On Twitter and Facebook, NPR asked its audience if they have used a mobile phone app to help manage insomnia. Nearly 100 people wrote back suggesting a range of apps, including podcasts created to put a listener to sleep.
“These are usually relaxation strategies, white noise, meditation,” Jason Ong, an associate professor of neurology specializing in sleep at Northwestern University’s Feinberg School of Medicine. He studies non-pharmacological treatments for various sleep disorders and treats patients at the university’s Sleep Medicine clinic. “It’s not that there’s something wrong with those apps. It’s a reasonable first thing to try.”
But, he adds, these kinds of apps aren’t based on scientifically-proven solutions, and they don’t really fix the problem of why someone is not sleeping.
Ong wanted to do something about that, so a few years ago, he consulted for a team that developed an app that uses a science-based approach to address insomnia called Sleepio. (However, he doesn’t have any ongoing financial interest in the product, he says.)
Sleepio and a few other apps like SHUT-i and a free one developed by the Veterans Administration use the most sustainable and evidence-based solution for insomnia. It’s a kind of therapy called Cognitive Behavioral Therapy for Insomnia — CBT-I for short, he says. It helps the patient understand the biology of sleep and gives them a bag of tools and tricks to change their own thought patterns and behaviors to treat their underlying sleep issues.
“CBT for insomnia is a specific package … [that] includes different techniques like spending less time in bed [and] what to do if you are in bed and can’t sleep,” says Ong. “It’s teaching you how to change your behavior to better work with your brain to give you confidence that you’re going to be able to sleep on a regular basis.”
It may be surprising to us, but our own thought patterns and sleep habits affect our biology, in this case how our brains regulate sleep. “If you modify some of your behaviors, you can work better with how your brain regulates sleep and wake,” he says.
The American College of Physicians first recommended Cognitive Behavioral Therapy for Insomnia as the first-line treatment for insomnia in 2016. “The evidence is quite strong to support the effectiveness of CBT-I treatment and there really aren’t a lot of side effects,” says Ong. And, because it changes behavior, “in the long run CBT-I tends to perform quite well in maintaining the benefits.”
In the past the only way for people to get Cognitive Behavioral Therapy for Insomnia was to see a therapist, now they can access the therapy on their mobile phones.
“In Sleepio, it’s like an avatar of a real therapist that’s walking the patient through that process,” explains Ong. Sleepio also allows users to keep a sleep diary so the app can use its algorithm to suggest a better bedtime schedule. It also reminds people to get up when they’ve spent too much time in bed trying to fall asleep, for example.
Like a real therapist, the apps that use Cognitive Behavior Therapy for Insomnia also provide practical tools to help the user worry less about their sleep and over time, be less anxious and more confident about their ability get a good night’s rest. “It’s very similar to what we do face-to-face with patients,” adds Ong.
Studies show that CBT-I delivered digitally through mobile phone apps is effective in treating insomnia. And a recent study of Sleepio by Ong and the team that developed the product found that participants who used the product reported an improvement in insomnia symptoms and overall wellbeing.
“It’s an impressive study in size and scope,” says John Torous, the director of digital psychiatry at Beth Israel Deaconess Medical Center. “But like any study, we have to interpret it within reason.”
The participants in the study were mostly white and female, he notes, and so it’s hard to generalize the findings to the larger population. And, he adds that the study was designed and funded by Big Health, the company that created the app and is now marketing it.
Also, Sleepio is only available on a limited basis. You can get it through employers, health insurance and national health systems at the moment, says Mike Radocchia, the marketing and business development lead at Big Health. Although the company does give it to researchers and charities for free.
And while apps that use Cognitive Behavior Therapy for Insomnia cost less than in-person therapy, they can be pricey. A 26-week subscription of SHUTi costs $149.
That’s why Torous often directs his patients with insomnia to a free app developed by the Veterans Administration called CBT-I Coach.
“Anyone can access it. You don’t have to be a veteran,” Torous says.
Jake Hanks, a mental health counselor based in Glenwood Springs, Colorado, agrees. “CBT-I Coach would be my absolute favorite,” he says. “It includes a lot of the cognitive restructuring, the true things about sleep that we want patients to keep in mind.” And so, he too, recommends the free app to his patients.
However, Torous notes that these apps don’t work for everyone. The recent study by Ong and his colleagues hints at why.
“Even in this clinical study, less than 50 percent [of people who were assigned to use the app in a randomized controlled trial] are able to make it through the entire course of CBT delivered through digital platforms,” he notes. “For some people it may be hard to make it through all the sessions of CBT.”
This is true of most health and wellness apps, he says. Torous has studied this and found that of the 10,000 mental health apps out there, very few are actually being used. “I don’t think we really understand how people are using technology towards their health and recovery,” he notes.
But in some ways, he says, people with insomnia may be ahead of scientists in figuring out what works well for them.
“If you find something that works [for you], I think that’s always a good first step,” he says. “Quick fixes or simple solutions may get you feeling better right away.”
But, he notes, insomnia is a complex disorder with many underlying causes. Sometimes it can be caused by a medical condition that’s easily treatable, like a thyroid problem, he adds.
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