Use of mindfulness mobile apps has become popular, however, there is little information about subscribers' perceptions of app content and its impact on sleep and mental health. The purpose of this study was to survey subscribers to Calm, a popular mindfulness meditation app, to explore perceived improvements in sleep and mental health, evaluate what components of the app were associated with improvements in sleep and mental health, and determine whether improvements differed based on sleep quality. Calm subscribers who had used a sleep-related component in the last 90 days completed a Web-based investigator-developed survey and the Pittsburgh Sleep Quality Index. The survey included questions about using Calm for sleep, sleep disturbances, mental health diagnoses (i.e., anxiety, depression, PTSD) and perceived impacts of the app. Participants reported on the extent to which they felt that using Calm had improved their sleep and mental health. Most participants reported sleep disturbance, and almost half reported a mental health diagnosis. The majority of participants reported that using Calm helped them fall asleep, stay asleep, and get restful sleep. All sleep components were associated with perceived improvements in sleep disturbance. Severity of sleep disturbance moderated relationships between using Calm components and reporting improved sleep. Among subscribers with mental health diagnoses, most reported that Calm helped improve symptoms. Perceived improvement in anxiety and depression was associated with using Calm's meditation components but not Sleep Stories or music/soundscapes. Severity of sleep disturbance did not moderate relationships between using Calm components and reporting mental health improvements. Given the accessibility of app-based meditation, research is needed to evaluate the efficacy of meditation apps to improve sleep disturbance. While some sleep content may be helpful for sleep, more research is needed to test what specific content affects mental health.

Background

Over 30% of Americans report regular sleep disturbance, and consumers are increasingly seeking strategies to improve sleep. Self-guided mindfulness mobile apps may help individuals improve their sleep. Despite the recent proliferation of sleep content within commercially available mindfulness apps, there is little research on how consumers are using these apps for sleep.

Objective

We conducted a cross-sectional survey among subscribers to Calm, a popular, consumer-based, mindfulness-based meditation app, and described and compared how good sleepers, poor sleepers, and those with self-reported insomnia use the app for sleep.

Methods

Participants who were paying subscribers of Calm and had used a sleep component of Calm in the last 90 days were invited to complete an investigator-developed survey that included questions about sleep disturbance and the use of Calm for sleep. Based on self-reports of sleep disturbances and of insomnia diagnosis, participants were categorized as "good sleepers," "poor sleepers," or "those with insomnia diagnosis." Chi-square tests compared reasons for downloading the app and usage patterns across participants with and without sleep disturbance.

Results

There was a total of 9868 survey respondents. Approximately 10% of participants (1008/9868, 10.21%) were good sleepers, 78% were poor sleepers (7565/9868, 77.66%), and 11% reported a diagnosis of insomnia (1039/9868, 10.53%). The sample was mostly White (8185/9797, 83.55%), non-Hispanic (8929/9423, 94.76%), and female (8166/9578, 85.26%). The most common reasons for sleep disturbances were racing thoughts (7084/8604, 82.33%), followed by stress or anxiety (6307/8604, 73.30%). Poor sleepers and those with insomnia were more likely than good sleepers to have downloaded Calm to improve sleep (χ²₂=1548.8, P<.001), reduce depression or anxiety (χ²₂=15.5, P<.001), or improve overall health (χ²₂=57.6, P<.001). Respondents with insomnia used Calm most often (mean 5.417 days/week, SD 1.936), followed by poor sleepers (mean 5.043 days/week, SD 2.027; F₂=21.544, P<.001). The most common time to use Calm was while lying down to sleep (7607/9686, 78.54%), and bedtime use was more common among poor sleepers and those with insomnia (χ²₂=382.7, P<.001). Compared to good and poor sleepers, those with insomnia were more likely to use Calm after waking up at night (χ²₂=410.3, P<.001). Most participants tried to use Calm on a regular basis (5031/8597, 58.52%), but regular nighttime use was most common among those with insomnia (646/977, 66.1%), followed by poor sleepers (4040/6930, 58.30%; χ²₂=109.3, P<.001).

Conclusions

Of the paying subscribers to Calm who have used one of the sleep components, approximately 90% have sleep difficulties, and 77% started using Calm primarily for sleep. These descriptive data point to areas of focus for continued refinement of app features and content, followed by prospective trials testing efficacy of consumer-based meditation mobile apps for improving sleep.

The objective of this randomized controlled trial was to test whether a commercially available, mindfulness meditation mobile app, (i.e., Calm app), was effective in reducing fatigue (primary outcome), pre-sleep arousal, and daytime sleepiness (secondary outcomes) in adults with sleep disturbance (Insomnia Severity Index Score >10) as compared to a wait-list control group. Associations between the use of the Calm app (i.e., adherence to the intervention) and changes in sleep quality was also explored in the intervention group only. Adults with sleep disturbance were recruited (N = 640). Eligible and consenting participants (N = 263) were randomly assigned to the intervention (n = 124) or a wait-list control (n = 139) group. Intervention participants were asked to meditate using the Calm app ≥10 minutes/day for eight weeks. Fatigue, daytime sleepiness, and pre-sleep arousal were assessed at baseline, mid- (4-weeks) and post-intervention (8-weeks) in both groups, whereas sleep quality was evaluated only in the intervention group. Findings from intent-to-treat analyses suggest the use of the Calm app for eight weeks significantly decreased daytime fatigue (p = .018) as well as daytime sleepiness (p = .003) and cognitive (p = .005) and somatic (p < .001) pre-sleep arousal as compared to the wait-list control group. Within the intervention group, use of the Calm app was associated with improvements in sleep quality (p < .001). This randomized controlled trial demonstrates that the Calm app can be used to treat fatigue, daytime sleepiness, and pre-sleep arousal in adults with sleep disturbance. Given that the Calm app is affordable and widely accessible, these data have implications for community level dissemination of a mobile app to improve sleep-related symptoms associated with sleep disturbance. Trial registration: ClinicalTrials.gov NCT04045275.