There are now dozens of apps to use to help people overcome insomnia. Can they work?
For some people, yes.
A series of different cognitive-behavioral treatments have been tried in people who complain of poor sleep. The most recent – 303 people recruited through the Internet and provided Shut-I, one of the more popular of the apps. After six months, more than half said they were sleeping normally, compared to half given an online “placebo” treatment of advice.
Will This Work For Everyone?
Volunteers are a particular group. They are motivated, and generally do far more to help themselves than what is seen in general practice. The “volunteer effect” is a large confounder in normal epidemiologic (population) studies. It was the main cause of the false result of the national Nurse’s study showing hormone replacement therapy halved heart disease.
Volunteers are unlike most folks. They do better.
In this CBT-I (cognitive behavioral treatment of insomnia) case, they did considerably better, though quite a few remained on their drugs and other therapies.
There have been plenty of other “volunteer” studies of CBT-I. One in Australia showed improvement in all subjective sleep parameters, as well as some improvement in depression. However, as sleep is a part of most depression symptom checklists, this also skewed results.
In sum – some insomniacs can get a whole lot better doing CBT-I in the bosom of their homes.
Will This Replace Standard Treatments of Insomnia?
Not if the many millions of people addicted to sleeping pills is any guide. Given the choice of a sleeping pill or performing specific cognitive homework plus changing their pattern of behavior before, during and after sleep, much of the population opts for the simplicity of a sleeping pill.
Which is a mistake. In one of the largest clinical studies in the US, sleeping pill users had five times the mortality of those matched to them who did not use pills. The increased deaths came from cardiovascular sources, accidents and falls, and some increase in cancer deaths.
Many sleeping pill users want to get off. Whether they can do so with home based techniques remains to be seen. Many are skeptical that will work because:
1.Insomnia has many causes. They range from worries and concerns about sleep leading to sleeplessness (psychophyiologic insomnia,) to depression; anxiety disorders; alcoholism; many sleep disordering medications, including commonly used high blood pressure pills; biological clock disorders; and pretty much any medical problem that increases arousal and causes discomfort. CBT-I performed only on the net will have a hard time dealing with all those woes.
2. CBT-I needs constant, ongoing reinforcement. That can happen with some apps, but will need great improvement.
3. Lots of people with insomnia also experience other sleep disorders. A majority of people with sleep apnea who are treated with CPAP will still complain of insomnia. A large proportion of sleep apneics also complain of hypersomnia – often concurrent with insomnia. Treating this group with standardized online programs has quite a way to go to prove effectiveness.
4. The need to change medical therapy. Often, to get people with insomnia back to normal sleep requires changing their regular medical therapy. One example – many folks with Parkinson’s disease sleep terribly, but do better as their Parkinson’s treatment is refined – and especially when their frequent, comorbid depression is treated.
Cognitive behavioral techniques work for more than insomnia. They are among the most effective treatments of depression and anxiety.
And there’s plenty of that out there.
Also, cognitive-behavioral approaches can produce generalized health effects. Once people get used to seeing the world in terms of problem solving, that can help them improve aspects of their physical, social, and spiritual well-being.
So it’s time for CBT approaches to be utilized in secondary schools. Kids can become acquainted with these techniques in high schools, as part of regular health education classes. These can become integrated with apps that also focus on overall health as well as insomnia.
Will this be hard to do? Without funding, sure. With general interest by health educators, we might get a different story.
For depression is increasingly common in American children, and CBT is a standard treatment for it. And CBT should have a role in something more interesting – preventing, not just treating depression (more on this another time.)
For highly motivated individuals with insomnia as their single problem, starting with online CBT-I may be the way to go. For those with medical problems, clinics that do med/psych interventions and specialize in insomnia will probably remain the only effective choice – when you can find them.
Yet the most benefit from cognitive behavioral approaches may come using them for prevention rather than treatment. In the end, that may prove the cheapest health intervention of all.