Smartphone apps for insomnia: examining existing apps’ usability and adherence to evidence-based principles for insomnia management

Smartphone apps for insomnia: examining existing apps’ usability and adherence to... Abstract Insomnia affects up to 22% of the U.S. adult population. The use of mobile health applications (mHealth apps) has been posited as one way to increase access to evidence-based interventions for insomnia, such as cognitive behavioral therapy for insomnia (CBT-I). The purpose of the current study was to summarize the availability of mHealth apps that focus on providing users with the behavioral and/or cognitive skills to manage insomnia, assess their adherence to evidence-based principles, and examine their usability. The terms “insomnia,” “insomnia treatment,” and “sleep treatment” were used to search the Apple iTunes and Google Play stores in November 2016. Social network query within the authors’ professional networks was also conducted. Apps that met inclusion criteria for the study were downloaded and reviewed by the research team for their general characteristics; inclusion of CBT-I skills, strategies, and principles; and aesthetics and usability. Of the 357 apps initially found, 12 met criteria for further review. Overall, the apps were moderately adherent to CBT-I principles, with a mean app score of 1.44 out of 3.00, and moderately usable, with a mean usability score of 3.54 out of 5.00. Few apps currently exist that utilize evidence-based principles to help users practice the behavioral and cognitive skills shown to manage insomnia. Thus, there are exciting opportunities for clinicians, researchers, and mHealth experts to develop effective apps that can help ease the public health burden of insomnia. Implications Practice: Mobile health applications may be used to provide individuals with the behavioral and cognitive skills to manage their insomnia, thereby reducing the public health burden of this disorder. Policy: As the mobile health marketplace continues to grow, the role of health care providers in developing, disseminating, and regulating apps must be clarified. Research: Future research should focus on identifying how clinicians, researchers, and mHealth experts can collaborate to ensure that new and existing apps adhere to evidence-based principles for insomnia management and entice individuals to use them. Insomnia disorder (hereon referred to as “insomnia”) is characterized by difficulties initiating and maintaining sleep, accompanied by distress or impairment in daytime functioning [1]. The effects of insomnia are associated with mental and physical health problems, including mood lability, poor attention and concentration, fatigue, and increased risk of obesity, diabetes, heart disease, and hypertension [2]. The effects of insomnia are also associated with decreased work productivity and increased risk of accidents [3]. Prevalence estimates of insomnia vary. While some reports estimate that insomnia affects between 6% and 10% of the U.S. adult population [4–6], others report that it affects up to 22% of the U.S. adult population [7]. Regardless, insomnia represents a considerable public health concern. Cognitive behavioral therapy for insomnia (CBT-I) has been endorsed as the first-line treatment for chronic insomnia by several health and medical associations, including the National Institutes of Health [8], the American Academy of Sleep Medicine [9], the British Medical Association [10], the American College of Physicians [11], and the U.S. Department of Veterans Affairs and the Department of Defense [12]. As a nonpharmacological treatment, CBT-I focuses on providing patients with behavioral and cognitive skills to improve their sleep quality and quantity. Behavioral skills include sleep restriction to match time in bed with actual sleep time, stimulus control and sleep hygiene techniques to foster healthy sleep habits, and breathing and relaxation techniques to help patients relax at bedtime. Cognitive skills include changing dysfunctional beliefs about sleep that increase arousal [6]. Despite the well-established effectiveness of interventions like CBT-I, relatively few individuals with insomnia—by some estimates, as few as only 13% [13]—have sought professional help. This low rate may be related to barriers such as cost, difficulty accessing care, limited availability of well-trained behavioral sleep medicine specialists, and work demands that dictate atypical sleep cycles and poor sleep habits [6,14]. The use of mobile technology for health care delivery, often referred to as “mobile health” or “mHealth,” has been identified as a potential way to overcome such barriers and increase access to care [14]. A recent report by the Pew Research Center found that 95% of individuals in the USA. own a cellular phone and 77% own a smartphone [15]. While there is some variation in smartphone ownership based on age, education, and household income, there is still widespread use. Also ubiquitous is the use of mHealth applications (“apps”). In 2014, over 60% of smartphone owners in the USA used their phones to search for health information and nearly one-third used an mHealth app to improve their health and fitness [16,17]. Currently, there exist hundreds of apps purporting to help users lose weight, exercise more, practice meditation, manage diabetes, and improve chronic pain. There are also hundreds of apps promising to help users improve sleep. These include apps attempting to help users fall asleep by encouraging relaxation techniques or providing soothing sounds, apps that allow users to monitor or record their sleep, and apps that focus on reducing specific sleep problems such as snoring [14]. There are also apps that claim to implement CBT-I or teach behavioral strategies to combat insomnia. The delivery of CBT-I or other behavioral treatment for insomnia via mHealth is nontraditional, yet there is compelling evidence of its potential feasibility and effectiveness based on outcomes from studies of other technology-delivered CBT-I. For example, a study comparing SHUTi, a six-module Internet-delivered treatment based on CBT-I, to wait list control found that participants assigned to the intervention condition and granted access to SHUTi for 9 weeks demonstrated statistically significant improvements in insomnia severity, number of awakenings, and sleep efficiency compared with those assigned to the control condition. Moreover, these improvements were maintained at 6-month follow-up [18]. Similarly, a study comparing a six-session Internet-delivered CBT program, a six-session Internet-delivered imagery relief therapy program, and treatment-as-usual found that Internet-delivered CBT was superior to both comparison conditions in improving sleep efficiency and daytime functioning. These improvements were maintained at 8-week follow-up [19]. Finally, a recent meta-analysis of 11 randomized controlled trials including a total of 1,460 participants and comparing Internet-delivered CBT-I to at least one nonintervention control condition (e.g., wait list) found that Internet-delivered CBT-I improved participants’ insomnia severity, sleep efficiency, subjective sleep quality, total sleep time, and number of nocturnal awakenings. Notably, these outcomes were comparable with those found in studies of face-to-face CBT-I [20]. In sum, insomnia is a public health issue affecting millions of adults in the U.S. CBT-I is a well-established nonpharmacological treatment for the disorder, but access to it is limited by factors including cost and provider availability. The number of Americans owning smartphones, using their phones to search for health information, and downloading mHealth apps for health and fitness is on the rise; thus, the use of mHealth to provide individuals with the behavioral and cognitive skills to improve their sleep may help ease the public health burden of this disorder. There are currently hundreds of apps available that claim to help individuals improve their sleep; however, to our knowledge, there to date has been no systematic review of such apps. Therefore, the aim of this study was to summarize the availability of such apps, assess the adherence of existing apps to evidence-based principles, and examine their usability. METHODS Methods for app identification, selection, and review were informed by recent published reviews of mobile apps for a variety of health concerns, including weight loss [21,22] and chronic pain [23,24]. First, searches for existing apps for the self-management or treatment of insomnia were conducted in the Apple iTunes and Google Play stores, as Apple and Google represent over 99% of the mobile operating systems market [25]. Searches were also conducted in the scientific literature, app clearinghouse websites, and social media to identify any additional apps. Next, the first author completed an initial screen of available apps to determine whether apps met inclusion criteria for download and further review. Two raters then downloaded each app that met inclusion criteria and coded each app on its adherence to evidence-based principles for insomnia treatment, as well as its usability. The first author and raters (K.E.M., K.T.L.) were doctoral-level clinical psychology trainees (i.e., postdoctoral fellows) with expert training and supervision in the evidence-based assessment and treatment of insomnia (e.g., CBT-I). As all information utilized in this review was retrieved from the public domain, the study was exempt from review by the authors’ Institutional Review Board. App selection As previously noted, Apple and Google currently claim over 99% of the mobile operating systems market [25] and thus the Apple iTunes and Google Play Stores were used as the two platforms in which to search for existing insomnia apps. To identify available apps, the first author first conducted a search in each app store in November 2016 with the search terms “insomnia,” “sleep treatment,” and “insomnia treatment.” These search terms were used to ensure comprehensiveness of results. To further ensure that as many apps as possible were included in the review, the research team also used the following methods, consistent with Boudreaux and colleagues’ recommendations for evaluating and selecting mobile health apps, to identify additional apps for the treatment of insomnia: (1) review the scientific literature, (2) search app clearinghouse websites, and (3) conduct