Insomnia is a common problem encountered in family medicine that causes significant morbidity for patients. A survey of Canadian adults found that 40.2% met at least one symptom of insomnia,13.4% met all criteria and 13% had consulted a healthcare provider for sleep difficulties at least once in their lifetime (1). Patients with insomnia have daytime fatigue, increased physical discomfort and increased psychological distress (2). Patients with chronic insomnia have an increased risk of major depression, anxiety and substance use disorders (3). Chronic insomnia often has a bi-directional relationship with comorbid chronic disease including chronic pain and mental illness(4). Treating insomnia can provide relief to the direct symptoms of insomnia but also improve the suffering from comorbid disease. Hypnotic medications are often used as the primary treatment of insomnia with or without a discussion of sleep hygiene. However, sleep complaints often persist in patients treated with hypnotic medication and sleep hygiene has been shown to be ineffective as a monotherapy for chronic insomnia (5, 6). Cognitive Behavioural Therapy for Insomnia (CBT-i) is the treatment of choice for chronic insomnia and its efficacy is well established in the general population and also in patients who have comorbidities (7, 8). The reality is that time constraints prevent most primary care physicians from providing CBT-i, and it can be difficult to find other providers of CBT-i. Smart phone apps have the potential to fill this need for non-pharmacological treatment of insomnia. They have the potential to reduce medication use and to produce better long term outcomes for this ubiquitous problem.
We selected five apps for clinical review. Two of the apps were built using the principles of Cognitive Behavioural Therapy for Insomnia, providing education, relaxation exercises and allowing users to track and monitor their sleep. The other three apps are more limited in their scope, simply meant to be used to help calm the mind using various relaxation techniques.
This app was co-developed by the United States Department of Defense, Stanford University and the VHA National Centre for Post-Traumatic Stress Disorder as a tool for veterans struggling with insomnia. Although it has some recommendations specific to veterans (such as locking up or unloading weapons before sleep) it is generally suitable for use by the general population. It is meant to be used by those taking part in a face-to-face CBT-i course, but it may also be useful for patients who are only receiving brief counselling from their primary care provider. It includes a sleep diary with graphs to track progress and audio resources to help quiet the mind. Although its look is somewhat dated, it is free and based on evidence-based principles of CBT-I, making it a good option for many patients.
The app delivers CBT-i education in a text-only format. It includes suggestions on how to wind down and audio exercises to help quiet the mind. It includes a sleep diary and displays graphs of the information recorded to track insomnia symptom changes. Although it has some great features, it is not sufficiently comprehensive to be used as a stand-alone intervention.
The application is designed around the principles of CBT-i, which is the recommended treatment for chronic insomnia in Canadian and international guidelines. A randomized controlled pilot study has been published on the tool for patients also receiving face-to-face CBT-i. Although participants who used the app found it helpful, there was no statistical difference in adherence or outcomes in the group using the app compared to the group only receiving face-to-face therapy.
The app appearance is dated, likely because it was released in 2013 and has had only minor updates since. However, it is easy to learn and logical to use. The app uses graphs to display information from the user’s sleep diary which participants in the randomized controlled study found to be very helpful.
Privacy & Security+-
The app allows you to export non-encrypted user data to e-mail. A privacy warning notifies the user that this should only be sent to your own personal secure account and not to your healthcare provider. Since this is intended as a tool to augment face-to-face sessions with a healthcare provider, an option to communicate data securely would increase functionality. App settings give the option to provide anonymous usage data to improve the app but the default setting is not to provide this data. A privacy statement was not found for the app.
The app was fast and did not crash during testing. Error checking is used on data entry and does not allow users to enter data for future dates. The app has had two minor updates since its introduction in 2013.
The app is free and is available in both the Android and Apple app stores. The language used in the app is generally simple and understandable. Although it was developed for US veterans and has some specific recommendations for this population, it is still well-suited for a more general target audience.
Deep Sleep with Andrew Johnson
The app is essentially an envelope for distribution of two relaxation recordings created by Andrew Johnson. Johnson claims on his website that his recordings combine various techniques including relaxation therapy, stress management, clinical hypnotherapy, meditation and mindfulness. The recordings do come across as a hybrid of relaxation suggestions and meditation but it is unclear whether this hybridization increases or decreases their effectiveness. The app may be useful for patients with periodic acute insomnia and could be used as part of a comprehensive approach to chronic insomnia. However its scope is too limited for most patients suffering from chronic insomnia.
