Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial

Enhancing sleep health in urban American Indian/Alaska Native adolescents: Implications for culturally tailored interventions

BACKGROUND

Urban American Indian/Alaska Native (AI/AN) adolescents are vulnerable to sleep and other health-related disparities due to numerous social drivers, including historical trauma and relocation to urban areas. This study aims to identify strategies to increase protective factors and culturally tailor sleep health interventions for this population.

METHODS

Using community-based participatory research, the NAYSHAW study conducted in-depth interviews with urban AI/AN adolescents aged 12-19 years to understand critical components needed for developing a culturally sensitive sleep health intervention. Data from two qualitative subsamples (N = 46) and parent surveys (N = 110) were analyzed, focusing on factors that affect sleep health behaviors, including parental involvement, technology, and traditional practices.

RESULTS

Key findings include the detrimental impact of electronics use at night and protective effects of traditional practices on sleep. Parental involvement in sleep routines varied by adolescent's age. Adolescents desired sleep health education in interactive formats, whereas parents preferred workshops and digital applications for sleep health strategies. Findings suggest that interventions need to address electronics use and should also be culturally tailored to address the unique experiences of urban AI/AN adolescents.

CONCLUSIONS

Results underscore the importance of utilizing community-based strategies to develop culturally tailored sleep interventions for underserved populations, specifically urban AI/AN adolescents. Integrating traditional practices with evidence-based sleep health strategies can provide a holistic approach to improving sleep and overall well-being. Parental education and involvement will be critical to the success of such interventions.

Racial/ethnic disparities in the trajectories of insomnia symptoms from childhood to young adulthood

STUDY OBJECTIVES

To examine differences in the longitudinal prevalence of childhood insomnia symptoms across black/African American, Hispanic/Latinx, and non-Hispanic white groups.

METHODS

Participants were 519 children from the Penn State Child Cohort (baseline [V1] from 2000-2005) who were followed up 8 years later as adolescents (V2) and 15 years later as young adults (S3). Mean age at S3 was 24.1 ± 2.7 years. Approximately, 76.5% identified as non-Hispanic white, 12.9% as black/African American, 7.1% as Hispanic/Latinx, and 3.5% as "other" race/ethnicity. Insomnia symptoms were defined as parent-reported (childhood) or self-reported (adolescence and young adulthood) moderate-to-severe difficulties initiating/maintaining sleep. Longitudinal trajectories of insomnia symptoms were identified across three-time points and the odds of each trajectory were compared between racial/ethnic groups, adjusting for sex, age, overweight, sleep apnea, periodic limb movements, psychiatric/behavioral disorders, and psychotropic medication use.

RESULTS

Black/African Americans compared to non-Hispanic whites were at significantly higher odds of having a childhood-onset persistent trajectory through young adulthood (OR = 2.58, 95% CI [1.29, 5.14]), while Hispanics/Latinx were at nonsignificantly higher odds to have the same trajectory (OR = 1.81, 95% CI [0.77, 4.25]). No significant racial/ethnic differences were observed for remitted and waxing-and-waning trajectories since childhood or incident/new-onset trajectories in young adulthood.

CONCLUSIONS

The results indicate that disparities in insomnia symptoms among black/African American and, to a lesser extent, Hispanic/Latinx groups start early in childhood and persist into young adulthood. Identifying and intervening upon upstream determinants of racial/ethnic insomnia disparities are warranted to directly address these disparities and to prevent their adverse health sequelae.

CLINICAL TRIAL INFORMATION

N/A; Not a clinical trial.

"The worst thing is lying in bed thinking 'I want a cigarette'" a qualitative exploration of smoker's and ex-smoker's perceptions of sleep during a quit attempt and the use of cognitive behavioural therapy for insomnia to aid cessation

Smokers report poorer sleep quality than non-smokers and sleep quality deteriorates further during cessation, increasing risk of smoking relapse. Despite the use of cognitive behavioural therapy for insomnia (CBT-I) to aid quit attempts emerging in the area, little is known about smokers and ex smoker's experiences of sleep during a quit attempt or their perceptions of CBT-I. This study addresses this gap by exploring smoker's and ex-smoker's experiences of the link between smoking and sleep and how this may change as a function of smoking/smoking abstinence. It also explores views of traditional CBT-I components (i.e., perceived feasibility, effectiveness, barriers of use). We conducted semi-structured interviews with current and recently quit smokers (n = 17) between January and September 2022. The framework method was used for analysis. Four themes addressing research questions were described. These included: 1) A viscous cycle; poor sleep quality and negative psychological state during cessation; 2) Perceived engagement and effectiveness; the importance of feasibility, experience, value, identity and psychological state in assessing CBT-I as a cessation tool; 3) Striking a balance; tailoring CBT-I to reduce psychological overload in a time of lifestyle transition; and 4) Personalisation and digital delivery helping overcome psychological barriers during cessation. The analysis suggested during quit attempts smokers experienced a range of sleep problems that could increase risk of relapse due to a negative impact on psychological state. It also revealed participants thought that CBT-I is something they would use during a quit attempt but suggested changes and additions that would improve engagement and be better tailored to quitting smokers. Key additions included the integration of smoking-based cognitive restructuring, starting the intervention prior to a quit attempt, and the need for personalisation and tailoring.