a social media query within professional networks [26]. In this study, social media inquiry involved asking members of professional e-mail listservs to which the authors belonged about their awareness of any apps related to insomnia or sleep management. Apps discovered through these methods were then subject to the same review process as those apps found in the app store searches. Once the research team compiled a list of all available apps, the first author reviewed the description for each app written by the app developer and available in the app store prior to download to determine whether the app met criteria to be downloaded for further review. Inclusion and exclusion criteria were selected to ensure this review identified apps most likely to be beneficial to individuals struggling with insomnia and for users seeking the knowledge and skills to manage their sleep difficulty with the help of their smartphone only. Therefore, we purposefully excluded apps that were too broad in their focus, unrelated to insomnia, or required additional devices. To meet criteria for further review, an app had to be available in English and its app store description had to identify its purpose as the self-management or treatment of insomnia. An app was excluded from review if it focused only on services offered by specific clinics, provided only reading material on insomnia and/or sleep, was focused on a sleep problem other than insomnia (e.g., sleep apnea), provided only relaxing music or sounds for sleep, promoted only hypnosis for sleep, or required a wearable device (e.g., Fitbit) to use. App assessment Two raters (K.E.M., K.T.L.) independently downloaded and coded each app that met criteria for further review to assess the app’s basic features, its adherence to evidence-based principles for insomnia treatment, and its usability. After their independent reviews, the raters met to discuss any discrepancies. A protocol was developed for the raters to consult an expert in the assessment and treatment of insomnia in the event of continued disagreement; however, this did not prove necessary. The average inter-rater agreement across all apps after the raters’ independent review was 80% with a kappa coefficient of 0.78, indicating “substantial” agreement [27]. The raters reached consensus on all codes after discussion. Basic features In regard to basic features, the raters obtained the following information for each app: cost; average user rating from the app store; whether the app developer was an individual or group with reported expertise in the assessment and treatment of sleep problems; whether the app included a disclaimer about its use (e.g., that the app was intended to be used in conjunction with treatment from a health care professional); whether the app specified a program or duration of use; the inclusion of any education about sleep and sleep problems; the inclusion of interactive tools such as charts or graphs to depict users’ data; whether the app could be connected to another device (e.g., Fitbit); and whether the app could share data with users’ health care professionals. Evidence-based principles for insomnia treatment As previously discussed, CBT-I is recommended as the first-line treatment for adults with chronic insomnia. Therefore, apps were assessed according to whether they adhered to the skills, strategies, and techniques outlined in CBT-I. These skills, strategies, and techniques are hereon referred to as CBT-I “components” and include: conducting a sleep assessment; asking the patient to keep a sleep diary or log; providing education on sleep hygiene; providing education on stimulus control techniques; providing the patient with a sleep restriction prescription; introducing methods to reduce arousal around bedtime; and cognitive therapy for worries related to sleep [28]. Table 1 provides a brief description of each of these components. Table 1 | CBT-I Skills, Strategies, and Techniques Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. View Large Table 1 | CBT-I Skills, Strategies, and Techniques Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. View Large As they reviewed each app, the raters provided two ratings for each component listed above. The first rating related to the extent to which the app included the component. This rating ranged from 0 to 3, with 0 = not at all (e.g., the app included no education on sleep hygiene), 1 = some (e.g., the app included about one-third of the points typically made in sleep hygiene education), 2 = most (e.g., the app included about two-thirds of the points typically made in sleep hygiene education), and 3 = almost completely (e.g., the app included almost all of the points typically made in sleep hygiene education). The second rating related to the quality of the specific component. This rating ranged from low to high, with low = the feature was inaccurate based on CBT-I principles, or difficult to follow in the app (e.g., the app provided poor instructions); medium = the feature was accurate based on CBT-I principles, and easy enough to follow in the app (e.g., the app provided instructions but no demonstration of the feature); and high = the feature was accurate based on CBT-I principles, and very easy to follow in the app (e.g., the app provided instructions and demonstration of the feature). Usability The Mobile Application Rating Scale (MARS [29]) is a multidimensional, objective measure of app usability. It includes four subscales that measure an app’s engagement, functionality, aesthetics, and information quality. Items are rated on a scale specific to each item. For example, a sample item from the Engagement subscale is, “Is the app fun/entertaining to use? Does it use any strategies to increase engagement through entertainment (e.g., through gamification)?” Item responses range from 1 to 5, with 1 = dull, not fun or entertaining at all, and 5 = highly entertaining and fun, would stimulate repeat use. A sample item from the Functionality subscale is, “How easy is it to learn how to use the app; how clear are the menu labels/icons and instructions?” Item responses range from 1 to 5, with 1 = no/limited instructions; menu labels/icons are confusing; complicated, and 5 = able to use app immediately; intuitive; simple. The average of the item responses in each subscale constitutes the app’s Engagement, Functionality, Aesthetics, and Information Quality scores; these subscale scores are then averaged for an App Quality score. The MARS has been found to have high internal consistency [29]. In this study, the two raters completed the MARS for each downloaded app and the App Quality score was the primary outcome measure for app usability. Analytic plan To describe the extent to which an app included the skills, strategies, and techniques consistent with CBT-I, the average rating for each component of each app was calculated. The ratings for all components within each app were then averaged for an overall app score. In addition, the MARS App Quality score for each app was calculated to describe each app’s usability. RESULTS The initial search yielded 156 apps in the Apple iTunes Store and 199 apps in the Google Play Store (see Fig. 1 for flow chart). Six iPhone apps met inclusion criteria for full review. Two of these apps were also available in Google Play and were considered distinct from their Google Play versions in the event of variability due to differences in the operating systems. Along with these two apps, four additional Google Play apps met inclusion for further review. In addition, one app, available in both the iTunes and Google Play Stores, was identified via social media inquiry, specifically an e-mail sent to a behavioral health care listserv of which the first author was a member. No additional apps were identified in the scientific literature or app clearinghouse websites. Thus, a total of 12 apps were downloaded for further review. Table 2 provides a list of these apps, along with information on each app’s price, developer, app store user rating, component ratings and quality, overall app score, and usability rating. Table 2 | Apps’ General Characteristics, Component and Overall Scores, and MARS Usability Ratings App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 SD sleep diary; SA sleep assessment; SH sleep hygiene recommendations; SC stimulus control; SR sleep restriction prescriptions; AR methods to reduce arousal; CT cognitive therapy techniques. aApp Store Rating refers to average number of stars (0–5) provided by users. View Large Table 2 | Apps’ General Characteristics, Component and Overall Scores, and MARS Usability Ratings App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 SD sleep diary; SA sleep assessment; SH sleep hygiene recommendations; SC stimulus control; SR sleep restriction prescriptions; AR methods to reduce arousal; CT cognitive therapy techniques. aApp Store Rating refers to average number of stars (0–5) provided by users. View Large Fig 1 View largeDownload slide | Flowchart of app search process. Note: Of the 345 apps excluded from the study, 25% were excluded for focusing on a sleep problem other than insomnia; 23% for providing only relaxing music or sounds for sleep; 12% for focusing on hypnosis, meditation, or yoga for sleep; 11% for providing only reading material on insomnia and/or sleep; 8% for serving as screen savers only; and 21% for various other reasons (e.g., required a wearable device to use, not available in English). Fig 1 View largeDownload slide | Flowchart of app search process. Note: Of the 345 apps excluded from the study, 25% were excluded for focusing on a sleep problem other than insomnia; 23% for providing only relaxing music or sounds for sleep; 12% for focusing on hypnosis, meditation, or yoga for sleep; 11% for providing only reading material on insomnia and/or sleep; 8% for serving as screen savers only; and 21% for various other reasons (e.g., required a wearable device to use, not available in English). Of the excluded apps, 25% were focused on a sleep problem other than insomnia; 23% provided only relaxing music or sounds for sleep; 12% were apps that promoted hypnosis, meditation, or yoga for sleep; 11% provided only reading material on insomnia and/or sleep; 8% were apps with screen savers that dimmed phone screens or minimized their blue light; and 21% were excluded for various other reasons (e.g., required a wearable device to use, not available in English). Price