The app is fairly basic in its features and is more or less an envelope of distribution of two relaxation-for-sleep recordings. There is background music to the voice track but the user does not have the option to adjust or remove it. The recordings can be repeated or looped but that is the extent of the functionality. There are no tools to track or monitor sleep data. Similarly, the app does not contain any education tools on insomnia treatment.
Although the recording uses some meditation and mindfulness approaches that have been shown to be helpful, it also incorporates other relaxation techniques and it is unclear how these impact effectiveness. No research data could be found on the app or the recordings used in the app. It is unlikely that listening to the meditations alone would be helpful to those with chronic insomnia without additional support and education.
The app is generally friendly for all users. When you open the app there is a ‘begin’ button that then takes you to a screen where you can personalize the listening experience and a large Play button for when you are ready to begin. Most users should be able to get started using the app very quickly.
Privacy & Security+-
The app has not been updated since 2014 but this does not seem to pose a problem to its reliability. It works quite well for what it is and did not malfunction or crash during testing.
The app is $3.99 and is available in both the Android and Apple app stores.
A widely-used app with generally positive user reviews and testimonials. The company states that the app combines neuro-linguistic programming, enchanting music, sound effects and binaural beats with the goal of helping users achieve a more relaxed state and help them fall asleep. Neuro-linguistic programming is thought by many to be a pseudoscience and the evidence of the app’s effectiveness is limited to the anecdotal reports of users. The app uses an algorithm to create a slightly different soundtrack with each use. The company claims this is more effective for the subconscious than a fixed track. They do not however present any data to back up this claim. As a free app with positive user reviews, it could be an option for patients with occasional acute insomnia. It is doubtful however that it could make any meaningful difference for patients with chronic insomnia.
The app focuses exclusively on creating a relaxation track for the user to help them relax and sleep. The app does not offer a sleep diary for monitoring progress or education resources on sleep disorders. It has the potential to be useful for patients suffering from periodic acute insomnia but is unlikely robust enough for patients with chronic insomnia.
The app reports a large number of users and has generally positive reviews and testimonials. The company does not provide any research to the effectiveness of the app. Most importantly, research into the effectiveness of neuro-linguistic programming has failed to show that it is an effective practice suggesting the content of the voice track is not likely useful.
The app has a simple user interface that allows a user to open the app and get started with a default session with one-click. A few audio settings can be adjusted before starting the track but they unfortunately cannot be adjusted once you are listening to a track. There is an in-app tutorial explaining how to use features of the app.
Privacy & Security+-
Although no privacy statement could be found, the app does not collect any user data and privacy/security are unlikely to be of concern.
The app worked well in testing and never crashed. It has frequent updates, including five in 2016.
The app is free and is available in both the Android and Apple app stores. The language used in the app is simple and would be easy to understand for most users.
Relax & Rest Guided Meditation
A simple yet useful app that contains three meditations of various lengths (5, 13 and 24 minutes) to help users calm their minds and rest with the goal of falling asleep. Meditation has been shown to help in insomnia and is recommended in insomnia guidelines to be included as part of management. This app may be useful on its own for patients with acute insomnia or as a tool in the management of patients with chronic insomnia.
The app contains three guided meditations for rest and sleep but is otherwise limited in its scope in addressing many of the underlying issues in chronic insomnia. It does not offer a sleep diary for monitoring progress or education resources on sleep disorders. It however could be useful for individuals with periodic acute insomnia or as part of a comprehensive approach to chronic insomnia.
Meditation can be very helpful in the treatment of acute and chronic insomnia and it is reasonable to assume that the three meditations in this app would be of benefit to users. The company, however, does not present any data to back their claim of effectiveness. It is also unlikely that listening to the meditations alone would be helpful to those with chronic insomnia without further support and education from their healthcare provider.
The app has a very simple user interface that allows users to get started with one of three meditations right away and adjust volumes of voice and background music to their preference after the track has already started. Most users should find it very easy to use without instruction.
Privacy & Security+-
The app has a privacy statement that they do not collect any user information or location information. Privacy and security are unlikely to be of concern when using this app.
The app has not been updated since 2014 but this does not seem to pose a problem to its reliability. It works well and did not malfunction or crash during testing.
The app is $2.79 and is available in both the Android and Apple app stores. The app is simple and accessible for most users.
This app was co-developed by University of Oxford sleep medicine professor Dr. Colin Espie to distribute evidence-based CBT-i in a media-rich app and web application. Starting with the Sleepio app, the company strives to revolutionize healthcare by using technology to deliver proven behavioural therapies. The app offers custom tailored education sessions with an animated virtual sleep expert. It provides a sleep diary with the option of sharing data directly from your fitness tracker. It also offers meditation and mindfulness audio programs, an online community and the option of connecting with your healthcare provider. The downside of the app is its high cost – $300 US for a 12-month subscription – putting it out of reach for many patients suffering with insomnia.
