaries and sleep measures are available in select languages. The links to the available translations of these measures are listed below. Please note that the translated versions of these measures may not have undergone a full linguistic validation process.

• Sleep diaries

• Spanish: Sleep Diary - Spanish

• Polish: Sleep Diary - Polish

• Insomnia Severity Index (ISI) 

• Many languages: Insomnia Severity Index

• Dysfunctional Beliefs and Attitudes about Sleep (DBAS) 

• 30-item 

• Chinese: Dysfunctional Beliefs and Attitudes about Sleep - Chinese

• Spanish: Dysfunctional Beliefs and Attitudes about Sleep - Spanish

• 16-item

• Many languages: Dysfunctional Beliefs and Attitudes about Sleep – 16

• Epworth Sleepiness Scale (ESS) 

• Many languages: Epworth Sleepiness Scale 

• Pittsburgh Sleep Quality Index (PSQI) 

• Many languages: Pittsburgh Sleep Quality Index 

• Sleep Disorders Symptom Checklist-25 (SDS-CL-25) 

• Spanish: Sleep Disorders Symptom Checklist - Spanish

• Pre-Sleep Arousal Scale (PSAS) 

• Spanish: Pre-Sleep Arousal Scale - Spanish

• Sleep Impact Scale (SIS) 

• Many languages: Sleep Impact Scale 

• Functional Outcomes of Sleep Questionnaire (FOSQ) 

• Many languages: Functional Outcomes of Sleep Questionnaire 

• Sleep Apnea Quality of Life Index (SAQLI) 

• Ten languages: Sleep Apnea Quality of Life Index 

• Idiopathic Hypersomnia Severity Scale (IHSS) 

• French and English: Idiopathic Hypersomnia Severity Scale 

• Athens Insomnia Scale (AIS) 

• Five languages: Athens Insomnia Scale 

• Jenkins Sleep Evaluation Questionnaire (JSEQ) 

• Many languages: Jenkins Sleep Evaluation Questionnaire 

• Leeds Sleep Evaluation Questionnaire (LSEQ) 

• Many languages: Leeds Sleep Evaluation Questionnaire 

• REM Sleep Behavior Disorder Screening Questionnaire (RBDSQ) 

• There are several mobile app-based resources available for insomnia. Descriptions and links to these apps are provided below. Please note that the descriptions for each app are based on the information made available from each app’s website or app store page and may not be complete or up-to-date.

• Product: CBTi Coach

• Mobile OS: iOS/Android

• Rating(s): iOS 3.5 Stars; Android 4.0 Stars

• Link(s): https://mobile.va.gov/app/cbt-i-coach

• Status: Currently available to consumers

• Description: CBT-i Coach is meant for users who are receiving CBT-I from a health care provider, but it also can be used as a self-help resource for users who would like to improve their sleep habits. CBT-i Coach provides education about sleep and good sleep habits, assessments, a sleep diary with tracking, and a “sleep prescription” component (i.e., prescribed bedtime, wake time, and target efficiency) that can be managed with a provider. CBT-i Coach also provides reminders to complete the sleep diary, adhere to prescribed bedtime and wake time, and take assessments among other things. https://www.mirecc.va.gov/docs/visn6/Improve_Your_Sleep_SelfGuided_Approach_for_Veterans_with_Insomnia-March-2017.pdf

• Evidence: A feasibility randomized controlled trial compared treatment augmented with CBTi Coach to treatment without the use of the app and found that all participants engaged with the app as intended, found it to be highly acceptable to patients, and found that it did not undermine the benefits of CBT-I (Koffel et al., 2018). Another open trial examining the use of CBTi Coach as a self-management intervention found improvements in self-reported insomnia, sleep quality, and sleep-related functioning from pre- to post-intervention (Reilly et al., 2019) 

• References:

• Koffel E, Kuhn E, Petsoulis N, et al. A randomized controlled pilot study of CBT-I Coach: Feasibility, acceptability, and potential impact of a mobile phone application for patients in cognitive behavioral therapy for insomnia. Health Informatics J. 2018;24(1):3-13.

• Kuhn E, Weiss BJ, Taylor KL, et al. CBT-I Coach: A Description and Clinician Perceptions of a Mobile App for Cognitive Behavioral Therapy for Insomnia. J Clin Sleep Med. 2016;12(4):597- 606.

• Reilly ED, Robinson SA, Petrakis BA, et al. Mobile App Use for Insomnia Self-Management: Pilot Findings on Sleep Outcomes in Veterans. Interact J Med Res. 2019;8(3):e12408.

• Miller KE, Kuhn E, Owen JE, et al. Clinician Perceptions Related to the Use of the CBT-I Coach Mobile App. Behav Sleep Med. 2019;17(4):481-491.

