Joshua C. Magee

Efficacy of an Internet-Based Behavioral Intervention for Adults with Insomnia

CONTEXT Insomnia is a major health problem with significant psychological, health, and economic consequences. However, availability of one of the most effective insomnia treatments, cognitive behavioral therapy, is significantly limited. The Internet may be a key conduit for delivering this intervention. OBJECTIVE To evaluate the efficacy of a structured behavioral Internet intervention for adults with insomnia. DESIGN, SETTING, AND PARTICIPANTS Forty-five adults were randomly assigned to an Internet intervention (n = 22) or wait-list control group (n = 23). Forty-four eligible participants (mean [SD] age, 44.86 [11.03] years; 34 women) who had a history of sleep difficulties longer than 10 years on average (mean [SD], 10.59 [8.89] years) were included in the analyses. INTERVENTION The Internet intervention is based on well-established face-to-face cognitive behavioral therapy incorporating the primary components of sleep restriction, stimulus control, sleep hygiene, cognitive restructuring, and relapse prevention. MAIN OUTCOME MEASURES The Insomnia Severity Index and daily sleep diary data were used to determine changes in insomnia severity and the main sleep variables, including wake after sleep onset and sleep efficiency. RESULTS Intention-to-treat analyses showed that scores on the Insomnia Severity Index significantly improved from 15.73 (95% confidence interval [CI], 14.07 to 17.39) to 6.59 (95% CI, 4.73 to 8.45) for the Internet group but did not change for the control group (16.27 [95% CI, 14.61 to 17.94] to 15.50 [95% CI, 13.64 to 17.36]) (F(1,42) = 29.64; P < .001). The Internet group maintained their gains at the 6-month follow-up. Internet participants also achieved significant decreases in wake after sleep onset (55% [95% CI, 34% to 76%]) and increases in sleep efficiency (16% [95% CI, 9% to 22%]) compared with the nonsignificant control group changes of wake after sleep onset (8% [95% CI, -17% to 33%) and sleep efficiency (3%; 95% CI, -4% to 9%). CONCLUSIONS Participants who received the Internet intervention for insomnia significantly improved their sleep, whereas the control group did not have a significant change. The Internet appears to have considerable potential in delivering a structured behavioral program for insomnia. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00328250.

Cognitive Function Is Disrupted by Both Hypo- and Hyperglycemia in School-Aged Children With Type 1 Diabetes: A Field Study

OBJECTIVE We developed a field procedure using personal digital assistant (PDA) technology to test the hypothesis that naturally occurring episodes of hypo- and hyperglycemia are associated with deterioration in cognitive function in children with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 61 children aged 6–11 years with type 1 diabetes received a PDA programmed with two brief cognitive tests (mental math and choice reaction time), which they completed just before home glucose readings. The computer recorded time to complete each test and number of correct responses. Children completed several trials per day over 4–6 weeks for a total of 70 trials. Performance variables were compared across glucose ranges. Individual impairment scores (IISs) were also computed for each child by calculating the SD between performance during euglycemia and that during glucose extremes. RESULTS Time to complete both mental math and reaction time was significantly longer during hypoglycemia. During hyperglycemia, time to complete math was significantly longer and reaction time was marginally significant (P = 0.053). There were no differences on task accuracy. Decline in mental math performance was equivalent at glucose levels <3.0 and >22.2 mmol/l. IISs varied greatly across children, with no age or sex differences. CONCLUSIONS A decrease in mental efficiency occurs with naturally occurring hypo- and hyperglycemic glucose fluctuations in children with type 1 diabetes, and this effect can be detected with a field procedure using PDA technology. With blood glucose levels >22.2 mmol/l, cognitive deterioration equals that associated with significant hypoglycemia.