Eleven of the 12 downloaded apps (91.7%) were downloaded free of charge. However, one app that was downloaded for free (SleepRate) required users to purchase a plan costing between $9.99 and $89.99 per year to access several features of the app. In this study, raters based their reviews on the app’s free features only. The Sleep School was downloaded for $3.99. App store ratings In both the Apple iTunes and Google Play Stores, users can rate apps on a scale of 0–5 stars, with more stars indicating greater satisfaction with an app. Three of the downloaded apps did not have user ratings. Of the remaining nine, the average rating was 3.65 (range: 1–5), from an average of 66.9 users (range: 1–94). Developer type Ten of the 12 apps (83.3%) reported being developed by or with consultation from sleep experts. These reports were made within the app (e.g., in an “About” section) or on the developer’s website. For example, users can navigate to the “About MobileSleepDoc” section in MobileSleepDoc Pro, where it states: “MobileSleepDoc is the first available sleep diagnosis and therapy application created by a sleep specialist, based on medical evidence but designed to be user friendly.” In the “About” section in CBT-I Coach, it states: “CBT-I Coach was a collaborative effort between the VA’s National Center for PTSD, Stanford University Medical Center, and DoD’s National Center for Telehealth and Technology.” Upon discovering InsomniaFix in the Apple iTunes Store, users can click on “Developer Website” to navigate to the app’s website. On the home page is the following statement: “The InsomniaFix application for Apple and Android is a self-help, tutorial program designed by Dr. Brian Wind, a board certified specialist in the treatment of insomnia and host of the popular talk radio program, The Sleep Doctors.” Sleepify and Insomnia Help did not report being developed by or in consultation with a sleep expert. Disclaimer Seven of the 12 apps (58.3%) provided some disclaimer about their use, warning individuals that wzapp developers were not responsible for any outcomes related to app use. For example, the “Terms & Conditions” section of Sleep | Insomnia: Better Sleep with CBT indicated that users who download and use the app acknowledge that users are “solely responsible for deciding which of the suggested techniques [they] put into practice and how to apply those techniques.” It also stated that the app is intended “for information and not as medical advice and should not be seen as a replacement for consultation with a doctor or other qualified healthcare professional.” Duration Five of the 12 apps (41.7%) provided an estimate of how long an individual would need to use the app to experience benefit. For example, an introduction to InsomniaFix stated that its program was “designed to take 8 weeks.” Sleepify indicated that its methods for improving sleep were most effective “when practiced for at least 15 days in a row.” Sleep Guru provided users with 10 days to complete health habit challenges aimed to improve sleep. Educational materials Eleven of the 12 apps (91.7%) included some basic background information on sleep. This included information on the stages of sleep, common conditions associated with poor sleep or insomnia (e.g., sleep apnea, depression, and nightmares), and links to other sleep resources. Interactive tools Ten of the 12 apps (83.3%) included features that allowed users to input data and/or receive feedback on data. For example, CBT-I Coach, MobileSleepDoc Pro, and SleepRate all provided users with graphs summarizing their sleep time and sleep efficiency. CBT-I Coach also allowed users to set alarms and reminders for wind down, bed, and wake times. Adjunct devices Six of the 12 apps (50%) allowed users to connect other devices, such as Fitbits, to the app. SleepRate offered users the opportunity to purchase a “sleep improvement kit” that included a heart rate sensor, personalized sleep assessment, and customized sleep improvement plan. Of note, the kit proved necessary to access several features of the app, including its assessment and therapy. Professional support None of the 12 apps (0%) allowed users to directly share data with a health care professional within the app. However, CBT-I Coach did allow users to export and e-mail a CSV file containing their sleep diary entries and sleep assessment scores to other parties. Adherence to evidence-based principles for insomnia treatment Table 2 provides each app’s individual CBT-I component ratings and overall app score. The average overall app score was 1.44 out of 3, with a range from 0.14 to 2.85. CBT-I Coach included the greatest number of CBT-I components (7 out of 7) and had the highest overall app score (2.85 out of 3). Six of its components received a rating of 3 and were of “high” quality; one received a rating of 2 and was of “medium” quality. Insomnia Help included the fewest number of CBT-I components (1 out of 7) and had the lowest overall app score (0.14 out of 3). Six of its components receiving a rating of 0; one received a rating of 1 and was of “low” quality. Usability Table 2 provides each app’s MARS overall usability rating. The average MARS usability rating was 3.54 out of 5, with a range from 2.18 (Insomnia Help) to 4.40 (The Sleep School). DISCUSSION The aim of this study was to identify and evaluate existing mHealth apps that claim to provide users with the behavioral and/or cognitive skills to manage insomnia. To meet this aim, comprehensive searches were conducted in the Apple iTunes and Google Play Stores in November 2016 to identify all apps related to the search terms “insomnia,” “insomnia treatment,” and “sleep treatment.” From this search—as well social network outreach—a total of seven iPhone and five Android apps were downloaded for further review of their basic features; adherence to evidence-based skills, strategies, and techniques for insomnia treatment; and usability. The vast majority of apps were available free of charge (91.7%) and reportedly developed by or with consultation from sleep experts (83.3%). Most provided some disclaimer about their use (58.3%) and none allowed users to directly share data with a health care professional (0%). Overall, the apps were moderately adherent to CBT-I principles, with an average app score of 1.44 out of a maximum 3. They demonstrated moderately high usability, with an average MARS score of 3.54 out of 5. To date, CBT-I Coach is the only app to have been tested in a randomized clinical trial. A pilot study by Koffel et al. [30] found that participants who were randomly assigned to use CBT-I Coach as a supplement to face-to-face CBT-I consistently used the app as intended, were particularly engaged with features such as the sleep diary and reminder functions, reported that the app was highly acceptable to them, and witnessed significant improvements in their sleep. Thus, there is evidence that people like and will use insomnia apps. Together, Koffel et al.’s and our studies point to an exciting opportunity for clinicians, researchers, and mHealth experts to develop and improve insomnia apps. To begin, experts can focus on ensuring that apps are consistent with the most effective, evidence-based treatment. In this study, a top overall app score of 3 with ratings of “high” on each individual evidence-based component would have indicated that the app was fully adherent to CBT-I skills, strategies, and techniques. However, no app achieved this score. Thus, even the best existing apps can be enhanced to be more consistent with CBT-I. For example, arguably the most important elements of CBT-I are the sleep diary, sleep restriction, stimulus control, and sleep hygiene. In face-to-face treatment, data obtained from the sleep diary enable providers to determine sleep restriction prescriptions, and patients are encouraged to practice stimulus control and good sleep hygiene in order to adhere to these prescriptions. However, several of the downloaded apps failed to provide users with a sleep diary and the remaining provided diaries of varying quality. For example, CBT-I Coach’s diary, coded as “high” quality by the study’s raters, assessed users’ daily time to bed, time to sleep, sleep latency, number of awakenings, final wake time, and subjective sleep quality. Of note, this diary is based on an expert consensus, standardized sleep diary [31]. On the other hand, the Sleep School’s “low” quality diary primarily inquired about how users’ sense of restfulness affected their daytime functioning without obtaining data on actual sleep obtained. Unsurprisingly, CBT-I Coach’s directions for sleep restriction were tailored to the individual user’s sleep data, whereas Sleep School’s instructions were nonspecific. CBT-I Coach required users to complete at least five diary entries in 1 week in order to obtain prescribed sleep and wake times; Sleep School encouraged all users, regardless of their sleep schedule, to delay their sleep time for 30 minutes for 3 weeks. Similarly, stimulus control and sleep hygiene recommendations were of varying quality or completely absent from the downloaded apps. MobileSleepDoc Pro’s “high” quality stimulus control recommendations provided users with “5 main principles” for stimulus control (go to bed when feeling sleepy; get out of bed when not asleep for more than 15–20 minutes; avoid naps; use bed and bedroom for sleep only; and maintain a regular waking schedule), along with a clear rationale for these principles. On the other hand, stimulus control recommendations were absent from Sleep | Insomnia: Better Sleep with CBT. This app did, however, provide users with the opportunity to choose one or more items from a list of sleep hygiene recommendations in order to generate an individually tailored “personal bedtime checklist.” The list included items such as avoiding smoking, caffeine, and soda; keeping bedroom temperature cool; keeping pets out of the bedroom; and setting one’s phone to Do Not Disturb. Ensuring that evidence-based strategies are not only included in apps but also of high quality would increase the likelihood that users benefit from the apps. Next, clinicians, researchers, and mHealth experts can collaborate with product designers and engineers to build apps that engage and entice users. According to Everett Rogers’ Diffusion of Innovations theory, one metric by which potential users of an innovation determine whether to adopt it is the innovation’s