Become your own SLEEPexpert: design, development and evaluation of a pragmatic behavioral treatment program for insomnia in inpatient psychiatric care

Abstract

Introduction: Mental disorders are among the leading causes for reduced quality of life due to illness worldwide. The majority of patients with mental disorders suffer from insomnia (disrupted sleep), and insomnia is associated with adverse health outcomes. Current guidelines identify cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment. However, CBT-I is too complex for patients with severe mental disorders and not systematically implemented in clinical care. Rather, insomnia often remains untreated or treated with hypnotics, related to the risk of adverse effects and dependency. The current project aims to empower patients with mental disorders to take care of their own sleep health based on a pragmatic behavioral treatment program. Materials and Methods: We adapted CBT-I in a treatment development phase in collaboration with 24 patients (13F, 8M, age 36.2 ± 13.8 (19; 59) years) across diagnostic entities (transdiagnostic approach) and 30 health care providers (20F, 10M, 40.6 ± 14.5 (18; 64) years) on psychiatric wards (‘Become your own SLEEPexpert’). The program was implemented and evaluated by 15 patients (9F, 6M, age 41.7 ± 12.6 (19; 59) years) and 22 health care providers based on interviews and questionnaires before participation and prior to discharge. Results: Implementation research resulted in the SLEEPexpert intervention centering on the sleep/circadian science- and evidence-based treatment components bedtime restriction and circadian adaptation and consists of three phases (therapist-guided treatment initiation, self-management with nurse support, and self-management). Evaluative pre-post assessments in 15 patients demonstrated feasibility. An improvement of insomnia severity as indexed by the Insomnia Severity Index (ISI; 18.3 ± 4.6 vs. 11.4 ± 4.4, p < 0.001, d = 1.2) and sleep quality, indexed by the Pittsburgh Sleep Quality Index (PSQI; 12.9 ± 3.8 vs. 10.3 ± 3.3, p = 0.031, d = 0.6) was observed with a decreased self-reported time in bed (520 minutes ± 105.3 vs. 460 ± 78.1, p = 0.031, d = 0.6) and increased total sleep time (331 minutes ± 110.6 vs. 375 ± 74.6, p = 0.09, d = 0.5), resulting in increased sleep efficiency (65.3 % ± 21.8 vs. 81.9 ± 11.2%, p = 0.011, d = 0.8). Conclusions: We present a novel sleep-centered intervention that has the potential to be implemented and disseminated in routine clinical care for patients with severe mental disorders and comorbid insomnia. A control comparison is needed to further test for efficacy. Given the substantive burden of insomnia and mental disorders, the proposed developments are expected to be of high public health relevance.