Sexual Health Information Seeking Online: A Mixed-Methods Study Among Lesbian, Gay, Bisexual, and Transgender Young People

The current study used a mixed-methods approach to investigate the positive and negative aspects of Internet use for sexual health information among lesbian, gay, bisexual, and transgender (LGBT) young people. A diverse community sample of 32 LGBT young people (aged 16-24 years) completed qualitative interviews focusing on how, where, and when LGBT young people use the Internet for sexual health information. Results indicate that although many participants seek facts and statistics about sexually transmitted infections (STIs) and HIV online, few conduct searches about broader aspects of sexual health. Participants reported that fear about becoming infected with STIs/HIV is a common motivator of searches and noted a number of reasons for not using online sexual health information, including stigma associated with being observed accessing LGBT or HIV information. Together, the results revealed not only significant interest in online sexual health information but also concerns about the perceived limitations of this promising method of sexual health promotion.

The Interplay between Online and Offline Explorations of Identity, Relationships, and Sex: A Mixed-Methods Study with LGBT Youth

Although the Internet is commonly used by lesbian, gay, bisexual, and transgender (LGBT) youth to explore aspects of sexual health, little is known about how this usage relates to offline explorations and experiences. This study used a mixed-methods approach to investigate the interplay between online and offline explorations of multiple dimensions of sexual health, which include sexually transmitted infections, sexual identities, romantic relationships, and sexual behaviors. A diverse community sample of 32 LGBT youth (ages 16–24) completed semi-structured interviews, which were transcribed and then qualitatively coded to identify themes. Results indicated that, although many participants evaluated online sexual health resources with caution, they frequently used the Internet to compensate for perceived limitations in offline resources and relationships. Some participants turned to the Internet to find friends and romantic partners, citing the relative difficulty of establishing offline contact with LGBT peers. Further, participants perceived the Internet as an efficient way to discover offline LGBT events and services relevant to sexual health. These results suggest that LGBT youth are motivated to fill gaps in their offline sexual health resources (e.g., books and personal communications) with online information. The Internet is a setting that can be harnessed to provide support for the successful development of sexual health.

Psychopathology and thought suppression: a quantitative review.

Recent theories of psychopathology have suggested that thought suppression intensifies the persistence of intrusive thoughts, and proposed that difficulty with thought suppression may differ between groups with and without psychopathology. The current meta-analytic review evaluates empirical evidence for difficulty with thought suppression as a function of the presence and specific type of psychopathology. Based on theoretical proposals from the psychopathology literature, diagnosed and analogue samples were expected to show greater recurrence of intrusive thoughts during thought suppression attempts than non-clinical samples. However, results showed no overall differences in the recurrence of thoughts due to thought suppression between groups with and without psychopathology. There was, nevertheless, variation in the recurrence of thoughts across different forms of psychopathology, including relatively less recurrence during thought suppression for samples with symptoms of Obsessive-Compulsive Disorder, compared to non-clinical samples. However, these differences were typically small and provided only mixed support for existing theories. Implications for cognitive theories of intrusive thoughts are discussed, including proposed mechanisms underlying thought suppression.

Web-based measurement: Effect of completing single or multiple items per webpage

The current study was conducted to determine whether participants respond differently to online questionnaires presenting all items on a single webpage versus questionnaires presenting only one item per page, and whether participants prefer one format over the other. Of participants seeking self-help treatment on the Internet (for depression, social phobia, or panic disorder), 710 completed four questionnaires (Beck Depression Inventory, Beck Anxiety Inventory, Quality of Life Index, Montgomery-Asberg Depression Rating Scale) on the Internet on two occasions. The questionnaires were either presented with one questionnaire on one webpage (e.g., BDI on one webpage) or on multiple webpages (e.g., BDI on 21 webpages with one item each). Results suggest that the four web questionnaires measure the same construct across diagnostic group (depression, social phobia, panic), presentation type (single versus multiple items per page), and order of presentation (which format first). Within each diagnostic group, factor means for all questionnaires were equivalent across presentation method and time. Furthermore, factor means varied as expected across samples (e.g., depressed group scored higher on BDI), providing evidence of construct validity. The majority of participants in each diagnostic group preferred the single item per page format, even though this format required more time.