Ethical and Equitable Digital Health Research: Ensuring Self-Determination in Data Governance for Racialized Communities

Recent studies highlight the need for ethical and equitable digital health research that protects the rights and interests of racialized communities. We argue for practices in digital health that promote data self-determination for these communities, especially in data collection and management. We suggest that researchers partner with racialized communities to curate data that reflects their wellness understandings and health priorities, and respects their consent over data use for policy and other outcomes. These data governance approach honors and builds on Indigenous Data Sovereignty (IDS) decolonial scholarship by Indigenous and non-indigenous researchers and its adaptations to health research involving racialized communities from former European colonies in the global South. We discuss strategies to practice equity, diversity, inclusion, accessibility and decolonization (EDIAD) principles in digital health. We draw upon and adapt the concept of Precision Health Equity (PHE) to emphasize models of data sharing that are co-defined by racialized communities and researchers, and stress their shared governance and stewardship of data that is generated from digital health research. This paper contributes to an emerging research on equity issues in digital health and reducing health, institutional, and technological disparities. It also promotes the self-determination of racialized peoples through ethical data management.

Comparing patient-reported outcomes and lifestyle factors before and after the COVID-19 pandemic among Black and Hispanic breast cancer survivors in New Jersey

PURPOSE

The impact of the COVID-19 pandemic restrictions in the US since March 2020 on cancer survivorship among Black and Hispanic breast cancer (BC) survivors remains largely unknown. We aimed to evaluate associations of the pandemic with participant characteristics, patient-reported outcomes (PROs), and lifestyle factors among Black and Hispanic BC survivors in the Women's Circle of Health Follow-Up Study and the New Jersey BC Survivors Study.

METHODS

We included 447 Black (npre = 364 and npost = 83) and 182 Hispanic (npre = 102 and npost = 80) BC survivors who completed a home interview approximately 24 months post-diagnosis between 2017 and 2023. The onset of the pandemic was defined as March 2020. The association of the pandemic with binary outcomes was estimated using robust Poisson regression models.

RESULTS

Hispanic and Black BC survivors recruited after the onset of the pandemic reported higher socioeconomic status and fewer comorbidities. Black women in the post-pandemic group reported a higher prevalence of clinically significant sleep disturbance (prevalence ratio (PR) 1.43, 95% CI 1.23, 1.68), lower sleep efficiency, and lower functional well-being, compared to the pre-pandemic group. Hispanic women were less likely to report low health-related quality of life (vs. high; PR 0.62, 95% CI 0.45, 0.85) after the onset of the pandemic.

CONCLUSIONS

Ongoing research is crucial to untangle the impact of the pandemic on racial and ethnic minorities participating in cancer survivorship research, as well as PROs and lifestyle factors.

IMPLICATIONS FOR CANCER SURVIVORS

This study highlights the importance of considering the impact of the pandemic in all aspects of research, including the interpretation of findings.

Effect of daily discrimination on naturalistic sleep health features in young adults

OBJECTIVE

Racial inequities in sleep health are well documented and may be partially attributable to discrimination experiences. However, the effects of acute discrimination experiences on same-night sleep health are understudied. We quantified naturalistic discrimination experiences captured using ecological momentary assessment (EMA) and examined whether reporting discrimination on a given day predicted sleep health that night.

METHOD

Participants completed baseline assessments and a 17-day EMA protocol, with text prompts delivered four times daily to collect discrimination experiences. Seven different daily sleep characteristics were ascertained each morning. Discrimination reasons (e.g., because of my racial identity) were reported by participants and categorized into any, racial, or nonracial discrimination. Outcomes included the seven sleep diary characteristics. We fit generalized linear mixed effects models for each sleep outcome and discrimination category, controlling for key covariates.

RESULTS

The analytic sample included 116 self-identified Black and White individuals (48% Black, 71% assigned female at birth, average age = 24.5 years). Among Black participants, race-based discrimination was associated with a 0.5-hr reduction in total sleep time (TST). Among White individuals, nonracial discrimination was associated with a 0.6-hr reduction in TST, an earlier sleep offset, and reduced sleep efficiency (partly attributable to more nighttime awakenings).

CONCLUSIONS

Young adults may sleep worse on nights after experiencing discrimination, and different types of discrimination affect different sleep outcomes for Black and White individuals. Future studies may consider developing treatments that account for different sleep vulnerabilities for people experiencing discrimination on a given day. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury

OBJECTIVE

To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI).

METHOD

Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach.

RESULTS

Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support).

