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A Smartphone Application for Adolescent Insomnia Symptoms Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-026502 on 27 May 2019. Downloaded from Pilot evaluation of the Sleep Ninja: a smartphone application for adolescent insomnia symptoms Aliza Werner-Seidler,1 Quincy Wong,1,2 Lara Johnston,1 Bridianne O’Dea,1 Michelle Torok,1 Helen Christensen1 To cite: Werner-Seidler A, ABSTRACT Strengths and limitations of this study Wong Q, Johnston L, et al. Objectives The aim of this study was to test the Pilot evaluation of the feasibility, acceptability and preliminary effects of a ► This is the first study to evaluate app-delivered cog- Sleep Ninja: a smartphone recently developed smartphone application, Sleep Ninja, application for adolescent nitive–behavioural therapy for insomnia in adoles- for adolescent sleep difficulties. insomnia symptoms. BMJ Open cents with sleep difficulties. Setting The study was conducted online with Australian 2019;9:e026502. doi:10.1136/ ► The intervention being tested, Sleep Ninja, was de- individuals recruited through the community. bmjopen-2018-026502 veloped with input from young people, is fully au- Participants Participants were 50 young people aged Prepublication history for tomated and does not require internet coverage to ► 12–16 years with sleep difficulties. this paper is available online. function. Design A single-arm pre–post design was used to To view these files,please visit ► The evaluation included measures of feasibility and evaluate feasibility, acceptability and sleep and mental the journal online(http:// dx. doi. acceptability as well as detailed semistructured health variables at baseline and postintervention. org/ 10. 1136/ bmjopen- 2018- interviews about participants’ experience with the Intervention Cognitive–behavioural therapy for insomnia 026502). app. informed the development of the Sleep Ninja. The core ► As a preliminary study, this study did not include a strategies covered by the app are psychoeducation, stimulus control group. Received 10 September 2018 control, sleep hygiene and sleep-related cognitive therapy. Revised 21 March 2019 It includes six training sessions (lessons), a sleep tracking Accepted 3 April 2019 function, recommended bedtimes based on sleep guidelines, reminders to start a wind-down routine each night, a series 25% of young people reporting some degree of sleep tips and general information about sleep. Users 2 3 of sleep disturbance. http://bmjopen.bmj.com/ progress through each training session and conclude the Depression and insomnia are closely 6-week programme with a black belt in sleep. linked, with comorbidity levels as high as Outcome measures Feasibility was evaluated based on 4 consent rates, adherence and attrition, acceptability was 73% in young people. Insomnia is not only assessed using questionnaires and a poststudy interview, a symptom of depression, but is a common and sleep, depression and anxiety variables were assessed precursor, with high-quality longitudinal data at baseline and postintervention. having established insomnia as an indepen- Results Data indicated that the Sleep Ninja is a feasible dent risk factor for depression onset.5–7 For intervention and is acceptable to young people. Findings example, a recent meta-analysis found that on September 28, 2021 by guest. Protected copyright. showed that there were significant improvements on sleep insomnia was associated with a greater than variables including insomnia (within-group effect size twofold increase in depression risk.5 Although d=−0.90), sleep quality (d=−0.46), depression (d=−0.36) depression has multiple causes and main- and anxiety (d=−0.41). © Author(s) (or their taining factors that go beyond the presence Conclusions The Sleep Ninja is a promising intervention employer(s)) 2019. Re-use of sleep problems, the literature suggests that permitted under CC BY-NC. No that could assist adolescents who experience sleep commercial re-use. See rights difficulties. A follow-up randomised controlled trial is now sleep plays an important role, and targeting and permissions. Published by warranted. sleep in the context of depression may have 6 BMJ. Trial registration number ACTRN12617000141347 wide-reaching benefits. 1Black Dog Institute, University There is emerging evidence that addressing of New South Wales, Sydney, insomnia in individuals with concurrent NSW, Australia 2 insomnia and depression improves both sleep School of Social Sciences and 8–10 Psychology, Western Sydney INTRODUCTION and depression outcomes. This suggests that University, Sydney, NSW, Clinical insomnia is a sleep disturbance char- there may be value in targeting sleep to improve Australia acterised by difficulty falling asleep, staying insomnia symptoms, with potential downstream asleep or waking up too early, with associated effects on depression. To our knowledge, there Correspondence to 1 Dr Aliza Werner-Seidler; daytime impairment. It effects approximately have been three studies testing the hypothesis 2 a. werner- seidler@ blackdog. 