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

“Exclusion criteria were psychiatric or neurological impairment (as self-reported by participants), shift workers, high levels of psychological distress (Depression Anxiety and Stress Scales (Lovibond and Lovibond, 1995) scores ≥11 on the Depression scale, ≥15 on the Anxiety scale, and/or ≥13 on the Stress scale), high…”

“Mindfulness involves paying attention to one's internal experiences or surrounding environment as they occur in the present moment in a non-judgmental manner (Baer, 2003).”

“In examining the effectiveness of mindfulness for insomnia, research has focused on face-to-face group interventions such as mindfulnessbased stress reduction (Kabat-Zinn, 1982), mindfulness-based cognitive therapy for insomnia (Segal et al.”

“Models focusing on the role of cognitive arousal followed, leading to the addition of cognitive interventions aimed at modifying dysfunctional sleep-related cognitions (cognitive therapy for insomnia; Harvey, 2002).”

“Thus we anticipate improvements in insomnia from digital mindfulness training to be significant but of a slightly smaller magnitude to CBT-I.”

“This is particularly important, given the large proportion of individuals in the community with subclinical insomnia, and that there is a higher likelihood that symptoms of insomnia will progress to clinical levels if left untreated (Morin and Jarrin, 2013).”

“Actigraphy data was collected in oneminute epochs, which is the most commonly used and validated epoch length (Ancoli-Israel et al., 2015) and scored with Actilife software v6.”

“Total wake time (TWT) was chosen as the primary sleep outcome variable as it incorporates both SOL (amount of time taken to fall asleep) and WASO (amount of time spent awake during the night excluding sleep onset latency), which are the two recommended quantitative insomnia outcome measures for research (Lichstein et…”

“, 2003) and successfully validated against polysomnography (PSG) for insomnia (Lichstein et al., 2006; Quante et al., 2018).”

“More recent theoretical models (Lundh, 2005; Ong et al., 2012) have therefore highlighted the role of metacognition in addition to hyperarousal in maintaining insomnia.”

“The improvements in cognitive pre-sleep arousal are consistent with theoretical models of insomnia and previous intervention research (Ong et al., 2014; Ong et al., 2008; Ong et al., 2009).”

“observed improvements in self-reported TWT, with moderate to large effect sizes, is consistent with previous research reporting improvements in self-reported SOL and WASO following mindfulness-based group therapy (Gross et al., 2011; Garland et al., 2014; Heidenreich et al., 2006; Ong et al., 2014) and therapist-deliv…”

“, 2003) and successfully validated against polysomnography (PSG) for insomnia (Lichstein et al., 2006; Quante et al., 2018).”

“The improvements in cognitive pre-sleep arousal are consistent with theoretical models of insomnia and previous intervention research (Ong et al., 2014; Ong et al., 2008; Ong et al., 2009).”

“Exclusion criteria were psychiatric or neurological impairment (as self-reported by participants), shift workers, high levels of psychological distress (Depression Anxiety and Stress Scales (Lovibond and Lovibond, 1995) scores ≥11 on the Depression scale, ≥15 on the Anxiety scale, and/or ≥13 on the Stress scale), high…”

“observed improvements in self-reported TWT, with moderate to large effect sizes, is consistent with previous research reporting improvements in self-reported SOL and WASO following mindfulness-based group therapy (Gross et al., 2011; Garland et al., 2014; Heidenreich et al., 2006; Ong et al., 2014) and therapist-deliv…”

“Self-help interventions are not intended to replace face-to-face interventions, but may be effective as the initial stage in a stepped-care approach to insomnia (Ho et al., 2015; van Straten and Cuijpers, 2009) or for those with mild to moderate symptoms.”

“However, many individuals with insomnia do not seek professional help, reporting preferences for non-pharmacological and self-help interventions (Holbrook et al., 2000; Vincent and Lionber, 2001; Morin et al., 2006b).”

“Given that the rates of insomnia increase when subclinical symptoms are considered (Hillman and Lack, 2013), research investigating the effectiveness of mindfulness-based interventions in subclinical populations are also needed.”