CONCLUSIONS

Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Developing a culturally tailored digital health intervention for insomnia in Black women

Insomnia disorder is highly prevalent among Black women. Cognitive-behavioral therapy for insomnia (CBT-I) is considered the optimal treatment, but very little efficacy research has been conducted in minority populations. Culturally tailoring intervention content may increase participant engagement and improve treatment outcomes. We culturally tailored an Internet-delivered CBT-I program (Sleep Healthy Using the Internet; SHUTi) for Black women. First, relevant stakeholders were identified. Semi-structured interviews were conducted after stakeholders completed each of the six SHUTi intervention sessions. Questions focused on improving program relatability and engagement for Black women. Key themes pertinent to peripheral, evidential, and sociocultural strategies for cultural adaptation were identified using thematic content analysis, and adaptation recommendations were developed. A total of 50 interviews, across 9 stakeholders, were conducted. Two overarching themes were identified: (i) there was limited visual African American representation, and (ii) there was a lack of diversity in the environments and lifestyles of the patient vignettes. Respondents provided peripheral, evidential, and sociocultural recommendations for program modifications, emphasizing the importance of race-concordant visual content and didactic content exploring the diverse cultural and social contexts in which insomnia occurs for Black women. As more diverse patients seek evidence-based insomnia treatment, digital health interventions must consider whether it is therapeutically important to address and tailor for cultural differences. Here, stakeholders made clear recommendations for taking cultural contexts into account to improve patient engagement with the program. Further research should work to understand the extent to which culturally tailored interventions are beneficial for health outcomes among minority populations.

Addressing sleep deserts: A proposed call for action

Sleep deserts are a major cause of health inequity. They occur primarily in disadvantaged neighborhoods because of structural racism, social and environmental factors, and dearth of medical services. We describe several strategies that can serve as a feasible action plan to target structural racism, environmental pollution, and impact of climate change. We also suggest ways healthcare providers in these underserved areas can incorporate sleep medicine into their practice. Lastly, we highlight strategies to increase community awareness of sleep health in a culturally sensitive manner. There are several ways, from a policy level to healthcare that we can begin to eliminate sleep deserts, which is urgently needed.

Associations of sleep duration and daytime sleepiness with plasma amyloid beta and cognitive performance in cognitively unimpaired, middle-aged and older African Americans

STUDY OBJECTIVES

Given the established racial disparities in both sleep health and dementia risk for African American populations, we assess cross-sectional and longitudinal associations of self-report sleep duration (SRSD) and daytime sleepiness with plasma amyloid beta (Aβ) and cognition in an African American (AA) cohort.

METHODS

In a cognitively unimpaired sample drawn from the African Americans Fighting Alzheimer's in Midlife (AA-FAiM) study, data on SRSD, Epworth Sleepiness Scale, demographics, and cognitive performance were analyzed. Aβ40, Aβ42, and the Aβ42/40 ratio were quantified from plasma samples. Cross-sectional analyses explored associations between baseline predictors and outcome measures. Linear mixed-effect regression models estimated associations of SRSD and daytime sleepiness with plasma Aβ and cognitive performance levels and change over time.

RESULTS

One hundred and forty-seven participants comprised the cross-sectional sample. Baseline age was 63.2 ± 8.51 years. 69.6% self-identified as female. SRSD was 6.4 ± 1.1 hours and 22.4% reported excessive daytime sleepiness. The longitudinal dataset included 57 participants. In fully adjusted models, neither SRSD nor daytime sleepiness is associated with cross-sectional or longitudinal Aβ. Associations with level and trajectory of cognitive test performance varied by measure of sleep health.

CONCLUSIONS

SRSD was below National Sleep Foundation recommendations and daytime sleepiness was prevalent in this cohort. In the absence of observed associations with plasma Aβ, poorer self-reported sleep health broadly predicted poorer cognitive function but not accelerated decline. Future research is necessary to understand and address modifiable sleep mechanisms as they relate to cognitive aging in AA at disproportionate risk for dementia.

CLINICAL TRIAL INFORMATION

Not applicable.

Representation of race and ethnicity among cancer survivors in trials of cognitive behavioral therapy for insomnia (CBT-I): A systematic review

PURPOSE

For cancer survivors, insomnia is highly prevalent and debilitating. Although cognitive behavioral therapy for insomnia (CBT-I) is recognized as a gold standard treatment, it is unclear whether benefits of treatment generalize to racial and ethnic minorities in the USA. This systematic review characterizes the representation of racial and ethnic diversity among cancer survivors in CBT-I clinical trials and provides recommendations for research in sleep/cancer survivorship.

METHODS

Literature searches were conducted in five electronic databases (PubMed, Cochrane Library via Ovid, PsycINFO via Ovid, Embase, Web of Science Core Collection) using concepts of CBT, insomnia, and cancer survivors. Information about CBT-I intervention details, sample racial demographics, and whether authors explicitly analyzed race and ethnicity were recorded.

RESULTS

A total of 1673 citations were retrieved, and 967 citations were uploaded to Covidence. Of these, 135 articles went through full-text review and 13 studies were included. Race and ethnicity were reported in 11/13 trials (84.6%). Of those reporting race and ethnicity, 8/11 (72.7%) trials were comprised of samples that were ≥ 85% non-Hispanic White. Among the trials that explicitly analyzed race and ethnicity, CBT-I was more effective among cancer survivors who were White and highly educated, and non-White cancer survivors were less likely to have private insurance and ability to participate in clinical trials.

CONCLUSION

Non-Hispanic White cancer survivors are overrepresented in CBT-I trials, the best available treatment for insomnia. Underrepresentation of racial and ethnic minorities likely contributes to barriers in access and uptake. Recommendations include implementing sustained efforts to expand diversity in CBT-I clinical trials for cancer survivors.

