Insomnia is a highly prevalent and impairing disorder for many adults.1 Although cognitive behavioral therapies for insomnia (CBT-I), the recommended first-line treatment,2–4 have been developed, tested, and refined over the past several decades, access to care to this treatment remains problematic. The gap between the need for treatment and the availability of trained providers is wide.
Estimates of providers trained in CBT-I from directories accessible through the Society of Behavioral Sleep Medicine and the University of Pennsylvania indicate fewer than 400 providers in the United States. Although not an exhaustive list, it is indicative of the scarcity of providers trained to deliver CBT-I. Furthermore, these providers are often clustered in few urban settings (i.e., New York, Philadelphia, Chicago, San Francisco), leaving much of the country without access to those clinicians who are most adept at treating insomnia. The Department of Veterans Affairs, the largest integrated health-care system in the United States, has made a significant effort to disseminate training in CBT-I to 1,000 clinicians in order to provide better care for the high percentage of Veterans with chronic insomnia.5,6 For the millions of Americans who are not Veterans and who suffer from insomnia, there is no access to these trained providers. Key barriers to increasing access to care include the ability to train new providers, educating and informing the public about cognitive behavioral treatments, developing integrated treatment models (e.g., primary care, sleep medicine), and resolving reimbursement issues with various payer systems.7
The research presented in this issue of Journal of Clinical Sleep Medicine by Feuerstein and colleagues offers one promising example of how to reduce the gap between the high need for insomnia care and the availability of treatment providers.8 The study involved a randomized controlled trial of a computer-based CBT-I (cb-CBT-I) program, RESTORE, which was delivered within a community mental health center and compared to an information control intervention. Participants who used the cb-CBT-I program showed significant improvements in both sleep quality (Pittsburgh Sleep Quality Index9) and insomnia severity (Insomnia Severity Index10). The effect of cb-CBT-I was strong—posttreatment group differences showed a moderate effect size for sleep quality (Cohen d = 0.72) and a large effect size for insomnia severity (Cohen d = 1.10). Additionally, more than half the treatment group (53%) achieved a treatment response per the Insomnia Severity Index (more than eight-point reduction baseline to posttreatment). Perhaps an equally important finding was the feedback from the participants about the treatment itself. The majority of participants found cb-CBT-I understandable, were able to apply the knowledge learned, and considered it to be useful. These are crucial aspects to any treatment with a goal of widespread use.
The findings of the study are consistent with other trials of cb-CBT-I programs. Both SHUTi11 and Sleepio,12 well-tested commercial products similar to RESTORE, show high rates of treatment response with large effect sizes. The study by Feuerstein and colleagues, however, has several strengths and advantages compared to many previous cb-CBT-I studies. Most notable was the real-world setting. Treatment was delivered in a community mental health center, which served many patients who may not have been able to purchase and/ or utilize cb-CBT-I in their own home because of a lack of finances and resources. Furthermore, the sample had both medical and psychiatric comorbidities that are common among adults with chronic insomnia. Offering insomnia treatment within a community mental health center, where psychiatric treatment was already being delivered, likely served as a key facilitator for accessing care in a population already burdened by numerous limitations.
Important next steps include testing cb-CBT-I in larger, real-world samples and settings. Expanding cb-CBT-I treatment across multiple clinics and settings is needed to further assess its ability to be effective, feasible, and sustainable. Computerized treatments fit well into a stepped care model13 but as with many adapted treatments, especially those rooted in technology, they may not be appropriate nor desired by all patients. In a recent editorial by Drs. Andrew Krystal and Aric Prather14 about the published results of a large randomized clinical trial using SHUTi,11 an important question was posed: “Should Internet CBT-I be the first-line treatment for all patients with insomnia?” Their answer, not surprisingly, was that it is likely premature to take this approach. The reality is that for some patients, cb-CBT-I based in a community clinic may be the only realistic option for treatment. Others, with access to the appropriate resources, can start at the bottom of the stepped-care pyramid with a cb-CBT-I program and, if necessary, move up toward the top of the pyramid to receive tailored in-person treatment with a board certified insomnia provider.
