Monday, April 25, 2022

Tailoring Internet CBT for Insomnia to Black Women Found to Increase Therapy Engagement

Offering Black women with insomnia an online cognitive-behavioral therapy program that features Black sleep experts and acknowledges the contexts in which insomnia occurs for some Black women may increase their engagement with therapy and significantly improve sleep, reports a study in JAMA Psychiatry.

“These results showing that it is possible to adapt a proven intervention to significantly increase treatment engagement for a racial minority group are compelling,” wrote Eric S. Zhou, Ph.D., of Harvard Medical School and colleagues. “Improving participation with a treatment as challenging as CBT-I [cognitive-behavioral therapy for insomnia] is no small feat as it requires people to overhaul their sleep patterns, behaviors, and thoughts.”

To test the efficacy of the adapted CBT-I, Zhou and colleagues enrolled 333 Black women with insomnia disorder into a three-armed clinical trial. The average age of the participants was 59.5 years, and they were all participants in the national Black Women’s Health Study (BWHS). This is a study of 59,000 Black women that Boston University began in 1995.

One group of women had access to an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi). The SHUTi program is a six-session program (delivered over six to nine weeks) that incorporates the core elements of CBT-I, including relaxation exercises, avoiding activities in bed other than sleep, and reframing negative thoughts about sleep. The second group of women received an adapted version of SHUTi for Black women (SHUTi-BWHS); this therapy was developed by Zhou and colleagues in collaboration with stakeholders, including three Black women (a Black woman with a history of insomnia and two Black women with experience in clinical trials) as well as a sleep physician from a center that primarily treats racial and ethnic minority groups. The third group (control) was directed to a sleep website that included educational materials as well as basic strategies on improving sleep behavior.

Some adaptations to SHUTi for the SHUTi-BWHS program included replacing all visual content to feature only Black men and women; Black actors were used for patient vignettes, and videos featured Black women sleep physicians who served as the sleep experts in the program content.

After six months, the Black women who received either SHUTi or SHUTi-BWHS reported significantly greater reductions in insomnia (assessed with the Insomnia Severity Index, or ISI) compared with the control group. ISI scores dropped by 10.0 points in the SHUTi group, 9.3 points in the SHUTi-BWHS group, and 3.6 points in the control group. Women in the SHUTi-BWHS group were more likely to complete all six sessions compared with the SHUTi group (78.2% vs. 64.8%, respectively).

“Similar to prior SHUTi trials, there was a direct association between the participants’ level of intervention engagement and their improvement in sleep,” Zhou and colleagues wrote. “At the community level, the scale of public health improvement that is possible with a 13% increase in treatment engagement is immense, especially in a racial group that faces multiple barriers to treatment.”

To read more on this topic, see the American Journal of Psychiatry article “Using Insomnia as a Model for Optimizing Internet-Delivered Psychotherapy.”

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