relative advantage—that is, the degree to which the innovation is perceived as better than the product it is to succeed [32]. Potential advantages of mHealth apps include their ability to be used flexibly (e.g., on the go) and privately; capture real-time data and provide personalized feedback; sync with other apps and devices; and create social support networks [33]. In this study, all apps could be used flexibly and privately. Most collected data via a sleep assessment or diary, but not all apps that collected data provided feedback. Only half of the apps allowed users to connect the app with another device to sync data. None exposed users to a social support network. Thus, mHealth app developers have several opportunities to increase the relative advantage of insomnia apps. To our knowledge, this study is the first to evaluate existing insomnia apps for their adherence to evidence-based principles. In addition to providing new information, it extends previous research on other health-related apps (e.g., weight loss and pain) by also evaluating apps’ usability. Previous reviews of existing mobile apps for other presenting problems have largely focused on apps’ adherence to evidence-based treatment principles [21–24] without considering apps’ ability to engage users. While these reviews have reported apps’ average iTunes Store or Google Play ratings, such ratings are a reflection of apps’ popularity rather than objective measures of their visual appeal, engagement, and functionality. These design features are important, as users are more likely to use or recommend apps they find easy to use and pleasant to look at [34,35]—and any treatment, whether provided in person or otherwise, can be effective only if it is actually accessed. By using the MARS in this study, we were able to provide a more objective assessment of each app’s usability. Interestingly, we found that apps’ usability scores were not necessarily correlated with their overall app score. For example, The Sleep School received the highest usability score (4.40 out of 5), indicating that it was visually appealing, engaging, and easy to use, but it had one of the lowest overall app scores (1.57 out of 3), indicating that it did not fully adhere to the skills, strategies, and techniques of CBT-I. Conversely, CBT-I Coach received the highest overall app score (2.85 out of 3), but had a moderate usability score (3.67 out of 5). Again, collaboration between clinicians, researchers, and mHealth experts may help entice users to download apps and increase their adherence to evidence-based recommendations made within apps. A limitation of this study is the possibility that apps that indeed included evidence-based strategies to manage insomnia were excluded because their app store descriptions did not clearly specify their aim as the self-management or treatment of insomnia. Relatedly, another limitation of this study is its small sample size. Given the relatively high prevalence of insomnia and the plethora of sleep-related apps that were found in our initial search, it is surprising that so few apps met criteria for further review. This is in stark contrast to similar reviews for chronic pain, diabetes, and weight management that examined many more apps. However, our inclusion and exclusion criteria were more stringent than those of other reviews in that we downloaded only those apps that purported to help users with the behavioral and/or cognitive self-management of insomnia rather than sleep difficulties more broadly. Thus, we excluded over 100 apps that focused more generally on poor sleep, too narrowly on specific sleep problems (e.g., snoring or sleep apnea), or provided only relaxing sounds to help induce sleep. In addition, our inter-rater agreement of 80% and inter-rater reliability of 0.78 may appear low, though as previously noted a kappa coefficient of 0.78 is considered “substantial” agreement [27]. The majority of discrepancies between our two raters were related to MARS usability ratings. The features assessed by the MARS—in particular, engagement, functionality, and aesthetics—are inherently subjective and ratings may be prone to raters’ visual preferences. However, the MARS is the first and only measure to our knowledge to standardize such ratings and therefore we consider its use in the study a strength. Currently, there exist over 97,000 mHealth apps in various app stores, and it appears that this marketplace will continue to grow [36]. However, this growth is dynamic and even unstable as mHealth apps appear and disappear from app stores. A recent study by Larsen et al. [37] found that the search result “half-life” for depression-related apps, defined as the period of time after which 50% of apps identified by the search term “depression” changed and no longer appeared in the search results, was 130 days in Google Play and over 9 months in the iTunes Store. Further, they found that only 37.8% of apps remained in the Google Play store 9 months after the initial search. This percentage was greater for apps in the iTunes Store—82.7%. They made this stark conclusion: “The number of clinically relevant apps that were no longer available to download at the end of the study period was equivalent to a depression app disappearing every 3.7 days on Android, every 13.7 days on iOS, or every 2.9 days across both platforms” [37]. Apps may be removed from app stores for several reasons, but the instability of the mHealth marketplace raises the question of whether and how much individuals can rely on apps for high quality information, self-management, and support. Many mHealth apps focus on helping individuals with problems that are commonly diagnosed and treated by health care providers with specialized training, insomnia included. Thus, the development and dissemination of such apps raises myriad ethical concerns. The overarching question seems to be how to clarify the role of health care providers in regulating app use. On the one hand, app users may be viewed as consumers who curiously seek advice, information, and skills without input from health care professionals. If that is the case, the role of clinicians, researchers, and mHealth experts may be solely to help develop apps that consist of high-quality information. On the other hand, app users may be viewed as patients who need expert assessment and care. In this case, the role of clinicians in particular may be much greater. It may include thoroughly reviewing apps and developing protocols to “prescribe” certain apps and discourage use of others. As new insomnia apps are developed and made available in the mHealth marketplace, future research should aim to clarify health care professionals’ roles in reviewing and recommending apps and increase patient engagement in evidence-based apps. In conclusion, this study found that despite the hundreds of apps that are currently available in the mHealth marketplace and claim to help individuals improve their sleep, few are adherent to the evidence-based skills and strategies that have been shown effective in managing insomnia. It is hoped that this article will help inspire clinicians, researchers, and mHealth experts to collaborate on efforts to improve existing apps and develop new ones. It is also hoped that this article will help inform patients and providers about the apps that currently exist and how to evaluate them. Funding: The study received no funding. Ethical disclosures: The study provided no treatment to human or animal experimental subjects. As no human subjects were involved in the study, informed consent was not necessary. Publication: The findings reported here have not previously been published and the manuscript is not being simultaneously submitted elsewhere. 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Smartphone apps for insomnia: examining existing apps’ usability and adherence to evidence-based principles for insomnia management

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Abstract

Abstract Insomnia affects up to 22% of the U.S. adult population. The use of mobile health applications (mHealth apps) has been posited as one way to increase access to evidence-based interventions for insomnia, such as cognitive behavioral therapy for insomnia (CBT-I). The purpose of the current study was to summarize the availability of mHealth apps that focus on providing users with the behavioral and/or cognitive skills to manage insomnia, assess their adherence to evidence-based principles, and examine their usability. The terms “insomnia,” “insomnia treatment,” and “sleep treatment” were used to search the Apple iTunes and Google Play stores in November 2016. Social network query within the authors’ professional networks was also conducted. Apps that met inclusion criteria for the study were downloaded and reviewed by the research team for their general characteristics; inclusion of CBT-I skills, strategies, and principles; and aesthetics and usability. Of the 357 apps initially found, 12 met criteria for further review. Overall, the apps were moderately adherent to CBT-I principles, with a mean app score of 1.44 out of 3.00, and moderately usable, with a mean usability score of 3.54 out of 5.00. Few apps currently exist that utilize evidence-based principles to help users practice the behavioral and cognitive skills shown to manage insomnia. Thus, there are exciting opportunities for clinicians, researchers, and mHealth experts to develop effective apps that can help ease the public health burden of insomnia. Implications Practice: Mobile health applications may be used to provide individuals with the behavioral and cognitive skills to manage their insomnia, thereby reducing the public health burden of this disorder. Policy: As the mobile health marketplace continues to grow, the role of health care providers in developing, disseminating, and regulating apps must be clarified. Research: Future research should focus on identifying how clinicians, researchers, and mHealth experts can collaborate to ensure that new and existing apps adhere to evidence-based principles for insomnia management and entice individuals to use them. Insomnia disorder (hereon referred to as “insomnia”) is characterized by difficulties initiating and maintaining sleep, accompanied by distress or impairment in daytime functioning [1]. The effects of insomnia are associated with mental and physical health problems, including mood lability, poor attention