Validation of the Insomnia Severity Index as a Web-Based Measure

Although the Insomnia Severity Index (ISI) is already administered online, this frequently used instrument has not been validated for Web delivery. This study compares online and paper-and-pencil ISI versions completed by participants in a randomized controlled trial testing an Internet-delivered intervention for insomnia. Forty-three adults with insomnia completed both ISI versions during pre- (Assessment 1) and post-intervention (Assessment 2). Correlations between total scores of both versions were significant (rs ≥ .98, ps < .001). For both ISI versions, internal consistency was acceptable (Assessment 1, α = .61; Assessment 2, α ≥ .88). Among participants not receiving the parent study intervention, correlations between 1 format at Assessment 1 and the alternative format at Assessment 2 were generally significant (rs = .26–.82). Together, findings suggest the ISI can be delivered online.

Blood Glucose Awareness Training Delivered Over the Internet

OBJECTIVE—Blood glucose awareness training (BGAT), a psycho-educational intervention, trains individuals with type 1 diabetes to 1) detect/interpret internal cues to better detect extreme blood glucose levels, e.g., neurogenic and neuroglycopenic symptoms; and 2) interpret external cues to detect current and anticipate future extreme blood glucose levels, e.g., insulin timing/dose and recent self-monitoring of blood glucose results. Although outcome studies using BGAT are significant, limitations include the requirement of eight weekly meetings and limited professionals trained to deliver BGAT. RESEARCH DESIGN AND METHODS—Due to the limitations mentioned above, BGAT was converted for web-based delivery. The internet allows BGAT delivery to be dynamic, engaging, convenient, and personalized. Efficacy was evaluated using a 2 (BGAThome, n = 20, vs. control, n = 20) × 2 (pre/post) design. RESULTS—BGAThome was judged as useful and easy to use, was completed by 94% of the participants, and resulted in significant clinical improvements (P < 0.05). CONCLUSIONS—The internet may be an efficient and effective means of delivering diabetes interventions like BGAT.

User Preferences for a Text Message–Based Smoking Cessation Intervention

Younger adults are more likely to smoke and less likely to seek treatment than older smokers. They are also frequent users of communication technology. In the current study, we conducted focus groups to obtain feedback about preferences for a text message–based smoking cessation program from potential users. Participants (N = 21, M age = 25.6 years, age range = 20-33 years) were current or recently quit smokers (M cigarettes/day = 12.8) who used text messaging. Participants completed questionnaires and participated in a 2-hour focus group. Focus groups were conducted using an a priori semistructured interview guide to promote discussion of the content and functionality of the intervention. Major themes from analysis of the focus groups included support for the acceptability of a text-based cessation program, suggestions for a more technologically broad-based program, and adjustments to the program structure. Participants recommended including social networking functions, user control of program output through an online profile, and text message features to promote interaction with the system. Interestingly, many participants suggested the program should begin on individuals’ identified quit day, challenging the procedures used in most cessation programs, which begin by preparing participants for a future quit date. Overall, younger adult smokers appear to be interested in participating in a smoking cessation program that uses text messages and web-based elements. Qualitative feedback regarding the perceived optimal features and structure of a technology-based intervention challenged traditional methods of implementing smoking cessation interventions and will inform the development of future programs.

Exploring the Relationship between Parental Worry about their Children's Health and Usage of an Internet Intervention for Pediatric Encopresis

OBJECTIVE To investigate whether parental worry about their childrens health predicts usage of a pediatric Internet intervention for encopresis. METHODS Thirty-nine families with a child diagnosed with encopresis completed a national clinical trial of an Internet-based intervention for encopresis (www.ucanpooptoo.com). Parents rated worry about their childrens health, encopresis severity, current parent treatment for depression, and parent comfort with the Internet. Usage indicators were collected while participants utilized the intervention. RESULTS Regression analyses showed that parents who reported higher baseline levels of worry about their childrens health showed greater subsequent intervention use (beta =.52, p =.002), even after accounting for other plausible predictors. Exploratory analyses indicated that this effect may be stronger for families with younger children. CONCLUSIONS Characteristics of individuals using Internet-based treatment programs, such as parental worry about their childrens health, can influence intervention usage, and should be considered by developers of Internet interventions.