Perspectives on increasing the impact and reach of CBT-I

Cognitive behavioral therapy for insomnia is now recognized as the front-line treatment for chronic insomnia, yet many challenges remain in improving its impact and reach. This manuscript describes our perspective on some of these challenges. Based on the literature that maladaptive cognitions predict low adherence and that high levels of cognitive-emotional hyperarousal may be associated with poor outcomes, we propose added focus on cognitive therapy strategies in CBT-I. Specifically, we propose broadening the range of traditional cognitive therapy strategies, utilizing acceptance-based strategies, and fuller integration of the broadened range of cognitive strategies into CBT-I throughout the course of treatment. We also highlight a few other promising emerging approaches to enhance the impact of CBT-I. These include involving partners to promote adherence with CBT-I treatment recommendations, using culturally relevant treatment adaptations to increase retention of patients in treatment, and using strategies for timely identification of barriers to engagement. We propose broadening the public health impact of CBT-I by integrating support for reduction in long-term use of hypnotic sleep medications, which is in line with current medical guidelines. We advocate for a case conceptualization-based approach for implementing CBT-I in a patient-centered manner, flexibly, yet with fidelity, to enhance its impact by addressing the factors above. For increasing the reach of CBT-I, we discuss the need to train more clinicians and ways to combine therapist and digital deliveries of CBT-I, highlighting stepped care strategies.

An Update on Sleep Duration, Obesity, and Mortality Risk in Women

Sleep health is an essential component to overall health. Because of numerous societal, economic, and biological factors, obtaining adequate sleep poses a unique challenge to aging women. Yet, women have been traditionally understudied in sleep research. An increasing body of research supports abnormal sleep duration as a risk factor for obesity, cardiovascular disease, and mortality. This review focuses specifically on 3 areas of the discussion of insufficient sleep in women: (1) the mysterious poor health of long sleepers, (2) the potential underlying mechanisms linking abnormal sleep duration and cardiometabolic health, and (3) the need to investigate multiple levels of social determinants driving sleep disparities.

Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the front-line treatment for insomnia. Despite the demonstrated effectiveness of CBT-I, it is necessary to consider how CBT-I may be tailored to different individuals. The purpose of the present review is to provide a summary of literature on tailoring CBT-I to different individuals and provide directions for future research. This review focused on the following domains of adaptation: (i) tailoring CBT-I components to individuals with comorbid mental or physical health conditions such as comorbid depression and pain; (ii) adapting CBT-I delivery for different contexts in which individuals exist, such as inpatient, educational, and different social/cultural settings, (iii) adapting CBT-I to specific individuals via case-formulation in clinical settings. We highlight current gaps in the exploration of tailored CBT-I, including a lack of research methodology to evaluate tailored interventions, a need for the integration of ongoing individualised assessment to inform treatment, and the necessary involvement of consumers and stakeholders throughout the research and treatment development process. Together, this review showed abundant adaptations in CBT-I already exist in the literature. Future research is needed in understanding when and how to apply adaptations in CBT-I and evaluate the benefits of these adaptations.

Effects of a digital cognitive behavioral therapy for insomnia on sleep and alcohol consumption in heavy drinkers: A randomized pilot study

BACKGROUND

Insomnia is a well-established, prospective risk factor for Alcohol Use Disorder. Thus, targeting sleep problems could serve as a novel and efficacious means of reducing problematic drinking. Here, we examined the potential utility of a well-validated, interactive, easy to use, self-paced digital cognitive behavioral therapy for insomnia program. In a randomized, single-blind pilot study, we examined the impact of treatment with Sleep Healthy Using the Internet (SHUTi) on drinking and sleep outcomes in a sample of heavy drinkers with insomnia.

METHODS

Heavy drinking men (n = 28) and women (n = 42) with insomnia were randomly assigned to complete either the SHUTi program or a control patient education program. Subjective measures of sleep and alcohol use were administered at baseline, immediately following completion of the intervention, 3 months post-intervention, and 6 months post-intervention. Sleep outcomes were assessed using the Insomnia Severity Index and Pittsburgh Sleep Quality Index. Drinking outcomes were assessed using the 30-Day Timeline Follow-Back calendar. We used linear mixed effects models to compare groups on both insomnia and drinking outcomes.

RESULTS

Data from all 70 subjects (SHUTI: n = 40; control: n = 30) were analyzed. Linear mixed effects models showed that SHUTi significantly reduced insomnia symptoms (p = 0.01) and drinking outcomes (ps < 0.05) more than the control condition over time. Trend-level effects on sleep quality (p = 0.06) were also observed. No adverse events were reported.

CONCLUSIONS

Improving sleep may be an effective treatment intervention for reducing hazardous drinking in at-risk individuals. Further, findings provide preliminary support for the implementation of an easily accessible health behavior intervention with significant public health impact in a high-risk population.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial

BACKGROUND

Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans.

OBJECTIVE

The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans.

METHODS

We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters.

RESULTS

Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported.

