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      Treating subclinical and clinical symptoms of insomnia with a mindfulness-based smartphone application: A pilot study

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          Abstract

          Background/objectives

          Emerging research suggests that face-to-face group mindfulness-based therapies are an effective intervention for insomnia. This pilot study examined the effectiveness of a mindfulness-based smartphone application for improving objectively-measured sleep, self-reported sleep, insomnia severity, pre-sleep arousal and daytime mood.

          Method

          A community sample of 23 adults with subclinical to moderately severe symptoms of insomnia were randomized to either a mindfulness or progressive muscle relaxation (PMR) smartphone application for 40 or 60 days. Objective sleep outcomes assessed using actigraphy, and self-report measures of total wake time, cognitive and somatic pre-sleep arousal, and daytime positive and negative affect were assessed for 14 nights at baseline and post-intervention. Insomnia severity was recorded at baseline and post-intervention.

          Results

          A greater reduction in sleep onset latency was observed in the mindfulness group over time, relative to the PMR group. The mindfulness group also reported medium effect size improvements for sleep efficiency. No significant interaction effects were found for self-reported sleep measures, however, main effects of time were found for both groups for total wake time, insomnia severity, cognitive pre-sleep arousal, and daytime positive and negative affect.

          Conclusions

          These preliminary findings suggest that both mindfulness and PMR smartphone applications have the potential to improve symptoms of insomnia. In particular, this mindfulness-based smartphone application may improve sleep onset latency and reduce the duration of night-awakenings. Further research exploring digital therapeutics as a self-help option for those with insomnia is needed.

          Highlights

          • This pilot study examined the effectiveness of a mindfulness smartphone app for improving symptoms of insomnia in people with subclinical and clinical symptoms of insomnia.

          • Sleep onset latency was significantly reduced in the mindfulness group compared to progressive muscle relaxation intervention.

          • Of the eight participants who had clinical insomnia of moderate severity at baseline, three participants were in the subclinical range and five participants had no clinically significant symptoms of insomnia at follow-up.

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          Most cited references35

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          A cognitive model of insomnia.

          Insomnia is one of the most prevalent psychological disorders, causing sufferers severe distress as well as social, interpersonal, and occupational impairment. Drawing on well-validated cognitive models of the anxiety disorders as well as on theoretical and empirical work highlighting the contribution of cognitive processes to insomnia, this paper presents a new cognitive model of the maintenance of insomnia. It is suggested that individuals who suffer from insomnia tend to be overly worried about their sleep and about the daytime consequences of not getting enough sleep. This excessive negatively toned cognitive activity triggers both autonomic arousal and emotional distress. It is proposed that this anxious state triggers selective attention towards and monitoring of internal and external sleep-related threat cues. Together, the anxious state and the attentional processes triggered by it tricks the individual into overestimating the extent of the perceived deficit in sleep and daytime performance. It is suggested that the excessive negatively toned cognitive activity will be fuelled if a sleep-related threat is detected or a deficit perceived. Counterproductive safety behaviours (including thought control, imagery control, emotional inhibition, and difficulty problem solving) and erroneous beliefs about sleep and the benefits of worry are highlighted as exacerbating factors. The unfortunate consequence of this sequence of events is that the excessive and escalating anxiety may culminate in a real deficit in sleep and daytime functioning. The literature providing preliminary support for the model is reviewed and the clinical implications and limitations discussed.
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            Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors.

            To estimate the prevalence of insomnia symptoms and syndrome in the general population, describe the types of self-help treatments and consultations initiated for insomnia, and examine help-seeking determinants. A randomly selected sample of 2001 French-speaking adults from the province of Quebec (Canada) responded to a telephone survey about sleep, insomnia, and its treatments. Of the total sample, 25.3% were dissatisfied with their sleep, 29.9% reported insomnia symptoms, and 9.5% met criteria for an insomnia syndrome. Thirteen percent of the respondents had consulted a healthcare provider specifically for insomnia in their lifetime, with general practitioners being the most frequently consulted. Daytime fatigue (48%), psychological distress (40%), and physical discomfort (22%) were the main determinants prompting individuals with insomnia to seek treatment. Of the total sample, 15% had used at least once herbal/dietary products to facilitate sleep and 11% had used prescribed sleep medications in the year preceding the survey. Other self-help strategies employed to facilitate sleep included reading, listening to music, and relaxation. These findings confirm the high prevalence of insomnia in the general population. While few insomnia sufferers seek professional consultations, many individuals initiate self-help treatments, particularly when daytime impairments such as fatigue become more noticeable. Improved knowledge of the determinants of help-seeking behaviors could guide the development of effective public health prevention and intervention programs to promote healthy sleep.
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              Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004).

