A Sleep Program to Improve Sleep Quality in People With HIV

August 11, 2020 updated by: Lesley K. Fellows, McGill University

Efficacy Potential of an Internet-based Sleep Program to Improve Sleep Quality in People With HIV

Sleep problems, such as insomnia, are more frequent and intense in individuals living with HIV. These sleep difficulties can increase the difficulties in thinking and concentrating. Digital cognitive behavioral therapy for insomnia (dCBT-I) is a computer-based treatment intervention that provides strategies to improve sleep. This intervention has been shown to improve sleep and daytime function (concentration, productivity) in people with insomnia. However, the effects of this intervention in people living with HIV are unknown.

Study Overview

Status

Terminated

Conditions

Intervention / Treatment

Detailed Description

Sleep disturbances have been consistently reported in HIV+ individuals, and occur early in the course of infection. Among disorders of sleep commonly found in HIV, insomnia is by far the most frequent condition, affecting almost 75% of HIV-infected individuals. Compared to non-infected individuals, HIV+ patients are 17% more likely to develop insomnia. Furthermore, not only is insomnia more frequent in HIV; it is also more severe in HIV+ compared to HIV- individuals. The precise mechanisms underlying the vulnerability of this population to insomnia still remain hypothetical, and might involve neurodegenerative processes related to the infection, associated mood disorders (e.g., depression, anxiety), side effects of antiretroviral medications, and psychosocial factors. Importantly, sleep disorders in HIV have been demonstrated to affect the severity of the infection. For instance, sleep disturbances were shown to mediate the association between psychological distress and immune status (T-cytotoxic/suppressor cell counts). In addition, sleep disruption also affects responses to treatment, as illustrated by a report demonstrating that sleep disturbances mediate the association between medication adherence and self-reported HIV symptom severity. Finally, insomnia in HIV seems to be closely associated with the presence of cognitive disturbances. Indeed, virtually all HIV infected individuals with cognitive impairment present insomnia complaints, and greater sleep disturbances were associated with worse cognitive performance (e.g., executive functions, psychomotor speed) in this population. Therefore, insomnia has been shown to affect symptom severity, treatment adherence and cognition in HIV+ individuals.

Despite this demonstrated importance of sleep for the well-being of HIV patients, there are very few studies of sleep treatment interventions in HIV. Two studies have implemented an educational intervention promoting healthy sleep habits (e.g., healthy diet, reduced caffeine consumption, no exercise before bedtime, regular sleep-wake schedules), consisting of either one single session or 10 weekly sessions, with little or no consistent sleep improvement in this population. This is not surprising given that previous studies showed the very limited efficacy of interventions focusing solely on sleep hygiene in a general chronic insomnia population.

The most effective treatment for chronic insomnia currently consists of a multimodal psychological intervention, called cognitive-behavioral therapy for insomnia (CBT-I). CBT-I improves sleep to the same degree as hypnotic medications in the short term, but, in contrast to hypnotics, shows no side effects and remains effective in the long term, with sustained improvement in sleep and daytime functioning up to 2 years after completion of the therapy. CBT-I has proven effective in patients with primary insomnia (i.e. without associated medical condition), as well as in insomnia comorbid with depression or cancer. However, the efficacy of CBT-I has not been studied in HIV+ individuals with insomnia.

Digital Cognitive-Behavioural Therapy for Insomnia (CBT-I): the Sleepio program

CBT-I is an intervention aimed at breaking the patterns of maladaptive thinking and behavior that serve to maintain insomnia. It includes a range of techniques including a behavioral component (stimulus control, sleep restriction, relaxation) combined with a cognitive (managing sleep related worries, the racing mind and intrusive thoughts) and an educational (sleep hygiene) component. CBT-I is usually dispensed in group sessions, including 5 to 8 patients and a trained therapist. The different components of CBT-I are then covered in 6 to 8 weekly sessions of 60-90 minutes each. While CBT-I has been demonstrated as an efficacious treatment option, the personnel-intensive nature of CBT-I constitutes an important barrier to widespread clinical use.

Web-based (digital) CBT-I has been developed to overcome this barrier. Two randomized controlled trials (RCT) have evaluated separate digital CBT-I (dCBT-I) applications. In a first study, a six-week wait-list controlled trial of self-help dCBT-I was tested via a simple web-based platform delivering CBT-I content. Insomnia improvement was significantly better in the dCBT-I group when compared to wait-list control, at 4 weeks follow-up. In addition, 48 weeks following the intervention, within-subjects improvements in insomnia severity were also observed. The second RCT of CBT-I included a six-week placebo-controlled dCBT-I intervention, using a media rich, interactive application with an online discussion forum for users. This platform, named Sleepio (www.sleepio.com), allowed users to receive weekly, interactive sessions with an online virtual therapist. That RCT showed large effects on sleep efficiency (d=1.00) and insomnia severity (using the Sleep Condition Indicator (SCI) scale, d= .77), relative to the placebo control, at 8 week follow-up. Overall more than 75% of patients responded to the intervention, as defined by the recovery of healthy sleep efficiency levels. In addition, dCBT-I also significantly improved daytime function, including self-reported assessment of concentration and productivity, thereby suggesting a potential benefit of CBT-I for cognitive functions.

