Online CBT for Insomnia: Using the Internet to Get Some “SHUTi”

Research continues to show that online cognitive behavioral therapy may be an effective treatment for adults with ongoing insomnia.

A new study involved 44 people with an average age of 45 years. They had struggled with insomnia for an average of more than 10 years; most of the participants were women.

Half of the group was put on a wait list as a control; the other half completed a nine-week, online CBT program called “Sleep Healthy Using the Internet” – or SHUTi.

Results show that insomnia severity improved significantly for the Internet group; there was only a slight improvement for the control group. Members of the treatment group spent less time awake during the night. Their sleep also was more efficient; a higher percentage of their total time in bed was spent sleeping.

The online treatment also had a long-lasting effect; members of the Internet group were still sleeping better at a six-month follow-up.

SHUTi was developed at the University of Virginia Health System. The lead author of the new study was SHUTi creator Lee Ritterband, PhD. He also is the co-founder of the International Society for Research on Internet Interventions.

The AP reports that SHUTi is highly interactive; it uses stories, quizzes and games to teach healthy sleep habits. It also gives personalized advice based on a completed sleep diary.

The content is divided into core units that focus on specific methods for improving sleep. These include sleep restriction, stimulus control, sleep hygiene, cognitive restructuring and relapse prevention.

These methods are based on traditional, face-to-face CBT. The AASM recommends CBT as an effective treatment for chronic insomnia in adults.

In June the Sleep Education Blog reported on a study of another online CBT program. The five-week program helped most people in the treatment group; 81 percent reported at least mild improvement in their sleep.

Contact an AASM-accredited sleep center near you for help with insomnia.

Bedwetting & Obstructive Sleep Apnea in Children

A new study shows that “nocturnal enuresis” – bedwetting – is common in children with obstructive sleep apnea.

The study involved 149 children with some degree of sleep apnea – from minimal to severe. They were compared with 139 children in a control group. All children were between 5 and 15 years of age.

Results show that 80 percent of children with a bedwetting problem had some degree of sleep apnea. Children with a bedwetting problem were five times more likely to have sleep apnea.

Typically bedwetting is considered to be a problem if it persists beyond 5 years of age. Bedwetting can occur at any age when it is caused by another problem such as sleep apnea.

The study also found a link between a child’s weight and sleep apnea. Children who were overweight were four times more likely to have sleep apnea.

About two percent of young children have sleep apnea. In June the Sleep Education Blog reported that the causes of sleep apnea in children are complex.

Sleep apnea often occurs when a child has large tonsils and adenoids. But weight and nasal problems also can play a role.

Most children with sleep apnea have a history of snoring. It tends to be loud and may include obvious pauses in breathing and gasps for breath.

In addition to snoring and bedwetting, these are other warning signs that your child may have sleep apnea:

- A rib cage that moves inward as the child inhales
- Body movements and arousals from sleep
- Sweating during sleep
- Sleeping with the neck overextended
- Excessive daytime sleepiness
- Hyperactivity or aggressive behavior
- A slow rate of growth
- Morning headaches

Your child can get help for sleep apnea at an AASM-accredited sleep center near you.

Sleep Duration & Risk of Death

The AASM reports that most adults need about seven to eight hours of nightly sleep to feel alert and well rested during the day. But is it dangerous if you regularly get less sleep or more sleep? Does “short sleep” or “long sleep” increase your risk of death?

A new study took a look at the evidence. The systematic review analyzed data from other studies. In each study sleep duration was measured by self-report.

Sixteen studies measured short sleep and mortality. The combined results show that having a short sleep duration was associated with a 10 percent increase in the risk of death.

Why? Other research offers possible explanations. Studies have linked short sleep to an increased risk of diabetes, obesity and hypertension.

What about long sleep duration? Seventeen studies reported data on long sleep duration and mortality. The risk of death for long sleepers was increased by 23 percent; their risk of cardiovascular-related death was increased by 38 percent.