The core of the program is a series of weekly Cognitive Behavioural Therapy for Insomnia educational sessions presented by a virtual animated sleep expert, The Prof. The educational sessions are tailored to the individual user and their sleep problems using data collected by questionnaire on sleep habits as well as data entered into a daily sleep dairy. It can also pull sleep data directly from integrated devices such as the Jawbone or Fitbit fitness band. Users are supported through an online community and there is an option for their healthcare provider to register and share information. Finally, the app includes audio-based meditation and mindfulness techniques to help users relax their mind for sleep.
The Sleepio program was co-developed by a University of Oxford sleep medicine professor and takes the rare step for a medical app of validating the program with a placebo-controlled randomized controlled study. The app was found to help around 75% of people with persistent sleep problems to improve their sleep to healthy levels, as compared with the placebo and no treatment groups. Sleepio users rated their quality of sleep as having more than doubled (115%) and their energy and daytime wellbeing levels increased 58%. The app is based on Cognitive Behaviour Therapy for Insomnia which is the treatment of choice in Canadian and International insomnia guidelines.
The app has a clean, friendly and inviting interface. It is intuitive to use, allows quick entry of sleep data with reminders and the option to share data from fitness devices such as the Jawbone or Fitbit fitness band.
Privacy & Security+-
Error checking is used on data entry for the sleep diary to ensure plausible data is entered. The app has frequent updates and the company appears to be responsive to inquiries. The app also has an online community.
The app costs $300 US for a 12-month subscription which unfortunately makes it out of reach for many patients who would benefit from its use. The company offers a 14 day money back guarantee for any reason which makes it easier to recommend to patients. The program is likely lower cost than most face-to-face CBT-i programs, but less likely to be covered by third-party insurance. The language of the app is easy to understand for most users.
What Experts Say
Watch our interview with leading specialist Dr. Davidson regarding Insomnia.
‘Not sleeping properly is not taken seriously in the scale of things, okay so if you’ve got a heart condition, or you’ve got cancer that is serious and the doctor will give you 10 minutes; you go tell him you can’t sleep and he’ll give you half a minute.’
‘Well it started when I reached 50 but it would seem once you turn 70 they breathe a sigh of relief and say, “Age-related”.’
‘He didn’t ask me lots of questions, I just told him I was having problems sleeping, is there anything you can do; he said, “I can prescribe you tablets but the tablets are addictive”; that’s all, he never went through anything with me.’
‘Well the first thing he said was, “Are you worried about anything?”. I said “No”; he said, “Do you have money worries, marital worries? No worries?” No. The only worry I had was the fact that I couldn’t sleep.’
Insomnia patients who participated in ‘Patients’ and clinicians’ experiences of consultations in primary care for sleep problems and insomnia: a focus group study’, published in the British Journal of General Practice, 2010.
The study, which reports that one-third of UK patients suffer from insomnia, found that patients initially tried to resolve insomnia themselves; consulting was often a last resort. They felt they needed to convince practitioners that their sleep difficulties were serious. They described insomnia in terms of the impact it was having on their life, whereas clinicians tended to focus on underlying causes. By the time patients consulted, many expected a prescription. Clinicians often assumed this was what patients wanted and felt this would hamper patients’ ability to take non-drug treatments seriously.
- Morin CM, LeBlanc M, Belanger L, Ivers H, Merette C, Savard J. Prevalence of insomnia and its treatment in Canada. Canadian journal of psychiatry Revue canadienne de psychiatrie. 2011;56(9):540-8.
- Morin CM, LeBlanc M, Daley M, Gregoire JP, Merette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep medicine. 2006;7(2):123-30.
- Taylor DJ, Lichstein KL, Durrence HH. Insomnia as a health risk factor. Behavioral sleep medicine. 2003;1(4):227-47.
- Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, et al. Manifestations and Management of Chronic Insomnia in Adults: Summary. 2005.
- Hayward RA, Jordan KP, Croft P. The relationship of primary health care use with persistence of insomnia: a prospective cohort study. BMC family practice. 2012;13:8.
- Group TOPTI. Assessment to Management of Adult Insomnia: Clinical Practice Guideline 2015 Available from: http://www.topalbertadoctors.org.
- Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep. 2006;29(11):1398-414.
- Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clinical psychology review. 2005;25(5):559-92.