CONCLUSIONS

Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

Patient perspectives on facilitators and barriers to equitable engagement with digital CBT-I

STUDY OBJECTIVES

Digital cognitive behavioral therapy for insomnia has significant advantages for dissemination and scalability vs. in-person cognitive behavioral therapy for insomnia and is, therefore, well-positioned to be the first-line intervention for insomnia. However, only about half of patients remit following digital cognitive behavioral therapy for insomnia. Evidence suggests that treatment engagement is a critical driver of digital cognitive behavioral therapy for insomnia effectiveness, and barriers to engagement disproportionately impact people from under-resourced communities. For digital cognitive behavioral therapy for insomnia to be effective and scalable, we need to identify facilitators and barriers to digital cognitive behavioral therapy for insomnia engagement.

METHODS

Responses from an exit survey about participant experiences with digital cognitive behavioral therapy for insomnia were analyzed using mixed methods. The survey included quantitative measures of treatment engagement and a free-response item, which was coded and analyzed for themes using both inductive and deductive approaches.

RESULTS

Analyses revealed five themes that were relevant for engagement: (1) digital person-to-person components, (2) type and extent of information, (3) user's sense of autonomy, (4) app functionality, and (5) importance of tailored content. Facilitators included enjoyment of digital cognitive behavioral therapy for insomnia elements, particularly those that enhanced a sense of connection (eg, a digital therapist avatar); content presented clearly and at an appropriate pace; and smooth app functionality. Barriers included desire for additional human support, perception that digital cognitive behavioral therapy for insomnia did not account for clinical complexities, and factors that interfered with implementation of key treatment recommendations.

CONCLUSION

Many barriers and facilitators are influenced by health literacy and technological literacy. Those with access to health and technological literacy are better equipped to engage with digital cognitive behavioral therapy for insomnia. Recommendations for adaptations and enhancements are discussed.

Patient reported preferences for sleep interventions among women receiving buprenorphine for opioid use disorder

Aim

Among individuals receiving medication for OUD (MOUD), insomnia is highly prevalent and increases the risk for negative OUD outcomes. However, little is known about MOUD patient-reported preferences for insomnia treatments among women with OUD. This mixed-methods study explored acceptability of and patient preferences for sleep interventions among women in OUD treatment.

Methods

This is an analysis from an ongoing cross-sectional survey and interview study investigating the relationship between sleep and OUD recovery. The parent study is actively enrolling non-pregnant women between 18-45 years stabilized on buprenorphine from an outpatient program. Participants complete measures including the Insomnia Severity Index (ISI), with scores of ≥10 identifying clinically significant insomnia symptoms. A sub-sample who met this threshold completed semi-structured interviews. Descriptive statistics were generated for survey responses, and applied thematic analysis was used for interview data.

Results

Participants selected for the qualitative interview (n = 11) highlighted prior positive and negative experiences with sleep treatments, challenges with employing non-pharmacological sleep strategies, and preferences for both medical and behavioral sleep interventions while in recovery. Women emphasized the need for flexibility of sleep therapy sessions to align with ongoing social determinants (e.g., caregiving responsibilities) as well as for sleep medications without sedating effects nor risk of dependency.

Conclusions

Many women receiving MOUD have concomitant insomnia symptoms, and desire availability of both pharmacologic and behavioral sleep interventions within the OUD treatment setting. Qualitative findings underscore the need for evidence-based sleep interventions that account for the unique socioenvironmental factors that may impact strategy implementation in this population.

World sleep society international sleep medicine guidelines position statement endorsement of "behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of sleep medicine clinical practice guidelines"

This paper summarizes the position statement of the World Sleep Society (WSS) International Guidelines Committee regarding the Clinical Practice Guidelines on the Behavioral and Psychological Treatments for Chronic Insomnia Disorder in Adults prepared by a task force of the American Academy of Sleep Medicine (AASM). The practice guidelines were reviewed for their relevance and applicability to the practice of sleep medicine around the world. The WSS Work Group endorsed the AASM strong recommendation for Multicomponent Cognitive Behavioral Therapy as the treatment of choice for Insomnia Disorder and conditional endorsement for its single-therapy components (sleep restriction, stimulus control, relaxation); use of sleep hygiene education as single therapy was not endorsed due to lack of evidence for its efficacy. The strong recommendation for multicomponent CBT-I applied to patients with chronic insomnia disorder with or without comorbid psychiatric and medical conditions. Main caveats with regard to CBT-I remains the lack of adequately trained therapists and variability in terms of training available in different parts of the world. Unanswered questions about the applicability, availability, accessibility and potential sociodemographic (age, sex, ethnicity, regions) moderators of treatment outcomes were discussed. Despite growing evidence documenting the benefits of digital CBT-I, individual, in-person CBT-I delivered by a trained professional (mental health) provider is regarded as the optimal method to deliver CBT-I.

Culturally Adapting an Internet-Delivered Mindfulness Intervention for Indonesian University Students Experiencing Psychological Distress: Mixed Methods Study

BACKGROUND

Psychological distress is prevalent among university students. However, the availability of evidence-based mental health treatment remains limited in many low- and middle-income countries, including Indonesia. Internet-delivered, mindfulness-based interventions that reduce distress have potential for treating university student distress at scale. Unfortunately, evidence-based, internet-delivered mindfulness treatments are not yet available in Indonesia. Cultural adaptation of established evidence-based, internet-delivered mindfulness interventions is needed.

