Digital cognitive behavioral therapy for insomnia promotes later health resilience during the coronavirus disease 19 (COVID-19) pandemic

Philip Cheng, Melynda D Casement, David A Kalmbach, Andrea Cuamatzi Castelan, Christopher L Drake, Philip Cheng, Melynda D Casement, David A Kalmbach, Andrea Cuamatzi Castelan, Christopher L Drake

Abstract

Study objectives: Stressful life events contribute to insomnia, psychosocial functioning, and illness. Though individuals with a history of insomnia may be especially vulnerable during stressful life events, risk may be mitigated by prior intervention. This study evaluated the effect of prior digital cognitive-behavioral therapy for insomnia (dCBT-I) versus sleep education on health resilience during the COVID-19 pandemic.

Methods: COVID impact, insomnia, general- and COVID-related stress, depression, and global health were assessed in April 2020 in adults with a history of insomnia who completed a randomized controlled trial of dCBT-I (n = 102) versus sleep education control (n = 106) in 2016-2017. Regression analyses were used to evaluate the effect of intervention conditions on subsequent stress and health during the pandemic.

Results: Insomnia symptoms were significantly associated with COVID-19 related disruptions, and those who previously received dCBT-I reported less insomnia symptoms, less general stress and COVID-related cognitive intrusions, less depression, and better global health than those who received sleep education. Moreover, the odds for resurgent insomnia was 51% lower in the dCBT-I versus control condition. Similarly, odds of moderate to severe depression during COVID-19 was 57% lower in the dCBT-I condition.

Conclusions: Those who received dCBT-I had increased health resilience during the COVID-19 pandemic in adults with a history of insomnia and ongoing mild to moderate mental health symptoms. These data provide evidence that dCBT-I is a powerful tool to promote mental and physical health during stressors, including the COVID-19 pandemic.

Clinical trial registration: NCT02988375.

Keywords: CBT-I; COVID-19; depression; digital health; engagement; insomnia; prevention; primary care; stress.

© Sleep Research Society 2020. Published by Oxford University Press on behalf of the Sleep Research Society. All rights reserved. For permissions, please e-mail journals.permissions@oup.com.

Figures

Figure 1.
Figure 1.
Insomnia symptom severity during the COVID-19 pandemic. Panel A: Bubble chart of the weighted association between insomnia symptoms and disruptions to daily life due to COVID-19 (r = 0.60). Larger points indicate stronger weighting. Panel B: Estimated marginal means for insomnia severity by group. Error bars represent one standard error. ***p ≤ 0.001, **p ≤ 0.01, *p ≤ 0.05, †p < 0.10.
Figure 2.
Figure 2.
Estimated marginal means for stress by group. Panel A: General stress; Panel B: COVID-19-specific stress as measured on the Impact of Events Scale specific to COVID-19. Error bars represent one standard error. ***p ≤ 0.001, **p ≤ 0.01, *p ≤ 0.05, †p < 0.10.
Figure 3.
Figure 3.
Odds ratios of clinical outcomes in the dCBT-I relative to the control group. Resurgent Ins = resurgence of moderate to severe insomnia during COVID-19 in individuals who showed symptom resolution following the SPREAD trial; Mod-Sev Dep = moderate to severe depression on the Quick Inventory of Depressive Symptomatology (QIDS-SR16); low GPH = Global Physical Health scores below half a standard deviation of the population norm; low GMH = Global Mental Health scores below half a standard deviation of the population norm. Error bars represent the 95% confidence intervals.

