Digital cognitive behavioral therapy (CBT) is an effective, scalable, safe, and acceptable intervention for improving insomnia symptoms in pregnant women at less than 28 weeks’ gestation, according to findings published in JAMA Psychiatry. The findings may be promising since anxiety and depressive symptoms improved alongside insomnia for the digital CBT intervention, which is highly scalable, low risk, and effective

Jennifer N. Felder, PhD, from the Osher Center for Integrative Medicine at the University of California, San Francisco, and colleagues conducted a randomized clinical trial to evaluate the effectiveness of digital CBT in 208 adult women (mean age, 33.6±3.7 years) who were pregnant for up to 28 weeks’ gestation and either reported elevated insomnia symptom severity or met the criteria for an insomnia disorder. Participants were randomized to receive either digital CBT (n=105) or standard treatment (n=103) for insomnia.

Digital CBT involved 6 weekly remote sessions (available via website or iOS app), each lasting approximately 20 minutes. This approach comprised sleep restriction, stimulus control, relaxation techniques, cognitive therapy, and sleep hygiene and education. Participants completed the Insomnia Severity Index at 10 weeks (postintervention) and 18 weeks (follow-up) after randomization; they used diaries to log their own sleep efficiency, duration, quality, and caseness. Women receiving standard treatment had no limits placed on the receipt of nonstudy treatments, including medication and psychotherapy.

A total of 68 women (64.8%) completed all 6 sessions. The mean gestational age was 17.6±6.3 weeks at baseline, and the majority of participants were white (66.3%) and married or cohabiting (94.2%). The sample also largely represented a high socioeconomic status, with 86.5% having a college degree and 67.8% earning $100,000 or more per year. Both groups experienced 3 adverse events each, mainly miscarriages.

Compared to women who received standard treatment, those who received digital CBT experienced greater improvements in insomnia symptom severity from baseline to postintervention (time-by-group interaction, difference = −0.36; 95% CI, −0.48 to −0.23; χ2 = 29.8; P <.001; d = −1.03). The digital CBT group had significantly higher remission rates as well (44.0% vs 22.3%; P =.002). Furthermore, alongside greater reductions in secondary sleep outcomes in the digital CBT group, participants in the experimental condition also experienced significantly reduced depressive (difference, -0.21; 95% CI, -0.30 to -0.11; P <.001) and anxiety (difference, -0.188; 95% CI, -0.26 to -0.10; P <.001) symptoms. Improvements from baseline to follow-up were similar to those from baseline to postintervention.

The study may be limited by the fact that participants were mostly wealthy, white, and highly educated; results may differ for patients from other backgrounds.

“Although more women randomized to receive digital CBT-I experienced remission in insomnia symptoms compared with those randomized to receive standard treatment, most women continued to experience at least subthreshold symptoms,” the investigators noted. The findings may be promising since anxiety and depressive symptoms improved alongside insomnia for the digital CBT intervention, which is highly scalable, low risk, and effective.

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NEWS BRIEF

What is the relationship between insomnia and anxiety during pregnancy? In the first prospective study of its kind, researchers found that mid-pregnancy insomnia may be a marker not only for concurrent anxiety but also may act as a predictor of postpartum anxiety.¹

In the study, which was part of the Norwegian Depression and Anxiety in the Perinatal Period (DAPP) study, 530 women received questionnaires during pregnancy week 17 (considered mid-pregnancy) and 8 weeks postpartum; the Bergen Insomnia Scale, Hopkins Symptom Checklist, and Mini-International Neuropsychiatric Interview were used to measure insomnia, anxiety, and obsessive-compulsive disorder symptoms, respectively. Most (97%) of the women were married; average age was 30.5. This was the first pregnancy for 38% of the women. A small percentage reported smoking (1.5%) and dipping tobacco use (1.4%) during pregnancy. At mid-pregnancy, 59.8% of the respondents reported insomnia.

About 12% of the women with insomnia reported a previous anxiety or related disorder, compared with 7% of their counterparts who had normal sleep during pregnancy. Similarly, 43% of the women with insomnia had previous depression, while 26% of the women with normal sleep reported previous depression.

After adjusting for potential confounders, Rannveig S Osnes, MD, and colleagues found a significant positive association (b = 0.01, p = 0.001) between mid-pregnancy insomnia and both concurrent and postpartum anxiety. However, mid-pregnancy insomnia was not more strongly associated with concurrent anxiety than postpartum anxiety, indicating it may be a predictor of postpartum anxiety. Women who reported insomnia also had higher levels of postpartum OCD symptoms than those participants who did not report sleeping difficulties.