              Recognition that psychological and behavioral factors play an important role in insomnia has led to increased interest in therapies targeting these factors. A review paper published in 1999 summarized the evidence regarding the efficacy of psychological and behavioral treatments for persistent insomnia. The present review provides an update of the evidence published since the original paper. As with the original paper, this review was conducted by a task force commissioned by the American Academy of Sleep Medicine in order to update its practice parameters on psychological and behavioral therapies for insomnia. A systematic review was conducted on 37 treatment studies (N = 2246 subjects/patients) published between 1998 and 2004 inclusively and identified through Psyclnfo and Medline searches. Each study was systematically reviewed with a standard coding sheet and the following information was extracted: Study design, sample (number of participants, age, gender), diagnosis, type of treatments and controls, primary and secondary outcome measures, and main findings. Criteria for inclusion of a study were as follows: (a) the main sleep diagnosis was insomnia (primary or comorbid), (b) at least 1 treatment condition was psychological or behavioral in content, (c) the study design was a randomized controlled trial, a nonrandomized group design, a clinical case series or a single subject experimental design with a minimum of 10 subjects, and (d) the study included at least 1 of the following as dependent variables: sleep onset latency, number and/or duration of awakenings, total sleep time, sleep efficiency, or sleep quality. Psychological and behavioral therapies produced reliable changes in several sleep parameters of individuals with either primary insomnia or insomnia associated with medical and psychiatric disorders. Nine studies documented the benefits of insomnia treatment in older adults or for facilitating discontinuation of medication among chronic hypnotic users. Sleep improvements achieved with treatment were well sustained over time; however, with the exception of reduced psychological symptoms/ distress, there was limited evidence that improved sleep led to clinically meaningful changes in other indices of morbidity (e.g., daytime fatigue). Five treatments met criteria for empirically-supported psychological treatments for insomnia: Stimulus control therapy, relaxation, paradoxical intention, sleep restriction, and cognitive-behavior therapy. These updated findings provide additional evidence in support of the original review's conclusions as to the efficacy and generalizability of psychological and behavioral therapies for persistent insomnia. Nonetheless, further research is needed to develop therapies that would optimize outcomes and reduce morbidity, as would studies of treatment mechanisms, mediators, and moderators of outcomes. Effectiveness studies are also needed to validate those therapies when implemented in clinical settings (primary care), by non-sleep specialists. There is also a need to disseminate more effectively the available evidence in support of psychological and behavioral interventions to health-care practitioners working on the front line.
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                Author and article information

                Contributors
                Journal
                Internet Interv
                Internet Interv
                Internet Interventions
                Elsevier
                2214-7829
                20 August 2020
                September 2020
                20 August 2020
                : 21
                : 100335
                Affiliations
                [a ]School of Health and Biomedical Sciences, RMIT University, Melbourne, Australia
                [b ]Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
                Author notes
                [* ]Corresponding author at: Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, 18 Innovation Walk, Clayton, VIC 3001, Australia. melinda.jackson@ 123456monash.edu
                Article
                S2214-7829(20)30101-9 100335
                10.1016/j.invent.2020.100335
                7479350
                32939342
                fd47e663-8bd4-4a15-84b3-7d1b62b6c46a
                © 2020 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 6 February 2020
                : 8 June 2020
                : 8 June 2020
                Categories
                Full length Article

                anova, analysis of variance,isi, insomnia severity index,mbsr, mindfulness-based stress reduction,na, negative affect,pa, positive affect,pmr, progressive muscle relaxation,psas, pre-sleep arousal scale,psas (cog), cognitive subscale of pre-sleep arousal scale,psas (som), somatic subscale of pre-sleep arousal scale,sfi, sleep fragmentation index,sol, sleep onset latency,tib, time in bed,tst, total sleep time,twt, total wake time,waso, wake after sleep onset,sleep,mindfulness,progressive muscle relaxation,pre-sleep arousal,smartphone applications

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