OBJECTIVE

In this paper, we describe the process of culturally adapting an Australian internet-delivered mindfulness program (Introduction to Mindfulness) to be relevant and appropriate for treating Indonesian university students' psychological distress.

METHODS

To assist the cultural adaptation process, we used a systematic cultural adaptation framework and a mixed methods approach combining quantitative and qualitative methods. In study 1 (information gathering), we administered an internet-delivered questionnaire to Indonesian university students (n=248) to examine their preferences regarding an internet-delivered mindfulness intervention. In study 2 (preliminary design), a draft program was developed and independently reviewed by Indonesian stakeholders. Stakeholders (n=25) included local Indonesian mindfulness and mental health professionals (n=6) and university students (n=19), who were selected to maximize sample representativeness regarding personal and professional characteristics. To evaluate the initial design and cultural congruence of the internet-delivered mindfulness program in the Indonesian context, we conducted interviews and focus groups with stakeholders. Stakeholders also completed the Cultural Relevance Questionnaire.

RESULTS

In study 1, most Indonesian university students (240/248, 96.8%) reported openness to an internet-delivered mindfulness program. Most of interested students (127/240, 52.9%) preferred the length of the program to be 3 to 4 sessions, with 45.8% (110/240) preferring brief lessons taking only 15 to 30 minutes to complete. They (194/240, 80.8%) recommended that the program be accessible both through websites and mobile phones. In study 2, Indonesian stakeholders generally found the internet-delivered program to be highly culturally appropriate in terms of language, concepts, context, treatment goals, and depictions of students' emotional and behavioral experiences. However, stakeholders also recommended some specific adaptations regarding the program's delivery model (eg, combining visual and audio modalities when delivering psychoeducation), cultural components (eg, including more social and spiritual activities), program practicality (eg, including rewards to promote engagement), and design elements (eg, including additional culturally relevant illustrations). Following stakeholder feedback, a new culturally adapted Indonesian internet-delivered mindfulness program called Program Intervensi Mindfulness Daring Mahasiswa Indonesia was created.

CONCLUSIONS

This study highlights the process and importance of cultural adaptation of an evidence-based mindfulness treatment and demonstrates how this may be achieved for internet-delivered psychotherapy programs. We found that a culturally adapted internet-delivered mindfulness program was relevant for Indonesian students with some adjustments to the programs' content and delivery. Future research is now needed to evaluate the clinical benefit of this program.

Application and Mechanisms of Internet-Based Cognitive Behavioral Therapy (iCBT) in Improving Psychological State in Cancer Patients

This review article is an overview of the effectiveness of internet-based cognitive behavioral therapy (iCBT) in Improving Psychological State in Cancer Patients. iCBT's effectiveness has been investigated in treating and managing conditions like depression, psychiatric disorders, generalized anxiety disorder (GAD), panic disorder, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), adjustment disorder, bipolar disorder, chronic pain, and phobias. iCBT's role in the treatment of medical conditions such as diabetes mellitus with comorbid psychiatric illnesses was also explored. We conducted a thorough literature search using PubMed, Embase, Google Scholar, and Wanfang with no restrictions on the date. iCBT's role in treating and controlling psychiatric illnesses in cancer patients has been established in the literature. Development and popularization of iCBT, treament forms of iCBT, platforms for iCBT, application of iCBT, strategies and efficacy of iCBT for insomnia in cancer patients, current status of iCBT application, and genetic researches on iCBT for anxiety disorders were all reviewed and discussed in this review. From the data compiled, we conclude that iCBT is useful in treating or improving psychological state in cancer patients.

"It was Just Good to Have an Outlet for Other Parents to Talk to": Feasibility and Acceptability of Integrating Mental Health and Wellness Services into Predominantly Black Early Childhood Education Centers During the COVID-19 Pandemic

Racial disparities in mental health care access and quality are associated with higher levels of unmet need for Black parents and families, a population disproportionately affected by the COVID-19 pandemic. Integrating services within early childhood education centers may increase mental health care access for Black families with young children. The current study examined the feasibility, acceptability, and perceived impact of an integrated program offering mental health care for parents, children, and dyads during the pandemic. Black parents (N = 61) completed measures of program satisfaction and perceived benefits of participation, and 47 parents also participated in focus groups further assessing perceptions of the program. Results demonstrated high levels of satisfaction and perceived benefit of the program for parents and children. Themes generated through analysis included: social support, creating a safe space, prioritizing self-care, and sharing parenting strategies. Parents' feedback provides preliminary feasibility and acceptability for the integrated mental health program.

Preliminary Evaluation of Translated and Culturally Adapted Internet-Delivered Cognitive Therapy for Social Anxiety Disorder: Multicenter, Single-Arm Trial in Japan

BACKGROUND

Internet-delivered cognitive therapy for social anxiety disorder (iCT-SAD), which is a therapist-guided modular web-based treatment, has shown strong efficacy and acceptability in English-language randomized controlled trials in the United Kingdom and Hong Kong. However, it is not yet known whether iCT-SAD can retain its efficacy following linguistic translation and cultural adaptation of treatment contents and implementation in other countries such as Japan.

