Novel Approaches to Insomnia Care: A Multi-Study Investigation at the Intersection of Technology, Sleep, and Mental Health

Abstract

As the most prevalent sleep disorder in Canada, insomnia has wide-ranging consequences on physical and mental health and represents a significant health burden for society. Insomnia is particularly common among individuals with psychological comorbidities such as depression and post-traumatic stress disorder (PTSD) and is now viewed as a core feature of these conditions. Insomnia is linked to greater severity and persistence of psychological conditions, and contrary to common assumptions, rarely resolve “on their own” following mental-health-focused treatments, emphasizing the need for sleep-focused care. As the first-line treatment for insomnia, cognitive behavioural therapy for insomnia (CBT-I) is effective in cases of co-occurring psychological disorders and contributes to meaningful improvements in both sleep and mental health. Despite its status as the gold-standard treatment for insomnia, substantial barriers restrict access to CBT-I and existing protocols often fail to address the clinical complexity associated with comorbid psychological disorders. Emerging technologies such as portable sleep monitors and digital interventions offer promising opportunities to enhance CBT-I and expand access for individuals with complex mental health needs. Given the widespread adoption of these technologies among the general population, a better understanding of how portable sleep monitors are used in real-world settings and of their potential influence on sleep is needed to inform their appropriate integration in clinical practice. Beyond technological innovations, multimodal treatment approaches that address multiple dimensions of sleep represent another pathway for improving outcomes in the context of psychological comorbidities. In particular, the combination of CBT-I and imagery rehearsal therapy (IRT) for nightmares has demonstrated efficacy in PTSD samples under highly controlled conditions, underscoring the need to assess its effectiveness in routine clinical settings. Study 1 (population-based survey) investigated the use of sleep wearables in a representative sample of 1,200 Canadians. This study highlights that one in five Canadians use commercial sleep wearables, reveals generally positive attitudes toward their impact on sleep, and identifies novel predictors of use, including sleep and psychological disorders. Compared to nonusers, wearable users had significantly poorer sleep and higher engagement in sleep-related health care, including medical consultations and medication use. These findings may reflect a greater interest in sleep monitoring technologies among individuals with heightened sleep difficulties. Wearable use was also identified as a moderator of the relationship between anxiety symptoms and sleep duration, with users experiencing greater declines in sleep quantity as anxiety increased relative to nonusers. Shifting from population-level adoption of sleep monitors to their implementation in clinical practice, Study 2 (randomized clinical trial) explored the integration of a portable EEG device in digital CBT-I in a sample with comorbid insomnia and depression symptoms (n = 47). Results from this study indicate comparable treatment adherence, acceptability, satisfaction, and effectiveness between participants monitoring their sleep with a standard sleep diary versus those using a portable EEG device. Yet, through quantitative and qualitative data, participants highlighted that integrating EEG monitoring in digital CBT-I yielded several advantages including gaining a better understanding of one’s sleep and increased treatment motivation. Challenges associated with EEG monitoring were also identified, indicating potential limitations in its suitability in some individuals and informing important considerations for clinical practice. Extending CBT-I adaptations to a different clinical population, Study 3 (clinical effectiveness study) assessed the real-world outcomes of a 10-week group intervention combining CBT-I and IRT in military and law enforcement personnel with PTSD (n = 60) receiving care at operational stress injury clinic. Significant improvements were observed from pre- to post-intervention across insomnia severity, nightmare frequency and distress, and PTSD symptoms. Parallel improvements were observed between insomnia, nightmares, and PTSD, illustrating the relevance of sleep-focused care as part of an integrated approach to psychological care for trauma-exposed populations. Collectively, these studies underscore both the widespread adoption and clinical relevance of sleep monitors, emphasize sleep as a key transdiagnostic target in comorbid psychological disorders, and highlight novel approaches to adapting and expanding access to insomnia care. Future studies should investigate additional applications of sleep monitors within insomnia interventions such as CBT-I/IRT, examine physiological changes during CBT-I at both macro- and micro-levels of sleep architecture, and explore strategies to make CBT-I more accessible, adaptable, and effective for individuals with diverse psychological comorbidities.