and concentration, fatigue, and increased risk of obesity, diabetes, heart disease, and hypertension [2]. The effects of insomnia are also associated with decreased work productivity and increased risk of accidents [3]. Prevalence estimates of insomnia vary. While some reports estimate that insomnia affects between 6% and 10% of the U.S. adult population [4–6], others report that it affects up to 22% of the U.S. adult population [7]. Regardless, insomnia represents a considerable public health concern. Cognitive behavioral therapy for insomnia (CBT-I) has been endorsed as the first-line treatment for chronic insomnia by several health and medical associations, including the National Institutes of Health [8], the American Academy of Sleep Medicine [9], the British Medical Association [10], the American College of Physicians [11], and the U.S. Department of Veterans Affairs and the Department of Defense [12]. As a nonpharmacological treatment, CBT-I focuses on providing patients with behavioral and cognitive skills to improve their sleep quality and quantity. Behavioral skills include sleep restriction to match time in bed with actual sleep time, stimulus control and sleep hygiene techniques to foster healthy sleep habits, and breathing and relaxation techniques to help patients relax at bedtime. Cognitive skills include changing dysfunctional beliefs about sleep that increase arousal [6]. Despite the well-established effectiveness of interventions like CBT-I, relatively few individuals with insomnia—by some estimates, as few as only 13% [13]—have sought professional help. This low rate may be related to barriers such as cost, difficulty accessing care, limited availability of well-trained behavioral sleep medicine specialists, and work demands that dictate atypical sleep cycles and poor sleep habits [6,14]. The use of mobile technology for health care delivery, often referred to as “mobile health” or “mHealth,” has been identified as a potential way to overcome such barriers and increase access to care [14]. A recent report by the Pew Research Center found that 95% of individuals in the USA. own a cellular phone and 77% own a smartphone [15]. While there is some variation in smartphone ownership based on age, education, and household income, there is still widespread use. Also ubiquitous is the use of mHealth applications (“apps”). In 2014, over 60% of smartphone owners in the USA used their phones to search for health information and nearly one-third used an mHealth app to improve their health and fitness [16,17]. Currently, there exist hundreds of apps purporting to help users lose weight, exercise more, practice meditation, manage diabetes, and improve chronic pain. There are also hundreds of apps promising to help users improve sleep. These include apps attempting to help users fall asleep by encouraging relaxation techniques or providing soothing sounds, apps that allow users to monitor or record their sleep, and apps that focus on reducing specific sleep problems such as snoring [14]. There are also apps that claim to implement CBT-I or teach behavioral strategies to combat insomnia. The delivery of CBT-I or other behavioral treatment for insomnia via mHealth is nontraditional, yet there is compelling evidence of its potential feasibility and effectiveness based on outcomes from studies of other technology-delivered CBT-I. For example, a study comparing SHUTi, a six-module Internet-delivered treatment based on CBT-I, to wait list control found that participants assigned to the intervention condition and granted access to SHUTi for 9 weeks demonstrated statistically significant improvements in insomnia severity, number of awakenings, and sleep efficiency compared with those assigned to the control condition. Moreover, these improvements were maintained at 6-month follow-up [18]. Similarly, a study comparing a six-session Internet-delivered CBT program, a six-session Internet-delivered imagery relief therapy program, and treatment-as-usual found that Internet-delivered CBT was superior to both comparison conditions in improving sleep efficiency and daytime functioning. These improvements were maintained at 8-week follow-up [19]. Finally, a recent meta-analysis of 11 randomized controlled trials including a total of 1,460 participants and comparing Internet-delivered CBT-I to at least one nonintervention control condition (e.g., wait list) found that Internet-delivered CBT-I improved participants’ insomnia severity, sleep efficiency, subjective sleep quality, total sleep time, and number of nocturnal awakenings. Notably, these outcomes were comparable with those found in studies of face-to-face CBT-I [20]. In sum, insomnia is a public health issue affecting millions of adults in the U.S. CBT-I is a well-established nonpharmacological treatment for the disorder, but access to it is limited by factors including cost and provider availability. The number of Americans owning smartphones, using their phones to search for health information, and downloading mHealth apps for health and fitness is on the rise; thus, the use of mHealth to provide individuals with the behavioral and cognitive skills to improve their sleep may help ease the public health burden of this disorder. There are currently hundreds of apps available that claim to help individuals improve their sleep; however, to our knowledge, there to date has been no systematic review of such apps. Therefore, the aim of this study was to summarize the availability of such apps, assess the adherence of existing apps to evidence-based principles, and examine their usability. METHODS Methods for app identification, selection, and review were informed by recent published reviews of mobile apps for a variety of health concerns, including weight loss [21,22] and chronic pain [23,24]. First, searches for existing apps for the self-management or treatment of insomnia were conducted in the Apple iTunes and Google Play stores, as Apple and Google represent over 99% of the mobile operating systems market [25]. Searches were also conducted in the scientific literature, app clearinghouse websites, and social media to identify any additional apps. Next, the first author completed an initial screen of available apps to determine whether apps met inclusion criteria for download and further review. Two raters then downloaded each app that met inclusion criteria and coded each app on its adherence to evidence-based principles for insomnia treatment, as well as its usability. The first author and raters (K.E.M., K.T.L.) were doctoral-level clinical psychology trainees (i.e., postdoctoral fellows) with expert training and supervision in the evidence-based assessment and treatment of insomnia (e.g., CBT-I). As all information utilized in this review was retrieved from the public domain, the study was exempt from review by the authors’ Institutional Review Board. App selection As previously noted, Apple and Google currently claim over 99% of the mobile operating systems market [25] and thus the Apple iTunes and Google Play Stores were used as the two platforms in which to search for existing insomnia apps. To identify available apps, the first author first conducted a search in each app store in November 2016 with the search terms “insomnia,” “sleep treatment,” and “insomnia treatment.” These search terms were used to ensure comprehensiveness of results. To further ensure that as many apps as possible were included in the review, the research team also used the following methods, consistent with Boudreaux and colleagues’ recommendations for evaluating and selecting mobile health apps, to identify additional apps for the treatment of insomnia: (1) review the scientific literature, (2) search app clearinghouse websites, and (3) conduct a social media query within professional networks [26]. In this study, social media inquiry involved asking members of professional e-mail listservs to which the authors belonged about their awareness of any apps related to insomnia or sleep management. Apps discovered through these methods were then subject to the same review process as those apps found in the app store searches. Once the research team compiled a list of all available apps, the first author reviewed the description for each app written by the app developer and available in the app store prior to download to determine whether the app met criteria to be downloaded for further review. Inclusion and exclusion criteria were selected to ensure this review identified apps most likely to be beneficial to individuals struggling with insomnia and for users seeking the knowledge and skills to manage their sleep difficulty with the help of their smartphone only. Therefore, we purposefully excluded apps that were too broad in their focus, unrelated to insomnia, or required additional devices. To meet criteria for further review, an app had to be available in English and its app store description had to identify its purpose as the self-management or treatment of insomnia. An app was excluded from review if it focused only on services offered by specific clinics, provided only reading material on insomnia and/or sleep, was focused on a sleep problem other than insomnia (e.g., sleep apnea), provided only relaxing music or sounds for sleep, promoted only hypnosis for sleep, or required a wearable device (e.g., Fitbit) to use. App assessment Two raters (K.E.M., K.T.L.) independently downloaded and coded each app that met criteria for further review to assess the app’s basic features, its adherence to evidence-based principles for insomnia treatment, and its usability. After their independent reviews, the raters met to discuss any discrepancies. A protocol was developed for the raters to consult an expert in the assessment and treatment of insomnia in the event of continued disagreement; however, this did not prove necessary. The average inter-rater agreement across all apps after the raters’ independent review was 80% with a kappa coefficient of 0.78, indicating “substantial” agreement [27]. The raters reached consensus on all codes after discussion. Basic features In regard to basic features, the raters obtained the following information for each app: cost; average user rating from the app store; whether the app developer was an individual or group with reported expertise in the assessment and treatment of sleep problems; whether the app included a disclaimer about its use (e.g., that the app