References

    1. Nelson BW, et al. Rapid assessment of psychological and epidemiological correlates of COVID-19 concern, financial strain, and health-related behavior change in a large online sample. PLoS One. 2020;15(11):e0241990.
    1. Wang C, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17(5):1729.
    1. Huang Y, et al. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res. 2020;288:112954.
    1. Rajkumar RP. COVID-19 and mental health: a review of the existing literature. Asian J Psychiatr. 2020;52:102066.
    1. Cellini N, et al. Changes in sleep pattern, sense of time and digital media use during COVID-19 lockdown in Italy. J Sleep Res. 2020;29(4):e13074.
    1. Torales J, et al. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020;66(4):317–320.
    1. World Health Organization. Global Health Estimates 2016: Disease burden by cause, age, sex, by country and by region, 2000–2016. 2018.
    1. Holmes EA, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry. 2020;7(6):547–560.
    1. Altena E, et al. Dealing with sleep problems during home confinement due to the COVID-19 outbreak: practical recommendations from a task force of the European CBT-I Academy. J Sleep Res. 2020;29(4):e13052.
    1. Galea S, et al. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Intern Med. 2020;180(6):817–818.
    1. Pfefferbaum B, et al. Mental health and the COVID-19 pandemic. N Engl J Med. 2020;383(6):510–512.
    1. Germain A, et al. Sleep in PTSD: conceptual model and novel directions in brain-based research and interventions. Curr Opin Psychol. 2017;14:84–89.
    1. Manber R, et al. Insomnia and depression: a multifaceted interplay. Curr Psychiatry Rep. 2009;11(6):437–442.
    1. Vargas I, et al. Insomnia and depression: clinical associations and possible mechanistic links. Curr Opin Psychol. 2020;34:95–99.
    1. Baglioni C, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135(1–3):10–19.
    1. Hertenstein E, et al. Insomnia as a predictor of mental disorders: a systematic review and meta-analysis. Sleep Med Rev. 2019;43:96–105.
    1. Pigeon WR, et al. Insomnia as a precipitating factor in new onset mental illness: a systematic review of recent findings. Curr Psychiatry Rep. 2017;19(8):44.
    1. Li L, et al. Insomnia and the risk of depression: a meta-analysis of prospective cohort studies. BMC Psychiatry. 2016;16(1):375.
    1. Soehner AM, et al. Prevalence and clinical correlates of co-occurring insomnia and hypersomnia symptoms in depression. J Affect Disord. 2014;167:93–97.
    1. O’Brien EM, et al. Severe insomnia is associated with more severe presentation and greater functional deficits in depression. J Psychiatr Res. 2011;45(8):1101–1105.
    1. Gehrman P, et al. Predeployment sleep duration and insomnia symptoms as risk factors for new-onset mental health disorders following military deployment. Sleep. 2013;36(7):1009–1018.
    1. Brownlow JA, et al. Influence of sleep disturbance on global functioning after posttraumatic stress disorder treatment. J Trauma Stress. 2016;29(6):515–521.
    1. Mason EC, et al. Insomnia before and after treatment for anxiety and depression. J Affect Disord. 2014;168:415–421.
    1. Pigeon WR, et al. Longitudinal relationships of insomnia, nightmares, and PTSD severity in recent combat veterans. J Psychosom Res. 2013;75(6):546–550.
    1. Schnurr PP, et al. Residual symptoms following prolonged exposure and present-centered therapy for PTSD in female veterans and soldiers. Depress Anxiety. 2019;36(2):162–169.
    1. Larsen SE, et al. Residual symptoms following empirically supported treatment for PTSD. Psychol Trauma. 2019;11(2):207–215.
    1. Xiao L, et al. Comparison of residual depressive symptoms and functional impairment between fully and partially remitted patients with major depressive disorder: a multicenter study. Psychiatry Res. 2018;261:547–553.
    1. Carney CE, et al. A comparison of rates of residual insomnia symptoms following pharmacotherapy or cognitive-behavioral therapy for major depressive disorder. J Clin Psychiatry. 2007;68(2):254–260.
    1. Nierenberg AA, et al. Residual symptoms after remission of major depressive disorder with citalopram and risk of relapse: a STAR*D report. Psychol Med. 2010;40(1):41–50.
    1. Kalmbach DA, et al. Sleep system sensitization: evidence for changing roles of etiological factors in insomnia. Sleep Med. 2016;21:63–69.
    1. Morin CM, et al. Role of stress, arousal, and coping skills in primary insomnia. Psychosom Med. 2003;65(2):259–267.
