How smartphone apps are changing behavioral sleep medicine.
If your patients have trouble falling sleep and staying asleep, there are more than a hundred apps out there that promise to guide them through actionable changes and track progress over time. Only a handful are developed with the advice of credentialed sleep specialists, but those digital platforms could be especially important tools for people in rural locations who might not otherwise get the care they need.
The Society for Behavioral Sleep Medicine’s directory lists just 283 sleep psychologists in the United States. Many of these behavioral sleep medicine specialists are located in urban areas, near universities—leaving people outside these areas with few treatment options. Smartphone applications could help fill in this gap and potentially take some of the burden off of the health care system, according to a recent paper published in Translational Behavioral Medicine.1 This is especially true for insomnia, a disorder that many providers agree is best treated with cognitive behavioral therapy, explains sleep psychologist Richard Blackburn, PhD, LP, DBSM, CBSM, who works in Minnesota.
He recommends a smartphone application called CBT-i Coach, developed in collaboration between the Veteran Administration’s National Center for PTSD and Stanford School of Medicine. CBT-i Coach uses cognitive behavioral therapy for insomnia, a proven way to treat insomnia by changing thought patterns and sleeping habits.
“It’s a wonderful thing. I use it with most of my patients,” he says. “The relaxation exercises are really nice. I used to spend hours showing people different relaxation exercises. And now I just show them the app.”
CBT-i Coach, available for free in the Apple App Store, features audio recordings of guided meditation and breathing exercises to help people calm down before going to sleep. There are guided sessions on a technique called progressive muscle relaxation, in which the user notices the tension in their body and releases it by intentionally tensing and relaxing muscles.
The app also gives tips like those a behavioral sleep medicine provider might give to their patients, like avoiding caffeine and going to bed only when sleepy. There is a checklist for optimizing the sleep environment, ensuring that the room is dark and the temperature is comfortable.
According to the paper published in Translational Behavioral Medicine, smartphone applications like the CBT-i Coach present an exciting new opportunity for clinicians to treat sleep disorders, but there is still a lot of work that needs to be done to evaluate these programs. The researchers found that out of more than a hundred applications available to consumers for insomnia, CBT-i Coach was the only app for insomnia that has been tested in a randomized clinical trial.
A pilot study published in Health Informatics Journal found that patients who used CBT-i Coach as a supplement to traditional psychotherapy experienced significant improvements in their sleep.2
Another app that taps into cognitive behavioral therapy for insomnia is Night Owl – Sleep Coach, which offers education in the form of reading and video presentations. Through the use of sleep logs, the app provides recommendations tailored to each user.
There are daily tasks that help educate people on healthy sleep habits. After 56 days of working with Night Owl – Sleep Coach, people should see noticeable changes in their sleep quality, but often improvements are seen earlier.
“CBT-I is arguably the best treatment providers have available for insomnia. Unfortunately, there are not enough people trained to deliver that treatment,” says sleep psychologist Ryan Wetzler, PsyD, who developed Night Owl – Sleep Coach.
He says that people who stick to it do tend to see results. “The outcomes are tremendous when using cognitive behavioral therapy for insomnia. It is really quite rare to have someone who doesn’t respond,” says Wetzler.
The app is targeted at consumers, available in the App Store for $9.99, but providers who want to evaluate the app can request a free promo code.
Another digital platform, DrLullaby, is currently in development. It’s focused on pediatrics, an even more underserved population, says the developer Lisa Medalie, PsyD, who also serves as the director of the University of Chicago’s Pediatric Insomnia Program.
The digital platform helps parents establish sleep goals for their children. It will be available directly to individuals, but Medalie hopes that clinicians also see the value in DrLullaby and recommend it to their patients.
Apps are also tackling other common problems that behavioral sleep medicine providers face. Providers often have trouble with patients forgetting their paper sleep log at home, an essential part of cognitive behavioral therapy for insomnia, says Blackburn.
To keep better track of their patients’ sleep, Blackburn, CEO of the small tech firm Sumus Health, is developing an internet-based subscription service called SleepScribe, which is essentially a sleep diary with data that is easily shared with patients’ providers.
SleepScribe will be available to consumers, but there will also be packages for sleep centers that want to use it with all of their patients. There will be another version of the app called the SleepScribePro, which will be specifically for providers, featuring a dashboard for monitoring all patients who are using the sleep log.
“They can see which patients are making progress as expected, which patients aren’t; which patients are completing the sleep log, which ones aren’t; and so it will allow them to quickly manage a population of patients,” says Blackburn.
There are even apps that target behavioral change in sleep apnea. CPAP manufacturers ResMed and Philips have both released smartphone applications that help users better understand their sleep disorder.
By educating patients and inspiring them to play a larger role in their health care, compliance rates tend to trend up, says Shawna Wilkerson, senior sleep product manager at ResMed.
Users of ResMed’s myAir app wake up to a score showing how they slept on CPAP the night before, which is broken down into four factors (CPAP usage hours, mask seal, events per hour, and mask on/off events). Patients receive personalized coaching to help address any therapy issues along with encouragement via badges and therapy milestones.
“By providing easy-to-understand insights and motivation, myAir empowers patients to stay engaged with their therapy and ultimately take control of their health,” says Wilkerson.
“The desire to attain high myAir scores also helps drive people to make sleep therapy a long-term habit, helping them benefit from the improved daytime energy and alertness that many adherent PAP users enjoy.”
Research published in the journal CHEST showed that PAP users whose nightly use was remotely and self-monitored with ResMed’s AirView and myAir platforms, respectively, were more than 87% adherent to therapy, compared to 70% of those only remotely monitored.3
The Philips DreamMapper mobile app has also been shown to help people adhere to CPAP. According to a white paper published by the company, on average 58% more people use their therapy every night when they use the app.
“We are recognizing the need to engage people in their health behavior and people are consumers of health more than they ever have been before,” says Mark Aloia, PhD, global lead for behavior change with Philips Healthcare and associate professor of medicine at National Jewish Health in Denver, Colo.
“As behavioral change specialists, we run on the premise that behavior is hard to change and it is. I can say that we are doing a darn good job changing it, and we have more ways to grow, and we are learning where we want to go in the future.”
Lisa Spear is the associate editor of Sleep Review.
1. Yu JS, Kuhn E, Miller KE, Taylor K. Smartphone apps for insomnia: examining existing apps’ usability and adherence to evidence-based principles for insomnia management. Trans Behav Med. 2019 Jan 1;9(1):110-9.
2. Koffel E, Kuhn E, Petsoulis N, et al. A randomized controlled pilot study of CBT-I Coach: Feasibility, acceptability, and potential impact of a mobile phone application for patients in cognitive behavioral therapy for insomnia. Health Informatics J. 2018 Mar;24(1):3-13.
3. Malhotra A, Crocker ME, Willes L, et al. Patient engagement using new technology to improve adherence to positive airway pressure therapy. Chest. 2018 Apr;153(4):843-50.