Ritterband LM, Bailey ET, Thorndike FP, Lord HR, Farrell-Carnahan L, Baum LD. (2012). Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. Psycho-oncology, 21 , 695-705.
Designed to enhance the quality of life for cancer survivors with insomnia, this internet-based intervention includes interactive modules that describe insomnia and sleep, sleep behaviors to regulate the sleep-wake cycle, cognitive restructuring to change thoughts about sleep, and problem prevention; a daily sleep diary; and goal-setting exercises. The study showed increases in sleep efficiency, soundness of sleep, and feeling refreshed upon awakening and decreases in sleep onset latency, insomnia severity, and various measures of fatigue.
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Insomnia is the most common sleep disturbance in cancer patients. In this population, insomnia is most often secondary to physical or psychological factors, such as anxiety and depression, associated with cancer diagnosis or treatment. Cognitive behavioral therapy for insomnia (CBT-I) has been found to be as effective as prescription medications for short-term treatment of insomnia and to produce longer-lasting effects compared with medications. Data evaluating CBT-I in cancer survivors are limited and primarily specific to women with breast cancer.
Sleep Healthy Using the Internet (SHUTi) is an interactive, Internet-based CBT-I intervention designed to improve the sleep of adults with insomnia. Initially tested in a sample of adults with primary insomnia (DSM-IV-TR criteria), SHUTi has also been evaluated in adult cancer survivors with insomnia. Completed over 6-9 weeks, SHUTi includes six interactive "cores", each of which take 45-60 minutes to complete:
-- Core 1: Overview. The first core defines insomnia, discusses its impact and associated risk factors, and introduces the participant to SHUTi, explaining the rationale for its effectiveness in treating insomnia.
-- Core 2: Sleep Behavior 1. This core provides a set of rules to regulate the sleep-wake schedule and strengthen the association between the bed/bedroom/bedtime and sleep through sleep restriction and stimulus control practices. Sleep restriction involves limiting time spent in bed to the actual amount of sleep (i.e., sleep window) to strengthen the homeostatic sleep drive and increase sleep efficiency. Stimulus control practices include going to bed only when sleepy; getting out of bed when unable to sleep and returning to bed only when sleep is imminent; curtailing sleep-incompatible activities in the bedroom (e.g., reading, problem solving, watching television); avoiding daytime napping; and arising at the same hour every day.
-- Core 3: Sleep Behavior 2. This second behavioral core reinforces sleep restriction and stimulus control practices introduced in the first core and reiterates the set of rules to regulate the sleep-wake schedule and strengthen the association between the bed/bedroom/bedtime and sleep, first introduced in Sleep Behavior 1.
-- Core 4: Sleep Education. This module provides educational information about sleep and good sleep hygiene practices, such as increasing daily physical exercise and avoiding consumption of a large meal, nicotine, caffeine, and alcohol before bedtime.
-- Core 5: Sleep Thoughts. Core 5 centers on cognitive restructuring and attempts to help participants address and change unhelpful beliefs and thoughts about sleep (e.g., the belief that one must obtain 8 hours of sleep nightly, excessive worry about the consequences of not getting enough sleep).
-- Core 6: Problem Prevention. This core is designed to promote adherence to the behavioral, cognitive, and educational components of SHUTi, identify potential risk situations, and incorporate strategies to prevent insomnia relapse.
Each core includes a variety of interactive features, such as animations, vignettes, "myth" and "reality" buttons that reveal common misperceptions and facts about sleep, "learn more" buttons that provide in-depth information about a topic, and quizzes. All cores follow a similar structure with objectives, main content, homework, and review. Participants are free to revisit cores as many times as they like.
Upon logging in to SHUTi, participants are presented with a personalized home page that reflects their progress through the intervention. A new participant will see a welcome page and instructions about beginning the intervention; a participant who is further along will see information about completing the next treatment assignment. Participants progress through each SHUTi core sequentially, with each new core becoming available 1 week after completion of the previous core. Automated emails notify participants when a new core is available and follow up with participants if a login is not recorded within a specified period of time.
Feedback and individual tailoring of SHUTi is provided based on information entered by participants in an online daily sleep diary. The sleep diary consists of 10 questions that ask the participant to estimate various characteristics of the previous night's sleep, such as the hour of bedtime, minutes to fall asleep, number of nighttime awakenings, duration of nighttime awakenings, hour of awakening in the morning, and a description of any sleep aids used. In addition, two questions are rated on a five-point scale: (1) How exhausted/refreshed did you feel upon awakening? and (2) How restless/sound was your sleep?