was intended to be used in conjunction with treatment from a health care professional); whether the app specified a program or duration of use; the inclusion of any education about sleep and sleep problems; the inclusion of interactive tools such as charts or graphs to depict users’ data; whether the app could be connected to another device (e.g., Fitbit); and whether the app could share data with users’ health care professionals. Evidence-based principles for insomnia treatment As previously discussed, CBT-I is recommended as the first-line treatment for adults with chronic insomnia. Therefore, apps were assessed according to whether they adhered to the skills, strategies, and techniques outlined in CBT-I. These skills, strategies, and techniques are hereon referred to as CBT-I “components” and include: conducting a sleep assessment; asking the patient to keep a sleep diary or log; providing education on sleep hygiene; providing education on stimulus control techniques; providing the patient with a sleep restriction prescription; introducing methods to reduce arousal around bedtime; and cognitive therapy for worries related to sleep [28]. Table 1 provides a brief description of each of these components. Table 1 | CBT-I Skills, Strategies, and Techniques Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. View Large Table 1 | CBT-I Skills, Strategies, and Techniques Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. Skill, strategy, or technique Description Sleep diary Sleep diaries are used to log individuals’ sleep patterns, determine sleep prescriptions, and assess treatment progress. Sleep diaries include the following information: daytime napping; time into bed; time to sleep; sleep latency; middle-of-the-night awakenings; time awake; time out of bed; subjective sleep quality. Sleep assessment Sleep assessments help determine whether individuals meet criteria for insomnia, and the severity of the disorder. Sleep assessments include the following information: difficulty falling asleep; difficulty staying asleep; waking up too early; satisfaction with current sleep pattern; distress related to current sleep pattern; impact of current sleep pattern on daily functioning; impact of current sleep pattern on quality of life. Sleep hygiene Sleep hygiene refers to the behaviors, conditions, and practices that affect sleep. Sleep hygiene recommendations include: stick to a sleep schedule; exercise, but not too late in the day; avoid caffeine and nicotine; avoid alcohol; avoid large meals and beverages late at night; avoid naps; develop a sleep ritual; take a hot bath before bed; have a good sleeping environment; do not lie in bed awake; get adequate exposure to natural light; use the bed only for sleeping and sex. Stimulus control Stimulus control refers to efforts to break associations between stimulating activities in bed (e.g., reading, watching TV) and not falling asleep. Stimulus control recommendations include: go to bed only when sleepy; get out of bed when unable to sleep; use bed only for sleep and sex; wake at same time every morning; avoid naps. Sleep restriction Sleep restriction is used to consolidate individuals’ sleep in order to improve their sleep efficiency. Sleep restriction involves two things: prescribing a daily sleep time; prescribing a daily wake time. Methods to reduce arousal Arousal reduction enables individuals to manage anxiety and stress that may interfere with sleep. Common methods to reduce arousal include: create time to unwind before bed; schedule worry time; take time at end of day to write to-do list for tomorrow; relaxation training; shift focus from anxiety when trying to relax; discourage behaviors that reflect trying too hard to sleep. Cognitive therapy Cognitive therapy is used in CBT-I to help individuals control their worry and decrease irrational thoughts about sleep or that interfere with sleep. Cognitive therapy techniques include: defining cognitive distortions (e.g., all or nothing thinking, catastrophic thinking, jumping to conclusions); discussing how cognitive distortions/negative thinking/irrational beliefs/ racing thoughts are related to anxiety and sleep problems; providing worksheets for countering cognitive distortions/negative thinking/irrational beliefs; providing tips for managing racing thoughts. View Large As they reviewed each app, the raters provided two ratings for each component listed above. The first rating related to the extent to which the app included the component. This rating ranged from 0 to 3, with 0 = not at all (e.g., the app included no education on sleep hygiene), 1 = some (e.g., the app included about one-third of the points typically made in sleep hygiene education), 2 = most (e.g., the app included about two-thirds of the points typically made in sleep hygiene education), and 3 = almost completely (e.g., the app included almost all of the points typically made in sleep hygiene education). The second rating related to the quality of the specific component. This rating ranged from low to high, with low = the feature was inaccurate based on CBT-I principles, or difficult to follow in the app (e.g., the app provided poor instructions); medium = the feature was accurate based on CBT-I principles, and easy enough to follow in the app (e.g., the app provided instructions but no demonstration of the feature); and high = the feature was accurate based on CBT-I principles, and very easy to follow in the app (e.g., the app provided instructions and demonstration of the feature). Usability The Mobile Application Rating Scale (MARS [29]) is a multidimensional, objective measure of app usability. It includes four subscales that measure an app’s engagement, functionality, aesthetics, and information quality. Items are rated on a scale specific to each item. For example, a sample item from the Engagement subscale is, “Is the app fun/entertaining to use? Does it use any strategies to increase engagement through entertainment (e.g., through gamification)?” Item responses range from 1 to 5, with 1 = dull, not fun or entertaining at all, and 5 = highly entertaining and fun, would stimulate repeat use. A sample item from the Functionality subscale is, “How easy is it to learn how to use the app; how clear are the menu labels/icons and instructions?” Item responses range from 1 to 5, with 1 = no/limited instructions; menu labels/icons are confusing; complicated, and 5 = able to use app immediately; intuitive; simple. The average of the item responses in each subscale constitutes the app’s Engagement, Functionality, Aesthetics, and Information Quality scores; these subscale scores are then averaged for an App Quality score. The MARS has been found to have high internal consistency [29]. In this study, the two raters completed the MARS for each downloaded app and the App Quality score was the primary outcome measure for app usability. Analytic plan To describe the extent to which an app included the skills, strategies, and techniques consistent with CBT-I, the average rating for each component of each app was calculated. The ratings for all components within each app were then averaged for an overall app score. In addition, the MARS App Quality score for each app was calculated to describe each app’s usability. RESULTS The initial search yielded 156 apps in the Apple iTunes Store and 199 apps in the Google Play Store (see Fig. 1 for flow chart). Six iPhone apps met inclusion criteria for full review. Two of these apps were also available in Google Play and were considered distinct from their Google Play versions in the event of variability due to differences in the operating systems. Along with these two apps, four additional Google Play apps met inclusion for further review. In addition, one app, available in both the iTunes and Google Play Stores, was identified via social media inquiry, specifically an e-mail sent to a behavioral health care listserv of which the first author was a member. No additional apps were identified in the scientific literature or app clearinghouse websites. Thus, a total of 12 apps were downloaded for further review. Table 2 provides a list of these apps, along with information on each app’s price, developer, app store user rating, component ratings and quality, overall app score, and usability rating. Table 2 | Apps’ General Characteristics, Component and Overall Scores, and MARS Usability Ratings App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 SD sleep diary; SA sleep assessment; SH sleep hygiene recommendations; SC stimulus control; SR sleep restriction prescriptions; AR methods to reduce arousal; CT cognitive therapy techniques. aApp Store Rating refers to average number of stars (0–5) provided by users. View Large Table 2 | Apps’ General Characteristics, Component and Overall Scores, and MARS Usability Ratings App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 App name (price) Developer App store ratinga CBT-I component ratings (quality) Overall app score MARS usability rating SD SA SH SC SR AR CT iTunes  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 27) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions N/A 2 (Med) 0 (N/A) 3 (High) 3 (Med) 3 (Med) 1 (Med) 0 (N/A) 1.71 3.25  MobileSleepDoc Pro (free) Somnology, Inc. 4.5 (N = 82) 3 (High) 2 (Med) 2 (Med) 3 (High) 3 (Low) 1 (Low) 0 (N/A) 2.00 3.71  Sleep | Insomnia: Better Sleep with CBT (free) Learning 2 Sleep N/A 0 (N/A) 3 (High) 3 (Med) 0 (N/A) 3 (Med) 1 (Med) 2 (Med) 1.71 4.18  Sleep Guru (free) Merck & Co. 1 (N = 1) 0 (N/A) 0 (N/A) 3 (Med) 2 (Med) 3 (Low) 2 (Med) 0 (N/A) 1.43 3.79  Sleepify (free) Massimo Lomuscio N/A 0 (N/A) 0 (N/A) 3 (High) 1 (Low) 0 (N/A) 1 (Med) 0 (N/A) 0.71 2.70  SleepRate (free) HypnoCore Ltd. 3.5 (N = 49) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 Google Play  CBT-I Coach (free) U.S. Dept of Veterans Affairs 4 (N = 94) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 3 (High) 2 (Med) 2.85 3.67  InsomniaFix (free) NOVOS Behavioral Health Solutions 5 (N = 1) 2 (High) 0 (N/A) 3 (High) 3 (Med) 3 (High) 1 (Med) 0 (N/A) 1.71 3.25  Insomnia Help (free)s Dusko Savic N/A 0 (N/A) 1 (Low) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.14 2.18  The Sleep School ($3.99) The Sleep School 3.5 (N = 11) 1 (Low) 2 (Low) 3 (Med) 1 (Low) 1 (Low) 1 (Med) 2 (Med) 1.57 4.40  SleepRate (free) HypnoCore Ltd. 3.7 (N = 76) 2 (Med) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0 (N/A) 0.29 3.88 SD sleep diary; SA