Abstract
One of the fundamental purposes of sleep is to repair or reverse the effects of wakefulness on the body and the brain. Without regular and sufficient sleep, the wear and tear on our physiology accumulates. This can result in short-term consequences as well as longer term health risks. It’s a common refrain that modern day life is impinging on our ability to get adequate sleep. Indeed, with seemingly unlimited access to digital technology, the importance of sleep seems to have become further marginalized. Sleep deprivation and sleep disorders have profound health and economic costs. In 2016, CDC asserted that sleep deprivation had become an epidemic in the United States. 1 Sleep deprivation is also highly prevalent among the adult populations of many developed nations. 2
Impact on Health and Performance
Individuals experiencing sleep deprivation are more likely to suffer from chronic diseases such as obesity, diabetes, hypertension, and depression, as well as cancer, increased mortality, and reduced quality of life and productivity. 3 Regularly sleeping less than 5 hours each night increases the chance of death, from all causes, by about 15%. 4 Even modest sleep deprivation has a negative impact on mood, cognitive performance, and motor function. 5 –7
A common cause of sleep deprivation is insomnia, which is a sleep disorder characterized by difficulty falling asleep, staying asleep, awakening too early in the morning, or feeling generally unrefreshed the next day. Insomnia occurring at least 3 days a week for at least 3 months is considered to be chronic. Surveys of the general US population suggest that as many as 20% of adults experience chronic insomnia within a given year. 8 Insomnia also tends to affect women more than men and increases with age. 2 Employees found to be at risk for a sleep disorder were more likely to report difficulty with concentration, problems with organization, impatience with others, avoiding interactions with coworkers, boredom, decreased productivity, absenteeism, and falling asleep at work. 9
In contrast to insomnia, where sleep debt can accumulate in spite of sufficient opportunity for sleep, sleep deprivation can also occur when an insufficient amount of time is allotted for sleep. This type of sleep deprivation is called “insufficient sleep syndrome.” In this case, sleep deprivation is voluntary but not necessarily intentional. Lifestyle or other situational influences prevent the individual from obtaining enough opportunity for sleep. 10
From a mental health standpoint, sleep deprivation and disorders such as insomnia have been associated with mood disorders, most notably anxiety and depression. 11 Evidence suggests that insomnia is a risk factor for the development of depression, while anxiety tends to precede insomnia. 12 Nighttime anxiety about not sleeping can also become a major perpetuating factor for chronic insomnia, thereby establishing a vicious cycle.
Treatment Options
Cognitive behavioral therapy (CBT) is a multicomponent, nonpharmacological approach to the treatment of numerous causes of sleep deprivation. It is based on behavior modification and cognitive therapy. It is well validated and has gained increasing popularity. The core elements of CBT for insomnia are stimulus control, sleep compression, relaxation, cognitive therapy, and sleep hygiene. For chronic insomnia, CBT has been shown, in a number of randomized, controlled studies, to be highly effective, and moreover, it has been shown to have better long-term effectiveness than prescription sleep medication. 13 –15 Cognitive behavioral therapy is effective at reducing time to fall asleep and reducing time spent awake during the night. The duration of CBT typically ranges between 4 and 8 weeks.
Online CBT
Traditionally, CBT has been conducted in person with a qualified provider. Until recently, this produced a bottleneck in treatment delivery as there are a limited number of CBT specialists in the United States. With the advent of Internet and mobile technology, CBT has been increasingly delivered online. A number of online CBT programs such as SHUTi and Sleepio are currently available. The effectiveness of these applications has been published in a number of recent studies. 16 –18 In addition, a recent study demonstrated that an online CBT program can improve sleep and performance in a workplace environment. 19
ProjectZ is a unique Internet-based CBT application designed by Optisom, LLC. Users initially answer a set of 30 to 40 screening questions. Many of them are drawn from validated sleep disorder inventories. In addition to identifying insomnia symptoms and offering a personalized CBT program, it also identifies the perpetuating factors operative for a particular user. Moreover, ProjectZ detects symptoms from a wide range of other sleep disorders such as Obstructive Sleep Apnea (OSA), circadian rhythm disorders, restless legs syndrome, and sleep deprivation. A CBT program is created to address the symptoms of those disorders and as appropriate, users are advised to seek medical attention to address issues such as elevated SA risk. For those without significant sleep issues, a program of education and appropriate sleep hygiene tips is offered. All of the users who complete the screener are provided with a program of relevant material.
ProjectZ is gamified and self-paced. The user is offered a personalized series of therapeutic modules, such as stimulus control or sleep compression, based on their responses and utilizing validated CBT principles. Each module is presented as a series of challenge cards, each with an associated point value. Challenges that are most important, requiring greater effort or longer time to complete, have higher point values. Point totals can also be tied to incentive campaigns. Completion of the program occurs when the user has completed all of the assigned modules or reaches 1000 points. Sleep diary data are used to customize modules dynamically throughout the duration of the user’s engagement with the application.
