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This article was written by Hannah Arem, PhD, and Claire Starling, MPH.
Our research, published in JAMA Network Open, finds significant clinical improvements in insomnia symptoms among patients who have completed treatment for breast cancer.
A study recently completed at MedStar Health Research Institute and published in JAMA Open Network has found that cognitive behavioral therapy delivered at home via a daily, voice-activated smart speaker can significantly improve insomnia symptoms in patients after breast cancer treatment.
This randomized clinical trial recruited 76 breast cancer survivors divided evenly among two groups: One received a smart speaker with a voice-activated cognitive behavioral therapy insomnia (CBT-I) program, and the other group received web-based education on improving sleep.
After six weeks of at-home treatment, we used patient-reported Insomnia Severity Index (ISI) scores and sleep diaries to understand the change in their symptoms. The results were significant:
- 92.1% of participants enrolled in the voice-activated CBT-I arm of the study completed the daily treatment
- ISI scores improved in both groups, but the intervention group saw about three times more improvement (8.4 points) than the control group (2.6 points)
- Sleep quality: Participants who completed CBT-I got better sleep
- Wake after sleep onset: Participants reduced their time awake after initially falling asleep by 9.5 minutes more than the control group
- Sleep onset latency: Intervention group participants fell asleep about 8.3 minutes faster than the control group
- Sleep efficiency: The intervention group spent slightly more time sleeping in bed than the control group
The results of this study are precise: An in-home, voice-activated CBT-I program for breast cancer survivors improves insomnia symptoms.
Insomnia: A challenge for breast cancer survivors.
Following the rigors of breast cancer treatment, an estimated 30% to 50% of the 4 million breast cancer survivors in the U.S. struggle with sleep disturbances such as insomnia—the inability to achieve restful sleep.
While medications can help, they are only a short-term solution with side effects, and many patients prefer a non-pharmaceutical option. Cognitive behavioral therapy (CBT-I) is the most effective treatment for insomnia. Still, it can be difficult for patients to identify a trained provider or complete the course of therapy.
Smart speakers are gaining popularity, with 35% of U.S. households owning an Amazon Alexa or Google Home device. These speakers provide a novel way to reach individuals at home to collect information about sleep patterns and provide real-time feedback.
After surviving breast cancer, getting adequate sleep is particularly important because it helps strengthen the immune system, supports overall mental and physical health, and improves quality of life. Insomnia can be debilitating. Long-term impacts include:
- Decreased job performance and increased absenteeism
- Depression and anxiety
- Difficulty concentrating
- Increased risk of falls
- Medical disorders such as irritable bowel syndrome, fibromyalgia, and asthma
- Memory problems
- Reduced immune system function
CBT-I produces results similar to medication, without side effects and fewer relapses. Patients report CBT-I helps them fall asleep faster and stay asleep longer.
By studying the efficacy of automated CBT-I at home, we hope to identify how we can help more patients complete their therapy, restore beneficial sleep, and improve their quality of life.
Improving digital CBT-I with smart speaker delivery.
CBT-I is a psychological treatment that combines three approaches to relieve insomnia:
- Cognitive restructuring: Changing inaccurate or unhelpful thoughts about sleep.
- Behavioral change: Relaxation training, learning to control stimuli, and practicing techniques to build healthy sleep habits, often called sleep restriction therapy.
- Psychoeducational information: Learning about the connection between thoughts, feelings, behaviors, and sleep.
Typically, patients learn CBT-I techniques in person from a provider in a clinical setting. However, many patients have difficulty completing the six-week therapy due to logistical and scheduling challenges, and there aren’t enough trained providers to meet their needs.
Digital CBT-I (dCBT-I) can make it easier for patients to participate in the therapy on their schedule, get personalized information, and track their progress. Studies have shown that many people who visit dCBT-I websites do not complete the program, often because there is little guidance and the websites are either not intuitive or do not offer enough support.
Personalized dCBT-I delivered via an in-home smart speaker like the Alexa Echo Dot could eliminate some of these disadvantages. Patients would not need to log in to a website or use screens before bedtime, which is contraindicated in CBT-I.
Using the speaker allows for ongoing interaction and feedback, such as integrating information about their progress and preferences, to help restore restful sleep following breast cancer treatment.
Increasing access and comparing effectiveness.
Insomnia is prevalent among breast cancer survivors, but it is not always well-recognized. This research shows that new technologies, such as smart speakers, can help patients get treatment even when sleep therapists are in short supply.
As we look to help more patients access this technology, we are exploring several important questions:
- How can we implement this research in a way that helps the most people? Whether recommended by a provider integrated into survivorship programs, our challenge is understanding how to help more people who could benefit.
- How might we expand access to more cancer sites? If home-based interactive CBT-I helps breast cancer survivors, it can likely help other patients who struggle with insomnia after cancer treatment.
- Is CBT-I via smart speaker more effective than other methods? A comparative effectiveness study will help us assess this delivery method against others to understand which works best so we can personalize care.
CBT-I is an effective treatment for insomnia, and we know it can be successfully delivered with a smart speaker at home. This new delivery method demonstrates that emerging technologies can be essential in treating patients outside the doctor’s office.