“Lastly, health professionals such as doctors and psychologists receive minimal education in the management of sleep disturbances during their formal training (Meltzer et al., 2009; Mindell et al., 2011; Meaklim et al., 2020), and thus evidence-based self-help programs are vital to increase access to effective insomnia…”

“Both uncontrolled and controlled studies have demonstrated that these interventions have the potential to improve self-reported sleep in those with insomnia disorder (Garland et al., 2014; Gross et al., 2011; Heidenreich et al., 2006; Ong et al., 2014; Ong et al., 2008; Ong et al., 2009).”

“…sleep, excessive worry about sleep, and selective attention to sleep-related threats) (Norell-Clarke et al., 2014), but also attempt to control their thoughts (Harvey, 2001; Lundh and Hindmarsh, 2002) and struggle to accept spontaneously occurring physiological and mental processes (Lundh, 2005).”

“This may be due to the fact that actigraphy can underestimate sleep onset in comparison to polysomnography as it is cannot discriminate between motionless wake from sleep (Tonetti et al., 2008); although it is not feasible to use polysomnography in long-term studies.”

“Lastly, health professionals such as doctors and psychologists receive minimal education in the management of sleep disturbances during their formal training (Meltzer et al., 2009; Mindell et al., 2011; Meaklim et al., 2020), and thus evidence-based self-help programs are vital to increase access to effective insomnia…”

“observed improvements in self-reported TWT, with moderate to large effect sizes, is consistent with previous research reporting improvements in self-reported SOL and WASO following mindfulness-based group therapy (Gross et al., 2011; Garland et al., 2014; Heidenreich et al., 2006; Ong et al., 2014) and therapist-deliv…”

“…sleep, excessive worry about sleep, and selective attention to sleep-related threats) (Norell-Clarke et al., 2014), but also attempt to control their thoughts (Harvey, 2001; Lundh and Hindmarsh, 2002) and struggle to accept spontaneously occurring physiological and mental processes (Lundh, 2005).”

“Lastly, health professionals such as doctors and psychologists receive minimal education in the management of sleep disturbances during their formal training (Meltzer et al., 2009; Mindell et al., 2011; Meaklim et al., 2020), and thus evidence-based self-help programs are vital to increase access to effective insomnia…”

“Previous focus groups indicate that mindfulness can motivate participants to adopt healthy sleep lifestyles and may be applicable to aspects beyond sleep (Hubbling et al., 2014).”

“However, research has indicated that individuals with insomnia not only have a tendency to experience heightened physiological arousal and negative sleep-related cognitions (including dysfunctional beliefs about sleep, excessive worry about sleep, and selective attention to sleep-related threats) (Norell-Clarke et al.…”

“Face-to-face mindfulness meditation programs, such as mindfulness-based stress reduction (MBSR), have also been shown to provide significant improvement in sleep efficiency and sleep onset in comparison to other treatment groups, such as pharmacotherapy, in patients with chronic insomnia (e.g., Gross et al., 2011; Tay…”

“Actigraphy Actigraphs are wrist-worn devices that record movement data (Cheung et al., 2018).”

“There is also growing evidence of the efficacy of self-help tools, such as mindfulness apps, to treat subclinical and clinical symptoms of sleep disturbances [64].”

“Positive affect was examined in fi ve studies and measured with the Positive and Negative Affect Scale 48,49 or one-item measures in EMA studies 36,50,51 .”

“Insomnia, broadly characterized as a difficulty in initiating or maintaining sleep coupled with a daytime impairment, is a disease process with a notably higher prevalence in older adults and women (Roth, 2007; Low et al., 2020).”

“considered the role of mindfulness-based therapy as an alleviation for insomnia, using Headspace, a mindfulness smartphone application, in order to improve sleep [37].”

“Mindfulness is a practice to cultivate a purposeful awareness of the present moment through the careful observation of one’s experiences and sensations as they emerge moment-to-moment without applying judgement (Bishop et al., 2004; Kabat-Zinn, 2003; Marlatt and Kristeller, 1999).”

“While Headspace and other digital mental health companies [27-29] have developed sleep-specific content, to our knowledge, this is the first self-guided, app-based program to combine CBT-I techniques with mindfulness as a core component in a structured, 18-session sequential format.”

“pilot RCT indicated that an English mindfulness app improved insomnia in a community sample [25], but it does not have a Chinese version, and no Chinese apps have been tested.”

“Mindfulness interventions via smart-phone applications resulted in shorter sleep onset latency compared with progressive muscle relaxation interventions and had a moderate effect on sleep efficiency [27].”