OBJECTIVE

This study aimed to examine the preliminary efficacy and acceptability of the translated and culturally adapted iCT-SAD in Japanese clinical settings.

METHODS

This multicenter, single-arm trial recruited 15 participants with social anxiety disorder. At the time of recruitment, participants were receiving usual psychiatric care but had not shown improvement in their social anxiety and required additional treatment. iCT-SAD was provided in combination with usual psychiatric care for 14 weeks (treatment phase) and for a subsequent 3-month follow-up phase that included up to 3 booster sessions. The primary outcome measure was the self-report version of the Liebowitz Social Anxiety Scale. The secondary outcome measures examined social anxiety-related psychological processes, taijin kyofusho (the fear of offending others), depression, generalized anxiety, and general functioning. The assessment points for the outcome measures were baseline (week 0), midtreatment (week 8), posttreatment (week 15; primary assessment point), and follow-up (week 26). Acceptability was measured using the dropout rate from the treatment, the level of engagement with the program (the rate of module completion), and participants' feedback about their experience with the iCT-SAD.

RESULTS

Evaluation of the outcome measures data showed that iCT-SAD led to significant improvements in social anxiety symptoms during the treatment phase (P<.001; Cohen d=3.66), and these improvements were maintained during the follow-up phase. Similar results were observed for the secondary outcome measures. At the end of the treatment phase, 80% (12/15) of participants demonstrated reliable improvement, and 60% (9/15) of participants demonstrated remission from social anxiety. Moreover, 7% (1/15) of participants dropped out during treatment, and 7% (1/15) of participants declined to undergo the follow-up phase after completing the treatment. No serious adverse events occurred. On average, participants completed 94% of the modules released to them. Participant feedback was positive and highlighted areas of strength in treatment, and it included further suggestions to improve suitability for Japanese settings.

CONCLUSIONS

Translated and culturally adapted iCT-SAD demonstrated promising initial efficacy and acceptability for Japanese clients with social anxiety disorder. A randomized controlled trial is required to examine this more robustly.

Racial disparities in treatment engagement and outcomes in digital cognitive behavioral therapy for insomnia among pregnant women

OBJECTIVES

In the United States, Black women are disproportionately afflicted with prenatal insomnia. Although cognitive-behavioral therapy for insomnia (CBTI) may represent a strategy to reduce disparities in insomnia, racial minorities attend fewer healthcare appointments and have poorer outcomes from prenatal care and mental health treatment relative to white patients. The present study examined differences in treatment engagement and patient-reported outcomes in non-Hispanic Black and white pregnant women receiving digital CBTI.

METHODS

Secondary analysis of 39 pregnant women with clinical insomnia who received digital CBTI. Treatment engagement was operationalized as the number of sessions completed (≥4 considered an adequate dose). Treatment outcomes were assessed using the Insomnia Severity Index (ISI; insomnia) and Pittsburgh Sleep Quality Index (PSQI; global sleep disturbance).

RESULTS

Black women were 4 times more likely than white women to discontinue CBTI before receiving an adequate dose (8.3% vs. 33.3%). Regarding treatment outcomes, white women reported a mean reduction of 5.75 points on the ISI and a reduction of 3.33 points on the PSQI (Cohen's dz = 1.10-1.19). By comparison, Black women reported reductions of 2.13 points on the ISI and 1.53 points on the PSQI, which were statistically non-significant. Differences in treatment engagement did not account for the disparities in patient-reported outcomes.

CONCLUSIONS

During pregnancy, Black women completed fewer CBTI sessions and experienced poorer treatment outcomes in response to digital CBTI relative to white women. Enhancements to insomnia therapy and its digital delivery may improve adherence and outcomes in Black pregnant women.

Integrating technology to increase the reach of CBT-I: state of the science and challenges ahead

In this Round Table Discussion, an international panel of experts discuss issues related to the use of technology in the delivery of cognitive behavioral therapy for insomnia (CBT-I), in order to increase its reach. Panelists were, in alphabetical order, Carmela Alcántara, PhD, an Associate Professor at Columbia University School of Social Work in New York, USA, Bei Bei, PhD., an Associate Professor at Monash University in Melbourne, Australia, Charles M. Morin, PhD., a Professor of Psychology at Laval University in Quebec City, Canada, and Annemieke A. van Straten, PhD., a Professor of Clinical Psychology at the Vrije Universiteit in Amsterdam, the Netherlands. The session was chaired by Rachel Manber, PhD., a Professor of Psychiatry and Behavioral Sciences at Stanford University, in Palo Alto, California, USA. In their introductions each panelist discussed the use of technology in their respective country. All indicated that the most common way technology is used in the treatment of insomnia is through the use of video calls (telemedicine) to deliver individual CBT-I, and that this is mostly covered by publicly funded health insurance programs such as Medicare, especially since the COVID-19 pandemic. There are also some fully automated insomnia treatment programs, but they're often not covered by Medicare or other health insurance programs.

Associations between 24-h Movement Behavior and Internet Addiction in Adolescents: A Cross-Sectional Study

OBJECTIVE

This study aimed to explore the relationship between 24-h activity behavior and Chinese adolescents' Internet addiction.