Insomnia is a fairly common problem during pregnancy, with incidence increasing as pregnancy progresses. While incidence rates are close to 13% at the beginning of pregnancy, about 16% and 4% of women report moderate and severe insomnia, respectively, at a median of 39 weeks.² Similarly, research shows anxiety to be fairly common, with 1 in 5 women meeting criteria for at least one anxiety disorder and 1 in 20 meeting criteria for at least two anxiety disorders.³

Since overactive arousal systems are believed to be common in both insomnia and anxiety, the researchers noted negatively toned cognitive activity of insomnia might trigger arousal and distress, which in turn may lead to anxiety symptoms. They further hypothesized that cognitive behavioral therapy (CBT) for insomnia might improve or prevent perinatal anxiety. A recent study of digital CBT for pregnant women with insomnia confirms this hypothesis.⁴ In that study, researchers found digital CBT improved insomnia severity, sleep efficiency, global sleep quality, depressive symptoms, and anxiety symptoms.

Although further research is warranted, Osnes and colleagues¹ believe these results have great clinical implications. “Antenatal insomnia could be an important intervention target, and screening for insomnia during mid-pregnancy could be an efficient strategy for detecting women who are struggling with or at risk of developing anxiety, not least of all because reporting insomnia symptoms may feel less stigmatizing,” they concluded.

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In the past decade or so, it seems more and more celebrities are opening up about their “invisible” illnesses. These often debilitating conditions — such as depression, anxiety, inflammatory bowel disease, and more — are often overlooked because many sufferers appear to be okay on the outside. But in reality, they’re in intense pain — and often in silence. Which is why it’s so important when big names shed light on these invisible illnesses. And recently, Halsey opened up about learning she can have kids after being diagnosed with endometriosis.

But first, a bit of background information is needed. The “Nightmare” singer, 24, has remained open about having endometriosis through her years of fame. According to the National Institute of Health, in women with endometriosis, tissue similar to the lining of the uterus grows in other places of the body. In other words, this tissue builds up, sloughs off, and bleeds with your menstrual cycle — causing intense pain, irritation, cysts, and even fertility problems. Sounds pretty horrible, right? Unfortunately, 1 in 10 women suffer with the condition.

At one point, Halsey wasn’t sure if she’d ever be able to have children. But recently, she found out motherhood could very well be in the cards for her after all. Because of lifestyle changes and surgery, Halsey’s doctor informed her that egg freezing was no longer needed, according to E! Online. “I was like, ‘Wait, what did you just say? Did you just say I can have kids?” she told Rolling Stone. “It was like the reverse of finding out you have a terminal illness. I called my mom, crying.”

During an episode of The Doctors in April 2018, Halsey discussed her endometriosis story. “Doctors can tend to minimize the female experience when it comes to dealing with [endometriosis],” Halsey said, according to Billboard. “My whole life, my mother had always told me, ‘Women in our family just have really bad periods.’ It was just something she thought she was cursed to deal with and I was cursed to deal with, and that was just a part of my life.”

She went on to explain that she ended up collapsing outside of her tour bus, was repeatedly misdiagnosed, and even experienced a miscarriage while performing onstage. That’s when she “got really aggressive” about her treatment. In January 2017, Halsey had surgery to treat to treat her endometriosis. She also decided she was going to freeze her eggs.

“I’m 23 years old, and I’m going to freeze my eggs,” Halsey said on The Doctors. “And when I tell people that, they’re like, ‘You’re 23, why do you need to do that? Why do you need to freeze your eggs?’ She continued:

As the Daily Mail reported in March, Halsey tweeted that she has suffered from multiple miscarriages because of her endometriosis. The tweets have since been deleted, for whatever reason. But still. “I have endometriosis,” she wrote, according to the publication. “I’ve had 3 miscarriages, 4 surgeries, pretty much in pain every day of my life and I’ve donated/raised upwards of $300,000 in the name of research and support. I’m not trying to be quirky. Or different. I’m just trying to normalise an under-discussed illness.”

I can’t begin to imagine what Halsey has been through. Considering the intense pain, miscarriages, and surgeries she has endured through the years, though, I’m sure she was relieved when her doctor told her she’d be able to have children. Kudos to this brave woman for continuing to share her story — and for giving those who suffer from endometriosis a voice.

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