4% of adolescents, however, subthreshold that targeting insomnia can prevent depres- org. au symptoms are common, with approximately sive symptoms. In an adult study, insomnia Werner-Seidler A, et al. BMJ Open 2019;9:e026502. doi:10.1136/bmjopen-2018-026502 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-026502 on 27 May 2019. Downloaded from treatment led to a reduction in depression following the participants and their parents between April and June intervention and at 6 and 18 month follow-up, relative to 2017. A sample size of 50 was selected in order to success- an active control group.11 12 In a youth study, a face-to-face fully meet the study’s feasibility and acceptability aims. insomnia intervention was delivered to secondary school Inclusion criteria were: aged 12–16 years, presence of at students and results showed improvements on sleep and least mild insomnia, operationalised by endorsement of anxiety outcomes, but not symptoms of depression.13 Data at least one of the following symptoms over the preceding from the 2-year follow-up from this study have not yet been 2-week period: difficulty falling asleep, difficulty staying published.14 In a second youth study, a sleep intervention asleep or waking up too early. These items are the first delivered either in group format or digitally led to decreased three questions on the Insomnia Severity Index (ISI),24 depressive symptoms at both 2 and 12 months follow-up, an and were chosen to include a participant group with at effect that was mediated by improvements in insomnia.15 least mild levels of insomnia. For study inclusion, partic- The gold-standard treatment for insomnia is cognitive– ipants also needed to own a smartphone running iOS or behavioural therapy for insomnia (CBT-I; Australasian Android, have a valid email address, access to the internet Sleep Association, American College of Physicians), and and be able to provide personal and parental consent. there is accumulating evidence to support the use of digi- tally delivered CBT-I in both adults and young people.16–19 Measures Delivering sleep interventions via digital formats may be Insomnia Severity Index particularly well suited to young people, with adolescents The ISI is a psychometrically sound, seven-item self-re- showing a strong preference for digital delivery (97%) port measure of insomnia symptoms over the previous when given the choice between face-to-face and digital 2 weeks.24 25 Responses are reported on a Likert scale CBT-I.17 This preference may in part be explained by from 0 to 4, producing total scores of 0–28.24 25 Cut-off the fact that young people are reluctant to seek help for scores are as follows: 0–7 reflects no clinically significant psychological issues, for reasons that include stigma and insomnia, 8–14 indicates subthreshold insomnia, 15–21 a preference to manage the problem themselves.20 Sleep suggests moderate severity insomnia and 22–28 indicates is typically less stigmatised than disorders like depres- severe insomnia.24 The ISI was designed for use in adults sion, suggesting that targetting sleep it may be more but has been widely administered to, and validated in, appealing to adolescents. Currently, there are no digital adolescent samples.25–27 In one adolescent validation CBT-I programmes that are commercially available for study, reliability was strong (Cronbach’s α=0.83), and youth.21 The overall objective of this study was to evaluate test–retest reliability was acceptable, r=0.79.25 a newly developed digital CBT-I programme for adoles- cents with sleep difficulties. Pittsburgh Sleep Quality Index The aim of this pilot study was to examine the accept- The Pittsburgh Sleep Quality Index (PSQI) is a widely http://bmjopen.bmj.com/ ability, feasibility and preliminary effects of an intervention used self-report 19-item scale that assesses usual sleep (Sleep Ninja) delivered to adolescents via smartphones. In habits and experiences over the preceding month and line with the guidelines on the development of behavioural has been validated in adolescent samples, with strong interventions,22 23 the primary purpose of this study was to internal consistency (α=0.72) and test–retest reliability investigate recruitment rates, uptake, intervention comple- over a 6-week period (r=0.81).28 There are seven subscales tion, reasons for non-adherence and participant retention. which are sleep quality, sleep latency, sleep duration, The secondary aim was to use both quantitative and qual- habitual sleep efficiency (SE), sleep disturbances, use of 29 itative methods to determine the acceptability of the app sleeping medications, and daytime dysfunction. Each on September 28, 2021 by guest. Protected copyright. among young people with sleep difficulties and allow for the component is scored from 0 (no difficulty) to 3 (severe refinement of the intervention prior to a formal randomised difficulty), which are summed to obtain a Global PSQI evaluation. A final aim was to examine the impact of the score ranging from 0 to 21.30 Sleep Ninja app on sleep outcomes and mental health symp- toms. We used a single-arm, pre–post design to address these Patient Health Questionnaire-Adolescent Version aims.
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