    1. Palagini L, et al. Lack of resilience is related to stress-related sleep reactivity, hyperarousal, and emotion dysregulation in insomnia disorder. J Clin Sleep Med. 2018;14(5):759–766.
    1. Ebert DD, et al. It is time to invest in the prevention of depression. JAMA Netw Open. 2018;1(2):e180335.
    1. Germain A, et al. Sleep and resilience—a call for prevention and intervention. Sleep. 2016;39(5):963–965.
    1. Taylor DJ, et al. Insomnia as a health risk factor. Behav Sleep Med. 2003;1(4):227–247.
    1. Dolsen MR, et al. Insomnia as a transdiagnostic process in psychiatric disorders. Curr Psychiatry Rep. 2014;16(9):471.
    1. Qaseem A, et al. ; Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133.
    1. Riemann D, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26(6):675–700.
    1. Cheng P, et al. Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial. Psychol Med. 2019;49(3):491–500.
    1. Pillai V, et al. . The anxiolytic effects of cognitive behavior therapy for insomnia: preliminary results from a web-delivered protocol. J Sleep Med Disord. 2015;2(2):1017.
    1. Cheng P, et al. Depression prevention in digital cognitive behavioral therapy for insomnia: Is rumination a mediator? J Affect Disord. 2020;273:434–441.
    1. Jungquist CR, et al. The efficacy of cognitive-behavioral therapy for insomnia in patients with chronic pain. Sleep Med. 2010;11(3):302–309.
    1. Espie CA, et al. Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: a randomized clinical trial. JAMA Psychiatry. 2019;76(1):21–30.
    1. Cheng P, et al. Depression prevention via digital CBT for insomnia: a randomized controlled trial. Sleep. 2019;42(10). doi: 10.1093/sleep/zsz150.
    1. Cheng P, et al. Efficacy of digital CBT for insomnia to reduce depression across demographic groups: a randomized trial. Psychol Med. 2018; 49(3):491– 500.
    1. National Institutes of Health. Your Guide to Healthy Sleep. Bethesda, MD: National Institutes of Health; 2011.
    1. Kessler RC, et al. Reliability and validity of the brief insomnia questionnaire in the America Insomnia Survey. Sleep. 2010;33(11):1539–1549. doi:10.1093/sleep/33.11.1539.
    1. Espie CA, et al. The daytime impact of DSM-5 insomnia disorder: comparative analysis of insomnia subtypes from the Great British Sleep Survey. J Clin Psychiatry. 2012;73(12):e1478–84.
    1. Gray MJ, et al. Psychometric properties of the life events checklist. Assessment. 2004;11(4):330–341.
    1. Bastien CH, et al. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. doi:10.1016/S1389-9457(00)00065-4.
    1. Elo A-L, et al. Validity of a single-item measure of stress symptoms. Scand J Work Environ Health. 2003;444–451.
    1. Salminen S, et al. Is a single item stress measure independently associated with subsequent severe injury: a prospective cohort study of 16,385 forest industry employees. BMC Public Health. 2014;14(1):543.
    1. Weiss DS, et al. The impact of event scale-revised. In: Wilson JP, Keane TM, eds. Assessing Psychological Trauma and PTSD. New York: Guilford Press; 1997: 399–411.
    1. Rush AJ, et al. The 16-Item quick inventory of depressive symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573–583. doi:10.1016/S0006-3223(02)01866-8
    1. Cella D, et al. The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005-2008. J Clin Epidemiol. 2010;63(11):1179–1194. doi:10.1016/j.jclinepi.2010.04.011.
    1. Zhao Q, et al. BETS: the dangers of selection bias in early analyses of the coronavirus disease (COVID-19) pandemic. ArXiv Prepr ArXiv200407743. 2020.
    1. Sullivan SG. The need for robust epidemiological evidence during a pandemic. Clin Infect Dis. 2020.
    1. Kalmbach DA, et al. Treating insomnia improves depression, maladaptive thinking, and hyperarousal in postmenopausal women: comparing cognitive-behavioral therapy for insomnia (CBTI), sleep restriction therapy, and sleep hygiene education. Sleep Med. 2019;55:124–134.
    1. Seyffert M, et al. Internet-delivered cognitive behavioral therapy to treat insomnia: a systematic review and meta-analysis. PLoS One. 2016;11(2):e0149139. doi:10.1371/journal.pone.0149139.
    1. Christensen H, 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):333–341. doi:10.1016/S2215-0366(15)00536-2.
    1. Batterham PJ, et al. Trajectories of change and long-term outcomes in a randomised controlled trial of internet-based insomnia treatment to prevent depression. BJPsych Open. 2017;3(5):228–235. doi:10.1192/bjpo.bp.117.005231.