Participants are prompted at each login and through email reminders to enter sleep diary data each day. The program algorithm uses the sleep diary data to individually tailor sleep restriction schedules throughout the intervention. Additional email reminders to enter sleep diary data are sent to participants if a specified period of time has elapsed since the last logoff. Participants are required to complete at least five out of seven sleep diaries before accessing the initial Overview core to ensure that the first sleep window is based on an adequate amount of data. After the Overview core, if participants complete fewer than five sleep diary entries in a given week, they can progress to the next core but are not given a new sleep restriction schedule.
Additional SHUTi personalization occurs through goal-setting exercises. For example, participants are asked to set specific targets for different aspects of their sleep at the beginning of the intervention, which they re-evaluate at the end of the intervention. SHUTi participants are also given the opportunity to set longer-term goals using the knowledge, skills, and new cognitions acquired while progressing through the intervention.
The intervention requires 45-60 minutes per week over 6-9 weeks.
The intervention targets adults with insomnia. It has been tested with adult cancer survivors, aged 21 years or older, with insomnia.
The intervention is a web-based online program that can be accessed from any location with Internet access, such as a participant's home.
Materials required for implementation include:
-- SHUTi website
For costs associated with this program, please contact: Frances Thorndike. (See products page on the RTIPs website for contact information).
About the Study
A randomized clinical trial evaluated the effects of SHUTi on insomnia symptoms and perceived sleep in 28 adult cancer survivors with a diagnosis of chronic insomnia (DSM-IV-TR criteria). Study participants were assigned to the intervention group or a wait-list control group. Volunteer participants were recruited from a university-based cancer center and the surrounding community using flyers, local newspapers, online postings, notices in the cancer center's newsletters, and letters sent directly to patients of the cancer center's physicians.
On average, participants were 56.7 years of age and had completed 17 years of education; the majority were female (85.7%), married (79%), and White (93%). Most participants had an original diagnosis of Stage I (46%) or Stage II (21%) cancer, with almost 4 years since the completion of active treatment at study entry. On average, participants reported experiencing sleep difficulties for more than 6 years and were experiencing disrupted sleep on more than 5 nights per week at study entry.
Outcome data were collected using 2 weeks of daily sleep diary entries before and after the intervention and two questionnaires completed before and after the intervention. The sleep diary and questionnaires were completed online. The questionnaires included the Insomnia Severity Index (ISI) and the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). The ISI is a 7-item, self-report index of subjective sleep difficulty. The index uses a 5-point Likert scale to rate difficulty with sleep onset, sleep maintenance, early morning awakenings, interference with daytime functioning, how noticeable sleep problems are to others, distress caused by sleep difficulties, and overall sleep satisfaction. Total scores range from 0 to 28, with higher scores indicating greater insomnia severity. The MFSI-SF is a 30-item, self-report instrument that measures fatigue in the past week. It includes four Fatigue subscales (General Fatigue, Physical Fatigue, Emotional Fatigue, Mental Fatigue) and one Vigor subscale. Each subscale has 6 items rated on a scale of 0 to 4, with scores ranging from 0 to 24 (higher scores indicating greater fatigue or vigor). A total Fatigue score (0-96) is calculated by summing the Fatigue subscale scores.
Significant group differences were found at baseline for sex and for cancer type. Females accounted for 86% of the sample, and the four male participants were all randomized to the control condition; 93% of the intervention participants had a breast cancer diagnosis, compared with 36% of the control group participants. Participants in both groups were also comfortable using the Internet.
- From pre- to post-intervention, compared with control participants, intervention participants showed a greater increase in sleep efficiency percent (total sleep time by time in bed) (intervention: 72.2% to 85.7%; control: 75.6% to 79.8%, p<.01) and a greater reduction in sleep onset latencies (intervention: 48.42 to 19.88 minutes; control: 40.73 to 35.23 minutes, p=.03).
- From pre- to post-intervention, compared with control participants, intervention participants showed a greater increase in their sleep diary ratings of soundness of sleep (intervention: 2.55 to 3.38; control: 2.85 to 2.98, p<.01) and feeling refreshed upon awakening (intervention: 2.38 to 3.21; control: 2.82 to 2.91, p<.01).
- From pre- to post-intervention, compared with control participants, intervention participants had a greater decrease in ISI scores (intervention: 17.1 to 8.2; control: 15.9 to 14.4, p<.01).
- From pre- to post-intervention, compared with control participants, intervention participants had a greater decrease in both Total Fatigue (intervention: 22.86 to 9.50; control: 13.71 to 19.79, p<.01) and General Fatigue scores (intervention: 13.43 to 9.36; control: 9.93 to 11.14, p<.01).
- From pre- to post-intervention, compared with control participants, intervention participants had a greater decrease in Mental Fatigue scores (intervention: 7.43 to 5.29; control: 4.79 to 5.64, p<.01) and a greater increase in Vigor scores (intervention: 8.50 to 12.71; control: 11.36 to 9.86, p<.01).
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