A 2008 study in the journal Sleep suggested a possible explanation for this relationship. The study involved 9,789 U.S. adults between 32 and 86 years of age.

There was no link between sleep duration and mortality in middle-aged adults between the ages of 32 and 59. But in elderly adults between 60 and 86 years of age, both short sleep and long sleep were associated with an increased risk of death.

The mortality risk was increased by 27 percent in elderly adults who reported that they usually sleep five hours or less; the risk was increased by 36 percent in older adults who reported sleeping nine hours or more.

“The relationship between sleep duration and mortality is largely influenced by deaths in elderly subjects,” the authors concluded. “Long sleep duration is unlikely to contribute toward mortality.”

Brain Activity & Muscle Force in Morning and Evening Types

A new study measured changes in brain activity and muscle force from morning to night in morning and evening types.

The study involved 18 people. Nine were “evening types” who prefer to stay up late at night and sleep late in the morning; nine were “morning types” who prefer to go to bed early and wake up early. Data were collected four times in one day: at 9 a.m., 1 p.m., 5 p.m. and 9 p.m.



Results show a difference in brain activity between the two groups. In morning types their “cortical excitability” was highest at 9 a.m.; this level decreased throughout the day. The brain activity of evening types was highest at 9 p.m.

The study also tested reflex response and maximum muscle force. Reflex response was tested using spinal-cord stimulation; muscle force was measured by maximum contractions of the calf muscle.

Evening types became physically stronger during the day. Their reflex response improved and their muscle torque increased.

For morning types the results were mixed. Their reflex response improved throughout the day; but there was no change in the muscle force that they generated.

"We are suggesting that morning people may never reach their true maximum performance,” study co-author Dave Collins said in a University of Alberta article. “Their brain [activity] is going one way and their spinal cord activity is going the other, so it's offsetting. In evening people, both brain and spinal cord are at maximum in the evening, and they get maximum performance at night."

The authors suggest that these results may have implications for people who perform shift work.

Another recent study found that both morning and evening types performed well when tested 1.5 hours after waking. But the evening types pulled ahead when both groups were tested after being awake for 10.5 hours. They were more alert and had faster reaction times.

Learn more about chronotypes on the Sleep Education Blog.

Michael Jackson’s Struggle with Insomnia

The Associated Press reports today that Michael Jackson struggled with severe and chronic insomnia. A nurse told the AP that he wanted to obtain the drug propofol - also known as Diprivan - to help him sleep.

Diprivan is a powerful sedative that is injected into a vein. It is given to patients before an operation or medical test.



Jackson’s insomnia may have had a variety of causes.

The AP reports that the 50-year-old singer was rehearsing hard for his upcoming “This Is It” tour. This may have caused adjustment insomnia. This type of insomnia results from a source of stress.

His concern about being unable to sleep may have developed into psychophysiological insomnia. People with this sleep disorder worry too much about insomnia and about being tired the next day. As a result, they learn to become tense and anxious as bedtime approaches.

The AP article notes that Jackson would sleep with a computer on the bed. This is a sign that he may have developed bad habits that prevented him from sleeping well. This is called inadequate sleep hygiene.

The AP also reports that Jackson often was in pain. Painful medical problems often cause insomnia due to medical condition.

Jackson may have been taking a variety of prescription medications. Many medications can suppress or disrupt sleep. Insomnia due to drug or substance may result.

His insomnia also may have been related to a mental health problem. The AASM reports that insomnia due to mental disorder is the most common disorder in people who seek help from a sleep center for ongoing insomnia. Often it is related to depression or anxiety.

Do you struggle with insomnia? You can get help at an AASM-accredited sleep center near you.

Update - July 28, 2009: The AP reported today that authorities believe the drug propofol caused Jackson's heart to stop.

Update - Aug. 6, 2009: The Wall Street Journal reports that the abuse of propofol is a growing problem among medical professionals.

Update - Aug. 29, 2009: The AP reports that the Los Angeles County coroner's office determined the cause of death was "acute propofol intoxication."

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