Case Study
We sought to determine whether offering ProjectZ to a diverse group of employees could result in reduced symptoms of excessive daytime sleepiness and sleep deprivation. A pilot program utilizing ProjectZ was conducted with 5 employer groups: MetLife Inc, Hyatt Hotels Inc, Omaha Public Power District, Morrison Healthcare, and Manatee YourChoice Health Plan. Eligible employees were least 18 years of age and were either working full time or part time. ProjectZ was promoted to employees using the employers preferred communication channels (e-mail, newsletters, posters, on-site orientations, etc) and was also cross-promoted with their existing wellness/benefits programs. For employers with decentralized locations, a turnkey promotion and awareness campaign was provided which included educational content, marketing materials, and engaging sleep messages.
Outcome Measures
Sleep Deprivation Status and ESS
The Sleep Deprivation Status (SDS) of each employee was assessed. The SDS is a binary measure of subjective daytime impairment. The SDS score is based on user responses to 3 separate components of the screener. First, users were considered to have a “positive” SDS if their score on the ESS was ≥11. The Epworth is as common measure of daytime sleepiness that asks respondents to rate their chance of dozing in 8 commonplace situations and has a maximum score of 24. Scores higher than 10 are associated with at least mild sleepiness. The SDS was also deemed positive if a respondent endorsed “often” or “always” to either of the 2 additional questions which targeted (1) feelings of tiredness or fatigue or (2) the feeling that their sleep was negatively affecting their ability to function during the day. The SDS is deemed to be negative for employees for whom the ESS is <11 and both daytime impairment questions are answered in the negative.
Results
Screening Data
Among the 9380 eligible employees, 2126 (22.7%) employees completed the initial screening. Of the 2126 users who screened, 60.2% were female and the overall mean age was 43.5 years. Of those who screened, 335 (15.8%) completed ProjectZ and the post-CBT assessment and were used for pre/post comparisons of sleep deprivation. The mean BMI for both males and females was 29.9. The most common self-reported health conditions were anxiety (15.0%), hypertension (14.5%), and depression (10.2%). The percentage of employees with at least 1, 2, or 3 significant sleep issues was 75.6%, 50.5%, and 29.7%, respectively. Significant sleep issues included insomnia symptoms, increased risk for OSA, symptoms of sleep deprivation, restless legs symptoms, and circadian rhythm disorder symptoms. Of the employees who completed screening, approximately half (50.1%) had a positive SDS. A positive SDS was more common among women (53.5%) than men (45.0%). For the majority (56.9%), the cause of the positive SDS was a positive answer to one or both of the additional SDS questions. Of those with a positive SDS, the majority (56.3%) did not have significant insomnia symptoms.
Post-CBT End Point Findings
Of the 335 who completed the post-CBT assessment, 235 (70.2%) were female. The age range was 18 to 69 years, with a mean of 40.6 years. Mean BMI for males and females was 30.7 and 30.4, respectively. Nearly, 68.7% had at least 1 significant sleep issue at pre-CBT baseline, 43.9% had 2 or more sleep issues, and 25.7% had at least 3 major sleep issues. Median time to complete ProjectZ was 50.0 days (7.1 weeks).
At pre-CBT baseline, 46.9% of those who went on to reach the post-CBT assessment were classified as having a “positive” SDS. This percentage dropped to 12.2% by post-CBT assessment (χ2 =110.21; P < .0001), representing a 74.0% reduction in the prevalence of sleep deprivation symptoms. When scores on the ESS (range 0-24) were examined independently from the SDS, the average ESS score at pre-CBT baseline was 6.93. This was reduced to 4.48 at completion of the program (z = 12.93; P < .0001). Using a binary comparison of positive (a score of ≥11) versus negative scores on the Epworth, the percentage of employees positive at pre-CBT baseline (17.0%) was reduced to 3.9% by completion (χ2 = 34.24; P < .0001). This constituted a 77.2% reduction in such cases.
Conclusions
ProjectZ was highly effective at reducing symptoms of sleep deprivation and excessive daytime sleepiness in this pilot program. The magnitude of the impacts seen here is consistent with the positive effects others have reported for similar online CBT interventions for insomnia but also extends to individuals with other causes of sleep deprivation. Sleep deprivation is highly prevalent in the general population and in the workforce. The impact of poor sleep on health and daytime performance can be profound, resulting in long-term physical and mental health risks and associated costs. Work productivity and safety on the job may also be compromised. Online CBT platforms, such as ProjectZ, are a cost-effective delivery channel for practical nondrug strategies and sleep education to a diverse population of employees.