Poor sleep during adolescence is common, with insomnia, defined as chronic dissatisfaction with sleep quantity or quality, being the most prevalent sleep disorder [1,2]. Insomnia symptoms are reported by one-third of adolescents and up to a quarter fulfill the diagnostic criteria for insomnia, depending on the definition and method of assessment [3,4]. Insomnia symptoms are persistent [2] and are associated with significant mental health problems including depression, anxiety, substance abuse, and suicidal ideation [3,5-7].

Research examining the nature of association between adolescent sleep disturbance and mental health is limited and the findings are inconsistent [8]. There is evidence of a bidirectional relationship, where symptoms of insomnia during adolescence both predict and are predicted by depression and depressive symptoms [9-11]. However, overall, there is more evidence to suggest that insomnia symptoms precede the development of anxiety and depression in adolescence more than the reverse [8,12-14]. This suggests that the provision of interventions that directly address insomnia could reduce the risk of developing mental health problems or reduce current symptomatology [12].

With adults, there is well-established evidence that treating insomnia can improve mental health including depression [15], anxiety [16], and psychotic experiences [17]. Interventions are based on cognitive behavioral therapy for insomnia (CBTi) and typically include a range of techniques including stimulus control, relaxation training, sleep restriction, sleep hygiene, and cognitive techniques to manage worries and intrusive thoughts [18]. Insomnia interventions can be delivered via the internet, with systematic reviews concluding that Web-based CBTi is effective and improves both sleep and mental health [19-21].

With adolescents, research examining the effect of CBTi on sleep and mental health is promising but very limited [18,22]. An open, uncontrolled pilot study assessing a 5-week CBTi intervention for depressed adolescents with insomnia found postintervention improvements in sleep and mood [23]. Similarly, augmenting depression treatment with CBTi in a randomized controlled trial involving 40 adolescents aged 12-20 years resulted in positive effects on sleep and depression [24]. In a community study, Bruin et al [25] found that CBTi delivered either face-to-face or over the internet to 12-19-year olds with insomnia was similarly effective and resulted in comparable improvements in sleep and psychopathology (anxiety and depression) compared with a waiting list control group. The authors concluded that improvements in psychopathology were attributable to a reduction of insomnia and recommended that further research should be undertaken within clinical settings.

The aim of this study is to assess the feasibility of adding supported Web-based CBTi to the usual care for young people aged 14-17 years attending specialist Child and Adolescent Mental Health Services (CAMHS).

This is a pre-post uncontrolled mixed-methods feasibility study. The study was funded by the Wiltshire Child Mental Health Commissioning Group, and ethical approval was obtained from the South West-Central Bristol Research Ethics Committee (17/SW/0178).

The study will be undertaken in CAMHS within the Oxford Health National Health Services Foundation Trust. The Trust serves a wide geographical area that includes Bath and North East Somerset, Swindon, and Wiltshire.

Young people will be eligible to participate if they are aged 14-17 years, attending CAMHS with symptoms of insomnia (ie, time asleep/time in bed ≤85%) as either a primary issue or as a comorbidity, motivated to try and improve their sleep, and interested in using Sleepio.

Motivation is assessed by rating each of 3 questions on a 10-point Likert scale from 0 (strongly disagree) to 10 (strongly agree). The questions relate to problem severity (“At present, sleep is a big problem for me”), desire to change (“I want to change my sleep”), and self-efficacy (“I feel I can change my sleep”). For inclusion, each item must be rated ≥5.

Young people will be ineligible to participate if they are presenting with active suicidal ideation, they have been diagnosed with psychosis, there are current safeguarding concerns (ie, the young person has suffered abuse within the last 6 months or is the subject of a safeguarding investigation), or they have a significant developmental disorder (eg, autism) that prevents them from understanding the program.

As this is a feasibility study, any face-to-face intervention or medication that the young person is receiving through CAMHS will not be interrupted. This trial will, therefore, run alongside any treatment as usual.