• Product: Sleep as Android

• Mobile OS: Android

• Rating(s): Android 4.4 Stars

• Link: https://sleep.urbandroid.org/

• Status: Currently available to consumers

• Description: Sleep as Android provides notification alerts as users near bedtime and provides calming sounds to listen to when falling asleep. The app tracks sleep cycles and sleep phases throughout the night using phone accelerometer or smartwatch data and wakes the user with a nature sounds alarm clock and smart-light functionality. The app also detects and interrupts snoring. It uses features to motivate users to get out of bed by requiring them to take a picture of a QR Code or hover their phone near a NFC sensor to shut off the alarm. The app also provides stats on sleep cycles, deficits, and lifestyle patterns related to sleep. 

• Evidence: N/A

• References: N/A

• Product: Sleep Cycle

• Mobile OS: iOS/Android

• Rating(s): iOS 4.7 Stars; Android 4.5 Stars

• Link: https://www.sleepcycle.com/

• Status: Currently available to consumers

• Description: The Sleep Cycle alarm clock uses motion detection and sound analysis to identify sleep states such as light or deep sleep by tracking movements in bed. The alarm clock attempts to wake users up around their desired wake time but while they are in light sleep, or stages 1-2 of sleep. It wakes up the user through its smart alarm with a 30-minute-long wake-up phase during which it monitors signals from the body to wake the user in the lightest possible sleep state. Sleep Cycle also records snoring and provides sleep graphs showing regular vs. irregular sleep, statistics about sleep (e.g., bedtime, wake time, time in bed, sleep efficiency), and lifestyle statistics based on journaled events and their relation to the users’ quality of sleep.

• Evidence: One study compared measurements from the Sleep Cycle app to polysomnography and found no correlation between total sleep time or sleep latency. 

• References:

• Patel P, Kim JY, Brooks LJ. Accuracy of a smartphone application in estimating sleep in children. Sleep Breath. 2017;21(2):505-511.

• Product: Sleep Time

• Mobile OS: iOS/Android

• Rating(s): iOS 4.8 Stars; Android 4.1 Stars

• Link: https://www.azumio.com/s/sleeptime/index.html

• Status: Currently available to consumers

• Description: The Sleep Time app tracks sleep and identifies sleep states such as light or deep sleep by tracking movements in bed. The alarm clock attempts to wake users up around their desired wake time but while they are in light sleep, or stages 1-2 of sleep. It wakes up the user through its smart alarm with a 30-minute-long wake-up phase during which it monitors signals from the body to wake the user in the lightest possible sleep state. Sleep Cycle also records snoring and provides sleep graphs showing regular vs. irregular sleep, statistics about sleep (e.g., bedtime, wake time, time in bed, sleep efficiency), and lifestyle statistics based on journaled events and their relation to the users’ quality of sleep

• Evidence: One study compared measurements from the Sleep Time app to polysomnography and found the app to have high sensitivity but poor sensitivity in detecting sleep.

• References:

• Bhat S, Ferraris A, Gupta D, et al. Is There a Clinical Role For Smartphone Sleep Apps? Comparison of Sleep Cycle Detection by a Smartphone Application to Polysomnography. J Clin Sleep Med. 2015;11(7):709-15.

• Product: Pillow

• Mobile OS: iOS

• Rating(s): iOS 4.4 Stars

• Link: https://apps.apple.com/us/app/pillow-automatic-sleep-tracker/id878691772

• Status: Currently available to consumers

• Description: Pillow analyzes sleep cycles using movement data from the user’s Apple Watch or iPhone, which is placed on the bed at night. Pillow can integrate sleep data with heart rate analysis for more accurate tracking. It can record snoring, sleep apnea, and sleep talking. Data tracking and summary information about sleep trends are provided. Pillow uses a smart alarm clock to wake users during their lightest possible sleep stage. The app also includes mood tracking and notes about sleep sessions.

• Evidence: N/A

• References: N/A

• Product: Sleepzy Sleep Cycle Tracker

• Mobile OS: iOS

• Rating(s): iOS 4.2 Stars

• Link: https://apps.apple.com/us/app/good-morning-alarm-clock/id1064910141 

• Status: Currently available to consumers

• Description: Sleepzy tracks sleep cycles by microphone and includes a smart alarm that wakes users during their lightest sleep phase. Sleepzy tracks sleep quality (efficiency) and alerts users when they gain sleep debt. The app also provides relaxing sounds for falling asleep. 

• Evidence: N/A

• References: N/A

• Product: Good Morning Alarm Clock

• Mobile OS: iOS

• Rating(s): iOS 4.5 Stars

• Link:https://apps.apple.com/us/app/good-morning-alarm-clock/id989254177

• Status: Currently available to consumers

• Description: Good Morning Alarm Clock tracks movement during sleep using iPhone sensors to analyze sleep cycles and a smart alarm to wake users during their lightest sleep cycle. The app attempts to do this while taking users’ sleep goals into consideration. The app provides data summaries on sleep cycles and sleep quality and tips to improve sleep quality, along with reminders to engage in healthy sleep habits.

• Evidence: N/A

• References: N/A