Sleep and mental health
The Sleep Ninja - A smartphone app for young people with sleep difficulties
- Is the Sleep Ninja app an acceptable and feasible intervention for young people with sleep difficulties?
- Is the Sleep Ninja app effective in reducing symptoms of insomnia among young people?
- Is the Sleep Ninja app effective in the prevention of depression among young people at elevated risk?
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Adolescents commonly struggle to get the recommended 8-10 hours of sleep each night, with research indicating that about 40% of young people will experience some form of sleep problem by early high school. Sleep problems are associated with increased rates of depression, anxiety, suicidality and poor academic performance. Although depression has multiple causes and maintaining factors, research shows that sleep plays an important role, and that there is potential to prevent mental health problems by targeting sleep.
Cognitive behavioural therapy for insomnia (CBT-I) reduces the symptoms and consequences of insomnia, but despite this, most young people with sleep problems do not receive this treatment, at least in part due to cost and difficulty accessing a therapist. There is growing evidence that CBT-I can be effectively delivered in digital formats, which overcomes these barriers to accessing face-to-face therapy. Despite the promise of this approach, there are no digital CBT-I programs commercially available for youth.
History of the project
This work followed on from a successful trial in adults which showed that an online CBT-I program could prevent depression, in a large group of Australian adults who had sleep problems. The idea for the project was to see if this was also the case for young people.
The first phase of the project began in 2016 when researchers at the Black Dog Institute engaged with stakeholders to assist in the design and development of a sleep app. This involved a series of focus groups with young people, consultations with sleep experts and engagement with graphic and app design specialists, and resulted in the development of the Sleep Ninja app.
The second phase of the project involved a pilot study of the Sleep Ninja app to assess its feasibility, acceptability and preliminary outcomes for young people with sleep difficulties. A second pilot study was undertaken in 2018 to test the feasibility of testing the Sleep Ninja app in the school environment. Changes and refinements to the app have been made in response to feedback from young people collected during the piloting phase.
The third phase of this project, planned for 2019, is to test the effectiveness of the Sleep Ninja app on sleep and mental health outcomes using an online randomised controlled trial – The Dream On Study. The Sleep Ninja app will also be trialled in the Future Proofing Study among a subset of young people with elevated symptoms of depression.
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Twenty-one young people aged 12- 16, attended one of three focus groups to share what they felt would be appropriate to include in a sleep app. The focus groups were transcribed, and key themes were analysed.
Young people were largely in favour of an app for sleep and expressed a preference for personalised information, flexibility in the way the app could be used, as well as a game-playing component to keep them engaged. It was important to young people that the app look good, be easy to navigate and not be dependent on internet coverage. This information was then brought together with the literature on effective treatment of sleep problems to develop the Sleep Ninja app.
The results of this study have been published:
- Werner-Seidler A, O'Dea B, Shand F, Johnston L, Frayne A, Fogarty AS, Christensen H. A Smartphone App for Adolescents With Sleep Disturbance: Development of the Sleep Ninja. JMIR Ment Health 2017;4(3):e28 DOI: 10.2196/mental.7614 PMID: 28754651, https://mental.jmir.org/2017/3/e28/
Fifty young people aged 12-16 years with sleep difficulties were recruited through online channels to complete surveys and sleep diaries before and after accessing the Sleep Ninja app for six weeks. Participants were also invited to participate in an interview to elicit more detailed feedback about the app.
This study concluded that the Sleep Ninja is a feasible and acceptable intervention for young people with sleep problems. Participants made recommendations for improving the app, which have been incorporated into the version of the Sleep Ninja to be trialled in Phase 3. Participants also demonstrated improvements on sleep, depression and anxiety symptoms after using the app.
The results of this study have been published:
- Werner-Seidler A, Wong Q, Johnston L, et al. Pilot evaluation of the Sleep Ninja: a smartphone application for adolescent insomnia symptoms. BMJ Open 2019;9:e026502. doi: 10.1136/bmjopen-2018-026502, https://bmjopen.bmj.com/content/9/5/e026502.info
A randomised controlled trial with approximately 300 young people with sleep difficulties is planned for 2019. This entirely online study will compare the use of the Sleep Ninja app to an inactive control condition on sleep and mental health outcomes immediately after using the app and after a two-month follow-up period. This study will answer key research questions around the effectiveness of the Sleep Ninja app on sleep and mental health, as compared to a control group.
The Sleep Ninja app will also be trialled as part of the Future Proofing study among a subset of year 9 students with elevated symptoms of depression. Students will be randomised to receive either the Sleep Ninja app or an inactive control condition for six weeks, with sleep and mental health outcomes assessed over a four-year follow-up period.