Clinical staff working in CAMHS teams across Bath and North East Somerset, Swindon, and Wiltshire will identify eligible young people. Interested young people and their caregivers will be provided with a project information sheet, and their details will be passed to the research team. A research assistant will contact the young person to discuss the project, obtain written consent, and complete baseline measures. For those under the age of 16, parental consent will also be required. Meetings will take place at the individual’s home, at the University of Bath, via telephone, or at a community venue, depending on participants’ preference.

Sleepio is an established, fully automated, Web-based, self-administered sleep intervention that has been evaluated with adults [17,26,27]. The intervention is free to study participants and consists of 6 sessions, each lasting approximately 20 minutes, which are released each week. The sessions are accessed via a Web browser on a tablet, desktop, or mobile phone. The program is highly interactional, and content is presented via an animated cartoon therapist (The Prof). Participants complete daily mobile app or Web-based sleep diaries throughout the program, with an algorithm personalizing the content to the individual’s needs. Sleepio is based on CBTi and incorporates cognitive, behavioral, and educational components (Figures 1 and 2).

The study procedures are summarized in Figure 3.

Once eligible young people have provided consent and completed baseline measures, they will be emailed an individual access code for Sleepio. A Sleepio Assistant will contact each young person to discuss the goals that they wish to achieve at the end of Sleepio and agree times for future support calls. Sessions are released each week.

The Sleepio Assistants will monitor progress through the Sleepio dashboard, which summarizes when the young person has accessed each session. Reminder emails and telephone calls will be sent if young people are not engaging with their session. When the 6 sessions have been completed, a member of the research team will arrange to meet with the young person and conduct the postuse assessment.

The following standardized assessments will be completed pre- (baseline) and post-Sleepio completion (8-10 weeks). Although the program consists of 6 weekly sessions, previous research indicates that the majority of participants complete the course within 10 weeks [28]. Our primary outcome is changes in sleep, with secondary outcomes assessing symptoms of depression and anxiety.

Formal power calculations were not deemed necessary due to this being an initial feasibility study. Recruiting 50 young people should provide sufficient information to determine whether Sleepio is perceived as acceptable and results in improved sleep and mental health in young people [35].

We will present descriptive statistics summarizing the cohort in terms of age, gender, sleep, and anxiety and depressive symptomology. Descriptive statistics will also be used to summarize engagement with Sleepio in terms of the number of sessions completed versus the number of those who dropped out. t test analyses of mean scores will be conducted on the total scores for the pre- and postmeasures of sleep (ISI and SCI) and on the total and subscale scores for the pre- and postmeasures of mood (RCADS and MFQ). This will allow exploration of any changes in sleep or psychological functioning following Sleepio use. Postuse semistructured interviews will be analyzed to determine the acceptability of Sleepio among young people. The interviews will be audiorecorded and transcribed. A predefined framework will be derived from the interview schedule and adapted following participant responses for analysis.

This study aims to determine the feasibility of adding supported Web-based CBTi for young people aged 14-17 years attending specialist CAMHS. Our study is addressing an important problem and will provide preliminary evidence about whether supported Web-based CBTi is acceptable to young people with mental health problems and about the postintervention effects on sleep and symptoms of anxiety and depression. If found to have a positive effect on mental health, this low-intensity intervention delivered with minimal therapist support could readily increase the limited capacity of traditional CAMHS. However, the implementation, effectiveness, and sustainability of supported CBTi in child mental health services would need to be determined before its widespread adoption could be advocated.

Although this is a feasibility study, limitations in the study design need to be acknowledged. First, we are relying on self-report measures of sleep and are not using objective actigraphy measures. Retrospective self-report may be prone to inaccuracies, but while wearable devices are able to prospectively monitor and track sleep, they are not always reliable or accurate [36]. Subjective reports do provide useful information, which we will supplement with prospectively completed sleep diaries as young people progress through Sleepio [8].

Second, this is an open trial, and we do not have any control or comparison groups. This will not allow comparative insights into whether any improvements are due to the Sleepio intervention, the young person’s ongoing mental health intervention, or the passing of time. At this stage, our primary aim is to determine the acceptability and feasibility of using Sleepio with young adolescents, not to determine its efficacy. The inclusion of comparison group(s) to control for these variables will be considered in a subsequent trial.