    1. Nano M-M, et al. Measures of cardiovascular autonomic activity in insomnia disorder: A systematic review. PLoS One. 2017;12(10):e0186716. doi:10.1371/journal.pone.0186716.
    1. Dodds KL, et al. Heart rate variability in insomnia patients: A critical review of the literature. Sleep Med Rev. 2017;33:88–100. doi:10.1016/j.smrv.2016.06.004.
    1. Carter JR, et al. Assessment of sympathetic neural activity in chronic insomnia: evidence for elevated cardiovascular risk. Sleep. 2018;41(6). doi:10.1093/sleep/zsy048.
    1. Jarrin DC, et al. Cardiovascular autonomic dysfunction in insomnia patients with objective short sleep duration. J Sleep Res. 2018;27(3):e12663. doi:10.1111/jsr.12663.
    1. Kalmbach DA, et al. Nocturnal cognitive arousal is associated with objective sleep disturbance and indicators of physiologic hyperarousal in good sleepers and individuals with insomnia disorder. Sleep Med. 2020;71:151–160. doi:10.1016/j.sleep.2019.11.1184.
    1. Wassing R, et al. Slow dissolving of emotional distress contributes to hyperarousal. Proc Natl Acad Sci. 2016;113(9):2538–2543. doi:10.1073/pnas.1522520113.
    1. Kuisk LA, et al. Presleep cognitive hyperarousal and affect as factors in objective and subjective insomnia. Percept Mot Skills. 1989;69(3-2):1219–1225. doi:10.1177/00315125890693-228.
    1. Bonnet MH, et al. Hyperarousal and insomnia: State of the science. Sleep Med Rev. 2010;14(1):9–15. doi:10.1016/j.smrv.2009.05.002.
    1. Kalmbach DA, et al. Hyperarousal and sleep reactivity in insomnia: current insights. Nat Sci Sleep. 2018;10:193–201. doi:10.2147/NSS.S138823.
    1. Riemann D, et al. The hyperarousal model of insomnia: a review of the concept and its evidence. Sleep Med Rev. 2010;14(1):19–31. doi:10.1016/j.smrv.2009.04.002.
    1. Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015;147(4):1179–1192. doi:10.1378/chest.14-1617.
    1. Riemann D, et al. The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol. 2015;14(5):547–558. doi:10.1016/S1474-4422(15)00021-6.
    1. Irwin MR, et al. Cognitive behavioral therapy and Tai Chi reverse cellular and genomic markers of inflammation in late-life insomnia: a randomized controlled trial. Biol Psychiatry. 2015;78(10):721–729. doi:10.1016/j.biopsych.2015.01.010.
    1. Marques DR, et al. Neurobiological correlates of psychological treatments for insomnia. Eur Psychol. 2016;21(3):195-205. doi:10.1027/1016-9040/a000264.
    1. Casement MD, et al. Neural reward processing mediates the relationship between insomnia symptoms and depression in adolescence. Sleep. 2016;39(2):439–447. doi:10.5665/sleep.5460.
    1. Cannon WB. Bodily Changes in Pain, Hunber, Fear, and Rage: An Account of Recent Research Into the Function of Emotional Excitement. 2nd ed. New York, NY: Appleton-Century-Crofts; 1929.
    1. Ancoli-Israel S, et al. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. I. Sleep. 1999;22(Suppl 2):S347–S353.
    1. Sarsour K, et al. The association between insomnia severity and healthcare and productivity costs in a health plan sample. Sleep. 2011;34(4):443-450. doi:10.1093/sleep/34.4.443.
    1. Stoller MK. Economic effects of insomnia. Clin Ther Int Peer-Rev J Drug Ther. 1994;16(5):873–897.
    1. McCrae Christina S, et al. Impact of brief cognitive behavioral treatment for insomnia on health care utilization and costs. J Clin Sleep Med. 2014;10(2):127-135. doi:10.5664/jcsm.3436.
    1. Snedecor SJ, et al. Cost-effectiveness of Eszopiclone for the treatment of adults with primary chronic insomnia. Sleep. 2009;32(6):817.-. doi:10.1093/sleep/32.6.817.
    1. Jhaveri M, et al. Will insomnia treatments produce overall cost savings to commercial managed-care plans? a predictive analysis in the United States. Curr Med Res Opin. 2007;23(6):1431-1443. doi:10.1185/030079907X199619.
    1. Asche CV, et al. The direct costs of untreated comorbid insomnia in a managed care population with major depressive disorder. Curr Med Res Opin. 2010;26(8):1843-1853. doi: 10.1185/03007995.2010.488037.
    1. Bramoweth AD, et al. Chronic insomnia and health care utilization in young adults. Behav Sleep Med. 2012;10(2):106-121. doi:10.1080/15402002.2011.587067.
    1. Ho FY-Y, et al. Self-help cognitive-behavioral therapy for insomnia: a meta-analysis of randomized controlled trials. Sleep Med Rev. 2015;19:17-28. doi:10.1016/j.smrv.2014.06.010.

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