sleep assessment; SH sleep hygiene recommendations; SC stimulus control; SR sleep restriction prescriptions; AR methods to reduce arousal; CT cognitive therapy techniques. aApp Store Rating refers to average number of stars (0–5) provided by users. View Large Fig 1 View largeDownload slide | Flowchart of app search process. Note: Of the 345 apps excluded from the study, 25% were excluded for focusing on a sleep problem other than insomnia; 23% for providing only relaxing music or sounds for sleep; 12% for focusing on hypnosis, meditation, or yoga for sleep; 11% for providing only reading material on insomnia and/or sleep; 8% for serving as screen savers only; and 21% for various other reasons (e.g., required a wearable device to use, not available in English). Fig 1 View largeDownload slide | Flowchart of app search process. Note: Of the 345 apps excluded from the study, 25% were excluded for focusing on a sleep problem other than insomnia; 23% for providing only relaxing music or sounds for sleep; 12% for focusing on hypnosis, meditation, or yoga for sleep; 11% for providing only reading material on insomnia and/or sleep; 8% for serving as screen savers only; and 21% for various other reasons (e.g., required a wearable device to use, not available in English). Of the excluded apps, 25% were focused on a sleep problem other than insomnia; 23% provided only relaxing music or sounds for sleep; 12% were apps that promoted hypnosis, meditation, or yoga for sleep; 11% provided only reading material on insomnia and/or sleep; 8% were apps with screen savers that dimmed phone screens or minimized their blue light; and 21% were excluded for various other reasons (e.g., required a wearable device to use, not available in English). Price Eleven of the 12 downloaded apps (91.7%) were downloaded free of charge. However, one app that was downloaded for free (SleepRate) required users to purchase a plan costing between $9.99 and $89.99 per year to access several features of the app. In this study, raters based their reviews on the app’s free features only. The Sleep School was downloaded for $3.99. App store ratings In both the Apple iTunes and Google Play Stores, users can rate apps on a scale of 0–5 stars, with more stars indicating greater satisfaction with an app. Three of the downloaded apps did not have user ratings. Of the remaining nine, the average rating was 3.65 (range: 1–5), from an average of 66.9 users (range: 1–94). Developer type Ten of the 12 apps (83.3%) reported being developed by or with consultation from sleep experts. These reports were made within the app (e.g., in an “About” section) or on the developer’s website. For example, users can navigate to the “About MobileSleepDoc” section in MobileSleepDoc Pro, where it states: “MobileSleepDoc is the first available sleep diagnosis and therapy application created by a sleep specialist, based on medical evidence but designed to be user friendly.” In the “About” section in CBT-I Coach, it states: “CBT-I Coach was a collaborative effort between the VA’s National Center for PTSD, Stanford University Medical Center, and DoD’s National Center for Telehealth and Technology.” Upon discovering InsomniaFix in the Apple iTunes Store, users can click on “Developer Website” to navigate to the app’s website. On the home page is the following statement: “The InsomniaFix application for Apple and Android is a self-help, tutorial program designed by Dr. Brian Wind, a board certified specialist in the treatment of insomnia and host of the popular talk radio program, The Sleep Doctors.” Sleepify and Insomnia Help did not report being developed by or in consultation with a sleep expert. Disclaimer Seven of the 12 apps (58.3%) provided some disclaimer about their use, warning individuals that wzapp developers were not responsible for any outcomes related to app use. For example, the “Terms & Conditions” section of Sleep | Insomnia: Better Sleep with CBT indicated that users who download and use the app acknowledge that users are “solely responsible for deciding which of the suggested techniques [they] put into practice and how to apply those techniques.” It also stated that the app is intended “for information and not as medical advice and should not be seen as a replacement for consultation with a doctor or other qualified healthcare professional.” Duration Five of the 12 apps (41.7%) provided an estimate of how long an individual would need to use the app to experience benefit. For example, an introduction to InsomniaFix stated that its program was “designed to take 8 weeks.” Sleepify indicated that its methods for improving sleep were most effective “when practiced for at least 15 days in a row.” Sleep Guru provided users with 10 days to complete health habit challenges aimed to improve sleep. Educational materials Eleven of the 12 apps (91.7%) included some basic background information on sleep. This included information on the stages of sleep, common conditions associated with poor sleep or insomnia (e.g., sleep apnea, depression, and nightmares), and links to other sleep resources. Interactive tools Ten of the 12 apps (83.3%) included features that allowed users to input data and/or receive feedback on data. For example, CBT-I Coach, MobileSleepDoc Pro, and SleepRate all provided users with graphs summarizing their sleep time and sleep efficiency. CBT-I Coach also allowed users to set alarms and reminders for wind down, bed, and wake times. Adjunct devices Six of the 12 apps (50%) allowed users to connect other devices, such as Fitbits, to the app. SleepRate offered users the opportunity to purchase a “sleep improvement kit” that included a heart rate sensor, personalized sleep assessment, and customized sleep improvement plan. Of note, the kit proved necessary to access several features of the app, including its assessment and therapy. Professional support None of the 12 apps (0%) allowed users to directly share data with a health care professional within the app. However, CBT-I Coach did allow users to export and e-mail a CSV file containing their sleep diary entries and sleep assessment scores to other parties. Adherence to evidence-based principles for insomnia treatment Table 2 provides each app’s individual CBT-I component ratings and overall app score. The average overall app score was 1.44 out of 3, with a range from 0.14 to 2.85. CBT-I Coach included the greatest number of CBT-I components (7 out of 7) and had the highest overall app score (2.85 out of 3). Six of its components received a rating of 3 and were of “high” quality; one received a rating of 2 and was of “medium” quality. Insomnia Help included the fewest number of CBT-I components (1 out of 7) and had the lowest overall app score (0.14 out of 3). Six of its components receiving a rating of 0; one received a rating of 1 and was of “low” quality. Usability Table 2 provides each app’s MARS overall usability rating. The average MARS usability rating was 3.54 out of 5, with a range from 2.18 (Insomnia Help) to 4.40 (The Sleep School). DISCUSSION The aim of this study was to identify and evaluate existing mHealth apps that claim to provide users with the behavioral and/or cognitive skills to manage insomnia. To meet this aim, comprehensive searches were conducted in the Apple iTunes and Google Play Stores in November 2016 to identify all apps related to the search terms “insomnia,” “insomnia treatment,” and “sleep treatment.” From this search—as well social network outreach—a total of seven iPhone and five Android apps were downloaded for further review of their basic features; adherence to evidence-based skills, strategies, and techniques for insomnia treatment; and usability. The vast majority of apps were available free of charge (91.7%) and reportedly developed by or with consultation from sleep experts (83.3%). Most provided some disclaimer about their use (58.3%) and none allowed users to directly share data with a health care professional (0%). Overall, the apps were moderately adherent to CBT-I principles, with an average app score of 1.44 out of a maximum 3. They demonstrated moderately high usability, with an average MARS score of 3.54 out of 5. To date, CBT-I Coach is the only app to have been tested in a randomized clinical trial. A pilot study by Koffel et al. [30] found that participants who were randomly assigned to use CBT-I Coach as a supplement to face-to-face CBT-I consistently used the app as intended, were particularly engaged with features such as the sleep diary and reminder functions, reported that the app was highly acceptable to them, and witnessed significant improvements in their sleep. Thus, there is evidence that people like and will use insomnia apps. Together, Koffel et al.’s and our studies point to an exciting opportunity for clinicians, researchers, and mHealth experts to develop and improve insomnia apps. To begin, experts can focus on ensuring that apps are consistent with the most effective, evidence-based treatment. In this study, a top overall app score of 3 with ratings of “high” on each individual evidence-based component would have indicated that the app was fully adherent to CBT-I skills, strategies, and techniques. However, no app achieved this score. Thus, even the best existing apps can be enhanced to be more consistent with CBT-I. For example, arguably the most important elements of CBT-I are the sleep diary, sleep restriction, stimulus control, and sleep hygiene. In face-to-face treatment, data obtained from the sleep diary enable providers to determine sleep restriction prescriptions, and patients are encouraged to practice stimulus control and good sleep hygiene in order to adhere to these prescriptions. However, several of the downloaded apps failed to provide users with a sleep diary and the remaining provided diaries of varying quality. For example, CBT-I Coach’s diary, coded as “high” quality by the study’s raters, assessed users’ daily time to bed, time to sleep, sleep latency, number of awakenings, final wake time, and subjective sleep quality. Of note, this diary is based on an expert consensus, standardized sleep diary [31]. On the other hand, the Sleep School’s “low” quality diary primarily inquired about how users’ sense of restfulness affected their daytime functioning without obtaining data on actual sleep obtained. Unsurprisingly, CBT-I Coach’s directions for sleep restriction were tailored to the individual user’s sleep data, whereas Sleep