The current intervention sub-study will test the Sleepio dCBT-I intervention in people with HIV. Free access will be provided to the Sleepio program. The program will be delivered entirely online, in 6 weekly sessions spread over 6-12 weeks. The CBT-I sessions will be delivered by an animated virtual therapist, "The Prof". At the start of therapy, participants will complete a short questionnaire, which will be used to suggest examples of goals. Participants will be encouraged to complete a daily sleep diary online throughout the entire course, which will be used to provide personalized help. Indeed, all interactions with the virtual therapist will be dynamically driven by information from daily sleep diaries completed by the user, to provide baseline, adherence, performance and progress data; sleep diary information will also be used to tailor sleep restriction schedules as a function of to the patients' usual bedtimes. Within each therapy session, sleep diary data will be reviewed, goals will be reviewed and new targets will be set. The treatment content will be based on CBT for insomnia manuals and includes the following techniques: psycho-education, goal setting, sleep hygiene, sleep restriction, stimulus control, cognitive restructuring, paradoxical intention, mindfulness, positive imagery, relaxation (progressive muscle relaxation & autogenic training), putting the day to rest, thought stopping. Participants will be encouraged to select an appointment time for the Sleepio session and will be prompted via email if they do not attend. In addition, participants will receive an email reminder each morning to prompt them to fill in their sleep diary and will have access to a moderated online community and an online library of information about sleep throughout the course of the intervention. They will be able to view their online 'case file' which includes four sections: a progress review, a reminder of strategies to try out in between sessions, an agreed sleep schedule and a list of further reading. In addition to the Sleepio program, participants will be asked to complete a short set of questionnaires assessing mood, quality of life, cognitive symptoms and sleep quality via an online link prior at the start and end of the program, and at their next routine (main study) follow-up visit.

Study Type

Interventional

Enrollment (Actual)

27

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Canada
    • Quebec
      • Montreal, Quebec, Canada, H3A 2B4
        • Montreal Neurological Institute and Hospital (McGill University)

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

31 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

  • Evidence of insomnia disorder (Sleep Condition Indicator [SCI] ≤ 16)
  • Able to have convenient weekly access to the Internet
  • Stable medical condition
  • Have been on a stable HAART regimen for > 6 months
  • Have not had a change in medications that could potentially interfere with sleep or cognition in the past 4 months.

Exclusion Criteria:

  • Berlin questionnaire score indicating high risk of obstructive sleep apnea
  • Known history of sleep disorders (e.g., narcolepsy, hypersomnia, restless legs syndrome, REM-sleep behavior disorder) which currently require or previously required treatment
  • Ongoing involvement in night shift work
  • Not able to complete the 12 weeks of the sleep intervention due to a scheduling conflict

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Diagnostic
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: Single

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: Immediate dCBT-I group
Digital cognitive behavioural therapy for insomnia (dCBT-I) is a 6 session training program (spanning 6 to 12 weeks) designed to improve sleep. Participants in the immediate dCBT-I group will receive the Sleepio intervention shortly after enrollment.
Behavioral: Digital cognitive behavioural therapy for insomnia (dCBT-I)
dCBT-I is a computer-based treatment intervention that provides strategies to improve sleep and daytime function (concentration, productivity) in individuals with insomnia
Other Names:
  • Sleepio
Experimental: Waitlist control group
Participants in the waitlist control group will receive sleep hygiene recommendations from validated online resources for HIV patients (http://www.catie.ca/en/positiveside/winter-2013/sleep-tight) around the time of enrollment. They will start the digital cognitive behavioural therapy for insomnia (dCBT-I) intervention 12-14 weeks after the initial enrollment.
Behavioral: Digital cognitive behavioural therapy for insomnia (dCBT-I)
dCBT-I is a computer-based treatment intervention that provides strategies to improve sleep and daytime function (concentration, productivity) in individuals with insomnia
Other Names:
  • Sleepio

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Ratio of total sleep time over time in bed
Time Frame: 12 weeks
Obtained from the online self-reported sleep diaries aggregated over 7 days, completed at study entry and again at 12 weeks
12 weeks

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Insomnia Severity as assessed by the Insomnia Severity Index
Time Frame: 12 weeks
Obtained from the online self-reported questionnaire completed at study entry and again at 12 weeks
12 weeks
Cognitive performance as assessed by the Brief Cognitive Ability Measure (B-CAM)
Time Frame: 9 months
Ruler-like measure of cognitive ability combining self-report and performance items
9 months
Anxiety and Depression symptoms as assessed by the Hospital Anxiety Depression Scale
Time Frame: 9 months
Questionnaire
9 months
Quality of life as assessed by the WHO-QOL-HIV
Time Frame: 9 months
Questionnaire
9 months
Quality of life as assessed by the EQ-5D
Time Frame: 9 months
Questionnaire
9 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

McGill University

Collaborators

Sleepio

Investigators

  • Principal Investigator: Lesley K Fellows, MD, DPhil, McGill University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

May 1, 2015

Primary Completion (Actual)

August 1, 2020

Study Completion (Actual)

August 1, 2020

Study Registration Dates

First Submitted

August 25, 2015

First Submitted That Met QC Criteria

October 6, 2015

First Posted (Estimate)

October 8, 2015

Study Record Updates

Last Update Posted (Actual)

August 12, 2020

Last Update Submitted That Met QC Criteria

August 11, 2020

Last Verified

August 1, 2020

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 14-368-BMB
  • CTN S 290 (Other Identifier: CIHR Canadian HIV Trials Networ)

Plan for Individual participant data (IPD)

Plan to Share Individual Participant Data (IPD)?

Yes

IPD Plan Description

Fully anonymized individual data may be requested from the investigators.

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

Clinical Trials on Insomnia Disorder

Clinical Trials on Digital cognitive behavioural therapy for insomnia (dCBT-I)

Search Similar Trials

Sponsors and Collaborators

Medical Conditions

Drug Interventions

CROs by country

CROs in Algeria

Conditions

Rare Diseases

Drug Interventions

Dietary Supplements

Sponsor/Collaborators

Locations

Subscribe