Sleep disruption is a common complaint during pregnancy, with 15% to 80% of women reporting sleep problems during the first trimester and 66% to 97% of women in the third trimester.  There are data to support the safety of certain sleep-promoting medications during pregnancy, including benzodiazepines and sedative-hypnotic agents (Z-drugs); however, many women would prefer to avoid the use of medications during pregnancy, if possible.  

Cognitive-behavioral therapy (CBT-I) specifically designed for insomnia may be a useful adjunct or alternative to medication.  In a recent study, Manber and colleagues demonstrated that CBT-I was effective in a group of pregnant women with insomnia.  

So why don’t we refer all women with insomnia for CBT-I?  It can be challenging, even in metropolitan, medically well-endowed cities like Boston, to find providers with expertise in this modality of treatment, and there are many other places in the United States which have much worse access to mental health services.  

So what can we offer to women who would like CBT for insomnia?

A recent study from Felder and colleagues pilots the use of digitally delivered CBT for pregnant women with insomnia.  In this randomized controlled trial, pregnant women  up to 28 weeks’ gestation were assessed using an online self-report questionnaire, and 208 women reporting insomnia were randomized to receive digital CBT-I (n?=?105) or to treatment as usual (n?=?103) for insomnia. 

Women with acute depressive symptoms, as defined as a score of 15 or greater on the Edinburgh Postnatal Depression Scale (EPDS) scale, active suicidality, self-reported bipolar disorder or psychosis were excluded. 

Women randomized to digital CBT-I received six weekly sessions of approximately 20 minutes each. The digital CBT-I program, Sleepio (Big Health), could be accessed via website or iOS app and included 5 main components: sleep restriction, stimulus control, cognitive therapy, relaxation techniques, and sleep hygiene education. Participants also had access to a moderated online community and a library of sleep information.  

Women receiving treatment as usual had no limits placed on the use of non-study treatments, including medication and psychotherapy.

The 208 participants in this study had a mean age of 33.6 years and a mean gestational age of 17.6 weeks at baseline. Most of the participants were white (66.3%), married or cohabiting (94.2%), had a college degree (86.5%), and earned $100?000 or more per year (67.8%). 

Participants were assessed at 10 weeks after randomization (post-intervention) and at 18 weeks after randomization (follow-up).  Compared to women receiving standard care, women randomized to receive digital CBT-I experienced statistically significantly greater improvements in insomnia symptom severity, sleep efficiency, and global sleep quality. The magnitude of the effect size was large.  In addition, women receiving the CBT-I intervention experienced greater improvements in depressive symptoms and anxiety than women receiving standard care. The benefit of CBT-I treatment was maintained at the follow-up visit, which took place approximately 18 weeks after entry into the study. 

Some remaining questions about CBT-I

This is the first study to use a digital form of CBT-I in pregnant women with insomnia, and it has demonstrated that digital CBT-I may be an effective and practical approach to managing women with insomnia during pregnancy.  It is also exciting to see that CBT-I treatment was associated with improvements in depressive symptoms and anxiety.

Which women are most likely to benefit from this intervention? This study was carried out in a very homogeneous group of white, wealthy, married women.  Further studies are needed to make sure that this intervention is effective in more diverse populations.  

Does digital CBT-I work for women who also suffer from depression or anxiety? Most studies of CBT-I, including this one, exclude participants with acute depressive symptoms or anxiety, thus we cannot conclude that this intervention would be as effective in women who have comorbid depression or anxiety.  Especially in patients with more severe symptoms of depression and anxiety, effective treatment might include CBT-I while at the same time using other treatment strategies 

Can CBT-I be used to prevent perinatal depression? Many studies suggest that sleep disruption during pregnancy can contribute to or may be one of the earliest symptoms of perinatal depression.  There is also evidence to indicate that treating insomnia during pregnancy may decrease the risk of depression during the postpartum period.  Could CBT-I be used in this setting to protect against depression?

How do I get the app? You can access the Sleepio digital CBT-I platform online; however, it is not clear how to subscribe and for what cost. However, it is available for free to persons participating in research studies and those whose employers pay for a subscription.  According to tuck.com, an online source evidence-based sleep health information, there are other CBT-I programs out there but many of them have a pretty hefty price tag.  Some of them have been tested in clinical trials, others have not. CBT-I Coach, put out by the Veterans Administration, is free and has been tested in clinical trials, although it is not as pretty as the others.  

 

Ruta Nonacs, MD PhD

Felder JN, Epel ES, Neuhaus J, Krystal AD, Prather AA.  Efficacy of Digital Cognitive Behavioral Therapy for the Treatment of Insomnia Symptoms Among Pregnant Women: A Randomized Clinical Trial.  AMA Psychiatry. 2020 Jan 22.