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The most effective treatments of prolonged grief disorder (PGD) result in clinically relevant effects in only about half of the patients and can be emotionally taxing. This points to the importance of improving currently available treatment options. One promising target for enhancing the efficacy of the treatment of PGD is insomnia. Sleep disturbances are very common in bereavement and are proposed to play a causal role in maintaining PGD symptoms. Therefore, targeting sleep problems may be an effective treatment for people with PGD and insomnia disorder. This protocol presents a study, registered in the Dutch Trial Register (NL86238.042.24) that will evaluate the effects of cognitive behavioral therapy for insomnia (CBT-I) in individuals with comorbid PGD and insomnia using a replicated single-case experimental design (R-SCED). Twenty adults meeting diagnostic criteria for both disorders will be randomized to complete baseline between 5 and 14 weeks, after which they will receive CBT-I. Weekly PGD and insomnia symptom measures will be administered throughout the baseline (5–14 weeks), intervention (7–8 weeks) and post-intervention phase (4–13 weeks). Outcomes will be examined using visual inspection, Tau-U indices, and randomization tests. Results: We expect CBT-I to reduce both insomnia and PGD symptoms. This study will form the first systematic evaluation of CBT-I for PGD. Findings may help establish a novel, less emotionally demanding treatment option for bereaved individuals.

Introduction: Guidelines recommend cognitive behavioral therapy for insomnia (CBT-I) as the first line of treatment for insomnia in general practice, but CBT-I is rarely available. Nurse-guided Internet-delivered CBT-I might be a solution to improve access to care. Objective: We aimed to determine the effectiveness of nurse-guided Internet-delivered CBT-I (I-CBT-I) on insomnia severity experienced by patients in general practice. Methods: Nurse-guided I-CBT-I (“i-Sleep”) was compared to care-as-usual (and I-CBT-I after 6 months) in 15 participating general practices among 134 patients (≥18 years old) with clinical insomnia symptoms. Assessments took place at 8, 26 and 52 weeks. Primary outcome was self-reported insomnia severity (Insomnia Severity Index) at 8 weeks. Secondary outcomes were sleep diary indices, depression and anxiety symptoms (Hospital Anxiety and Depression Scale), fatigue, daytime consequences of insomnia, sleep medication and adverse events. Results: Two thirds of the 69 intervention patients (n = 47; 68%) completed the whole intervention. At the posttest examination, there were large significant effects for insomnia severity (Cohen’s d =1.66), several sleep diary variables (wake after sleep onset, number of awakenings, terminal wakefulness, sleep efficiency, sleep quality) and depression. At 26 weeks there were still significant effects on insomnia severity (d = 1.02) and on total sleep time and sleep efficiency. No significant effects were observed for anxiety, fatigue, daily functioning or sleep medication. No adverse events were reported. Conclusions: Nurse-guided I-CBT-I effectively reduces insomnia severity among general practice patients. I-CBT-I enables general practitioners to offer effective insomnia care in accordance with the clinical guidelines.

Although several hundreds of apps are available that (cl)aim to promote mindfulness, only a few methodologically sound studies have evaluated the efficacy of these apps. This randomized waiting-list controlled trial therefore tested the hypothesis that one such app (the VGZ Mindfulness Coach ) can achieve immediate and long-term improvements of mindfulness, quality of life, general psychiatric symptoms, and self-actualization. One hundred ninety-one experimental participants received the VGZ Mindfulness Coach, which offers 40 mindfulness exercises and background information about mindfulness without any form of therapeutic guidance. Compared to 186 control participants, they reported large (Cohen’s d  = 0.77) and statistically significant increases of mindfulness after 8 weeks and small-to-medium increases of the Observing, Describing, Acting with awareness, Nonjudging, and Nonreactivity mindfulness facets as measured with the Five Facet Mindfulness Questionnaire (Cohen’s d  = 0.66, 0.26, 0.49, 0.34, and 0.43, respectively). Also, there were large decreases of general psychiatric symptoms (GHQ-12; Cohen’s d  = −0.68) and moderate increases of psychological, social, and environmental quality of life (WHOQOL-BREF; Cohen’s d  = 0.38, 0.38, and 0.36, respectively). Except for social quality of life, these gains were maintained for at least 3 months. We conclude that it is possible to achieve durable positive effects on mindfulness, general psychiatric symptoms, and several aspects of quality of life at low costs with smartphone apps for mindfulness such as the VGZ Mindfulness Coach.