METHODS

A survey of 2045 adolescents (56.5% boys) was conducted, and adolescents' 24-h movement behavior and Internet addiction were measured via a questionnaire. Descriptive statistics were used to analyze the basic situation of the respondents; chi-square analysis was used to compare gender differences, and logistic regression was used to analyze the relationship between 24-h exercise guide entries and Internet addiction.

RESULTS

From the number of 24-h movement behavior guides, 25.3% of the children did not meet the recommended amount of any kind of activity behavior guide, while 50.4% and 21.7% of the children reached the recommended amount of one and two activity behavior guidelines, respectively; only 3.2% of the children met the recommended amount of all three activity behavior guidelines. Adolescents who did not meet the recommended 24-h activity behavior guidelines were more likely to have Internet addiction (OR = 8.46, 95 CI = 3.06-23.36), and were more likely to have one item (OR = 4.50, 95 CI = 1.64-12.39) or two items (OR = 3.12, 95 CI = 1.11-8.74).

CONCLUSIONS

Physical activity, static behavior, and sleep may all have a greater impact on adolescents' Internet addiction, among which physical activity has a greater impact on adolescents' Internet addiction. Different combinations of 24-h movement behavior have different effects on adolescents' Internet addiction.

How Would You Manage This Patient With Chronic Insomnia? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. The American Academy of Sleep Medicine (AASM) published recent guidelines on behavioral and psychological treatment as well as pharmacologic therapy for chronic insomnia disorder. Regarding behavioral and psychological approaches, the only intervention strongly recommended was multicomponent cognitive behavioral therapy for insomnia. Regarding pharmacologic treatment, the AASM, based on weak evidence, suggested a limited number of medications that might be useful and others that probably are not. Here, 2 clinicians with expertise in sleep disorders-one a clinical psychologist and the other a physician-debate the management of a patient with chronic insomnia who has been treated with medications. They discuss the role of behavioral and psychological interventions and pharmacologic therapy for chronic insomnia and how the primary care practitioner should approach such a patient.

Rapid sleep education: If you could tell people one thing about sleep, what should it be?

Informal learning settings such as museums provide unique opportunities for educating a local community about sleep. However, in such settings, information must be capable of immediately inciting interest. We developed a series of sleep "icebreakers" (brief, informal facts) to determine whether they elicited interest in sleep and encouraged behavioural change. There were 859 participants across three cross-sectional samples: (a) members of the local museum; (b) Mechanical Turk workers who responded to a "sleep" study advertisement; and (c) Mechanical Turk workers who responded to a "various topics" study advertisement that did not mention sleep. All three samples demonstrated high interest in sleep topics, though delayed recall of the icebreakers was strongest in participants who expected to learn about the sleep topics. Icebreaker interest ratings were independent of age, gender and race/ethnicity, suggesting that sleep is a topic of universal interest. Importantly, regardless of demographics and sample, the more the icebreakers interested the participants, the more likely participants were to indicate willingness to donate to a sleep exhibit, change their sleep behaviours, and post to social media. Thus, sleep icebreakers can rapidly elicit people's interest, and future outreach efforts should couple icebreakers with opportunities for subsequent personalized learning.

Advancing digital health Equity: Directions for behavioral and social science research

The field of digital health is evolving rapidly and encompasses a wide range of complex and changing technologies used to support individual and population health. The COVID-19 pandemic has augmented digital health expansion and significantly changed how digital health technologies are used. To ensure that these technologies do not create or exacerbate existing health disparities, a multi-pronged and comprehensive research approach is needed. In this commentary, we outline five recommendations for behavioral and social science researchers that are critical to promoting digital health equity. These recommendations include: (i) centering equity in research teams and theoretical approaches, (ii) focusing on issues of digital health literacy and engagement, (iii) using methods that elevate perspectives and needs of underserved populations, (iv) ensuring ethical approaches for collecting and using digital health data, and (v) developing strategies for integrating digital health tools within and across systems and settings. Taken together, these recommendations can help advance the science of digital health equity and justice.

Digital tools for the assessment of pharmacological treatment for depressive disorder: State of the art

Depression is an invalidating disorder, marked by phenotypic heterogeneity. Clinical assessments for treatment adjustments and data-collection for pharmacological research often rely on subjective representations of functioning. Better phenotyping through digital applications may add unseen information and facilitate disentangling the clinical characteristics and impact of depression and its pharmacological treatment in everyday life. Researchers, physicians, and patients benefit from well-understood digital phenotyping approaches to assess the treatment efficacy and side-effects. This review discusses the current possibilities and pitfalls of wearables and technology for the assessment of the pharmacological treatment of depression. Their applications in the whole spectrum of treatment for depression, including diagnosis, treatment of an episode, and monitoring of relapse risk and prevention are discussed. Multiple aspects are to be considered, including concerns that come with collecting sensitive data and health recordings. Also, privacy and trust are addressed. Available applications range from questionnaire-like apps to objective assessment of behavioural patterns and promises in handling suicidality. Nonetheless, interpretation and integration of this high-resolution information with other phenotyping levels, remains challenging. This review provides a state-of-the-art description of wearables and technology in digital phenotyping for monitoring pharmacological treatment in depression, focusing on the challenges and opportunities of its application in clinical trials and research.