School’s instructions were nonspecific. CBT-I Coach required users to complete at least five diary entries in 1 week in order to obtain prescribed sleep and wake times; Sleep School encouraged all users, regardless of their sleep schedule, to delay their sleep time for 30 minutes for 3 weeks. Similarly, stimulus control and sleep hygiene recommendations were of varying quality or completely absent from the downloaded apps. MobileSleepDoc Pro’s “high” quality stimulus control recommendations provided users with “5 main principles” for stimulus control (go to bed when feeling sleepy; get out of bed when not asleep for more than 15–20 minutes; avoid naps; use bed and bedroom for sleep only; and maintain a regular waking schedule), along with a clear rationale for these principles. On the other hand, stimulus control recommendations were absent from Sleep | Insomnia: Better Sleep with CBT. This app did, however, provide users with the opportunity to choose one or more items from a list of sleep hygiene recommendations in order to generate an individually tailored “personal bedtime checklist.” The list included items such as avoiding smoking, caffeine, and soda; keeping bedroom temperature cool; keeping pets out of the bedroom; and setting one’s phone to Do Not Disturb. Ensuring that evidence-based strategies are not only included in apps but also of high quality would increase the likelihood that users benefit from the apps. Next, clinicians, researchers, and mHealth experts can collaborate with product designers and engineers to build apps that engage and entice users. According to Everett Rogers’ Diffusion of Innovations theory, one metric by which potential users of an innovation determine whether to adopt it is the innovation’s relative advantage—that is, the degree to which the innovation is perceived as better than the product it is to succeed [32]. Potential advantages of mHealth apps include their ability to be used flexibly (e.g., on the go) and privately; capture real-time data and provide personalized feedback; sync with other apps and devices; and create social support networks [33]. In this study, all apps could be used flexibly and privately. Most collected data via a sleep assessment or diary, but not all apps that collected data provided feedback. Only half of the apps allowed users to connect the app with another device to sync data. None exposed users to a social support network. Thus, mHealth app developers have several opportunities to increase the relative advantage of insomnia apps. To our knowledge, this study is the first to evaluate existing insomnia apps for their adherence to evidence-based principles. In addition to providing new information, it extends previous research on other health-related apps (e.g., weight loss and pain) by also evaluating apps’ usability. Previous reviews of existing mobile apps for other presenting problems have largely focused on apps’ adherence to evidence-based treatment principles [21–24] without considering apps’ ability to engage users. While these reviews have reported apps’ average iTunes Store or Google Play ratings, such ratings are a reflection of apps’ popularity rather than objective measures of their visual appeal, engagement, and functionality. These design features are important, as users are more likely to use or recommend apps they find easy to use and pleasant to look at [34,35]—and any treatment, whether provided in person or otherwise, can be effective only if it is actually accessed. By using the MARS in this study, we were able to provide a more objective assessment of each app’s usability. Interestingly, we found that apps’ usability scores were not necessarily correlated with their overall app score. For example, The Sleep School received the highest usability score (4.40 out of 5), indicating that it was visually appealing, engaging, and easy to use, but it had one of the lowest overall app scores (1.57 out of 3), indicating that it did not fully adhere to the skills, strategies, and techniques of CBT-I. Conversely, CBT-I Coach received the highest overall app score (2.85 out of 3), but had a moderate usability score (3.67 out of 5). Again, collaboration between clinicians, researchers, and mHealth experts may help entice users to download apps and increase their adherence to evidence-based recommendations made within apps. A limitation of this study is the possibility that apps that indeed included evidence-based strategies to manage insomnia were excluded because their app store descriptions did not clearly specify their aim as the self-management or treatment of insomnia. Relatedly, another limitation of this study is its small sample size. Given the relatively high prevalence of insomnia and the plethora of sleep-related apps that were found in our initial search, it is surprising that so few apps met criteria for further review. This is in stark contrast to similar reviews for chronic pain, diabetes, and weight management that examined many more apps. However, our inclusion and exclusion criteria were more stringent than those of other reviews in that we downloaded only those apps that purported to help users with the behavioral and/or cognitive self-management of insomnia rather than sleep difficulties more broadly. Thus, we excluded over 100 apps that focused more generally on poor sleep, too narrowly on specific sleep problems (e.g., snoring or sleep apnea), or provided only relaxing sounds to help induce sleep. In addition, our inter-rater agreement of 80% and inter-rater reliability of 0.78 may appear low, though as previously noted a kappa coefficient of 0.78 is considered “substantial” agreement [27]. The majority of discrepancies between our two raters were related to MARS usability ratings. The features assessed by the MARS—in particular, engagement, functionality, and aesthetics—are inherently subjective and ratings may be prone to raters’ visual preferences. However, the MARS is the first and only measure to our knowledge to standardize such ratings and therefore we consider its use in the study a strength. Currently, there exist over 97,000 mHealth apps in various app stores, and it appears that this marketplace will continue to grow [36]. However, this growth is dynamic and even unstable as mHealth apps appear and disappear from app stores. A recent study by Larsen et al. [37] found that the search result “half-life” for depression-related apps, defined as the period of time after which 50% of apps identified by the search term “depression” changed and no longer appeared in the search results, was 130 days in Google Play and over 9 months in the iTunes Store. Further, they found that only 37.8% of apps remained in the Google Play store 9 months after the initial search. This percentage was greater for apps in the iTunes Store—82.7%. They made this stark conclusion: “The number of clinically relevant apps that were no longer available to download at the end of the study period was equivalent to a depression app disappearing every 3.7 days on Android, every 13.7 days on iOS, or every 2.9 days across both platforms” [37]. Apps may be removed from app stores for several reasons, but the instability of the mHealth marketplace raises the question of whether and how much individuals can rely on apps for high quality information, self-management, and support. Many mHealth apps focus on helping individuals with problems that are commonly diagnosed and treated by health care providers with specialized training, insomnia included. Thus, the development and dissemination of such apps raises myriad ethical concerns. The overarching question seems to be how to clarify the role of health care providers in regulating app use. On the one hand, app users may be viewed as consumers who curiously seek advice, information, and skills without input from health care professionals. If that is the case, the role of clinicians, researchers, and mHealth experts may be solely to help develop apps that consist of high-quality information. On the other hand, app users may be viewed as patients who need expert assessment and care. In this case, the role of clinicians in particular may be much greater. It may include thoroughly reviewing apps and developing protocols to “prescribe” certain apps and discourage use of others. As new insomnia apps are developed and made available in the mHealth marketplace, future research should aim to clarify health care professionals’ roles in reviewing and recommending apps and increase patient engagement in evidence-based apps. In conclusion, this study found that despite the hundreds of apps that are currently available in the mHealth marketplace and claim to help individuals improve their sleep, few are adherent to the evidence-based skills and strategies that have been shown effective in managing insomnia. It is hoped that this article will help inspire clinicians, researchers, and mHealth experts to collaborate on efforts to improve existing apps and develop new ones. It is also hoped that this article will help inform patients and providers about the apps that currently exist and how to evaluate them. Funding: The study received no funding. Ethical disclosures: The study provided no treatment to human or animal experimental subjects. As no human subjects were involved in the study, informed consent was not necessary. Publication: The findings reported here have not previously been published and the manuscript is not being simultaneously submitted elsewhere. Data: The data have not previously been reported. The authors have full control of all primary data and agree to allow the journal to review their data if requested. Conflicts of interest: The authors declare that they have no conflicts of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. References 1. American Psychiatric Association . Diagnostic and Statistical Manual of Mental Disorders . 5th ed . Washington, DC : American Psychiatric Association ; 2013 . 2. Division of Sleep Medicine at Harvard Medical School, WGBH Educational Foundation . The relationship between sleep and health. Healthy sleep website . Available at http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-disease-risk. December 18, 2007 . Accessibility verified March 1, 2017 . 3. Roth T . 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Translational Behavioral MedicineOxford University Press

Published: Mar 21, 2018

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