Several technologies have been proposed to support the reduction of insomnia complaints. A user-centered assessment of these technologies could provide insight into underlying factors related to treatment adherence. Gaining insight into adherence to technology-mediated insomnia treatment as a solid base for improving those adherence rates by applying adherence-enhancing strategies. Adherence to technology-mediated sleep products was studied in three ways. First, a meta-analysis was performed to investigate adherence rates in technology-mediated insomnia therapy. Several databases were queried for technology-mediated insomnia treatments. After inclusion and exclusion steps, data from 18 studies were retrieved and aggregated to find an average adherence rate. Next, 15 semistructured interviews about sleep-support technologies were conducted to investigate perceived adherence. Lastly, several scenarios were written about the usage of a virtual sleep coach that could support adherence rates. The scenarios were discussed in six different focus groups consisting of potential users (n=15), sleep experts (n=7), and coaches (n=9). From the meta-analysis, average treatment adherence appeared to be approximately 52% (95% CI 43%-61%) for technology-mediated insomnia treatments. This means that, on average, half of the treatment exercises were not executed, suggesting there is a substantial need for adherence and room for improvement in this area. However, the users in the interviews believed they adhered quite well to their sleep products. Users mentioned relying on personal commitment (ie, willpower) for therapy adherence. Participants of the focus groups reconfirmed their belief in the effectiveness of personal commitment, which they regarded as more effective than adherence-enhancing strategies. Although adherence rates for insomnia interventions indicate extensive room for improvement, users might not consider adherence to be a problem; they believe willpower to be an effective adherence strategy. A virtual coach should be able to cope with this \"adherence bias\" and persuade users to accept adherence-enhancing strategies, such as reminders, compliments, and community building.

Attentional bias toward sleep-related information is believed to play a key role in insomnia. If attentional bias is indeed of importance, changing this bias should then in turn have effects on insomnia complaints. In this double-blind placebo controlled randomized trial we investigated the efficacy of attentional bias modification training in the treatment of insomnia. We administered baseline, post-test, and one-week follow-up measurements of insomnia severity, sleep-related worry, depression, and anxiety. Participants meeting DSM-5 criteria for insomnia were randomized into an attentional bias training group (n = 67) or a placebo training group (n = 70). Both groups received eight training sessions over the course of two weeks. All participants kept a sleep diary for four consecutive weeks (one week before until one week after the training sessions). There was no additional benefit for the attentional bias training over the placebo training on sleep-related indices/outcome measures. The absence of the effect may be explained by the fact that there was neither attentional bias at baseline nor any reduction in the bias after the training. Either way, this study gives no support for attentional bias modification training as a stand-alone intervention for ameliorating insomnia complaints.

There is preliminary evidence that poor sleep quality is associated with emotional problems following loss, including symptoms of prolonged grief disorder (PGD) and depression. We conducted two studies to improve existing knowledge about the role of sleep difficulties in recovery from loss. Study 1 that relied on self-reported data from a heterogeneous sample of 177 bereaved individuals replicated prior findings of a linkage between increased sleep difficulties and increased PGD severity. This study also suggested that sleep difficulties are more strongly associated with depression than with PGD. In Study 2, we examined whether prior evidence that sleep complaints are a residual symptom of PGD treatment could be replicated in a sample of 43 bereaved individuals who underwent cognitive behavioural therapy for PGD. Outcomes showed that, although sleep difficulties declined significantly during this cognitive behavioural therapy, after this therapy, over half of all patients still had sleep difficulties above the average sleep difficulties observed in the general Dutch population.