To truly increase access to care, evidence-based insomnia interventions must affect the patient, provider, administrative, and even social systems.15 Creating sustainable interventions for insomnia that adapts to the needs of the population and setting, be it in-person CBT-I delivered by a doctoral level psychologist certified in behavioral sleep medicine or a cb-CBT-I program in a community health center, requires more than just evidence. Implementation of insomnia interventions requires buy-in from patients, front-line clinicians, and administrative leadership, along with time and effort from staff who can champion the intervention, and office space and equipment. Perhaps most importantly, for insomnia interventions such as cb-CBT-I to be successfully implemented and integrated into routine clinical care they need to be sustainable, scalable, and in demand.16 Implementation of CBT-I to increase access to care will differ by setting, but the overarching goal will be the same: how can high-quality care be best delivered to patients? The advances in the past decade of computerized and mobile evidence-based interventions have significantly expanded the capacity to deliver insomnia care. Much work remains, with gaps to bridge and barriers to surmount. However, the successful implementation of a cb-CBT-I program in a community mental health center is certainly a step in the right direction.
Dr. Bramoweth has indicated no financial conflicts of interest. Dr. Bramoweth is supported by Career Development Award 13-260 from the United States Department of Veterans Affairs Health Services Research and Development Service. The views expressed are those of the author and do not necessarily represent the views of the United States Department of Veterans Affairs or the United States Government.
Bramoweth AD. A step in the right direction: moving towards increased access to insomnia care. J Clin Sleep Med. 2017;13(2):161–162.
Roth T, Coulouvrat C, Hajak G, et al. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, tenth revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, second edition criteria: results from the America Insomnia Survey. Biol Psychiatry. 2011;69(6):592–600. [PubMed]
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–133. [PubMed]
National Institutes of Health. National Institutes of Health state of the science conference statement on manifestations and management of chronic insomnia in adults, June 13-15, 2005. Sleep. 2005;28(9):1049–1057. [PubMed]
Wilson S, Nutt D, Alford C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders. J Psychopharmacol. 2010;24(11):1577–1601. [PubMed]
Manber R, Carney C, Edinger J, et al. Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. J Clin Sleep Med. 2012;8(2):209–218. [PubMed Central][PubMed]
Trockel M, Karlin BE, Taylor CB, Manber R. Cognitive behavioral therapy for insomnia with veterans: evaluation of effectiveness and correlates of treatment outcomes. Behav Res Ther. 2014;53:41–46. [PubMed]
Schmitz MF. The ACP guidelines for treatment of chronic insomnia: the challenge of implementation. Behav Sleep Med. 2016;14(6):699–700. [PubMed]
Feuerstein S, Hodges SE, Keenaghan B, Bessette A, Foreselius E, Morgan PT. Computerized cognitive behavioral therapy for insomnia in a community health setting. J Clin Sleep Med. 2017;13(2):267–274.
Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213. [PubMed]
Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. [PubMed]
Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a web-based cognitive behavior therapy for insomnia intervention with 1-year follow-up: a randomized clinical trial. JAMA Psychiatry. 2017;74(1):68–75. [PubMed]
Espie CA, Kyle SD, Williams C, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep. 2012;35(6):769–781. [PubMed Central][PubMed]
Espie C. “Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep. 2009;32(12):1549–1558. [PubMed Central][PubMed]
Krystal AD, Prather AA. Should internet cognitive behavioral therapy for insomnia be the primary treatment option for insomnia? Toward getting more SHUTi. JAMA Psychiatry. 2017;74(1):15–16. [PubMed]
Parthasarathy S, Carskadon MA, Jean-Louis G, et al. Implementation of sleep and circadian science: recommendations from the Sleep Research Society and National Institutes of Health workshop. Sleep. 2016;39(12):2061–2075. [PubMed]
Kreuter MW. Novel directions in dissemination research. Oral presentation at: 9th Annual Conference on the Science of Dissemination and Implementation in Health; December 14-15, 2016; Marriott Wardman Park, Washington, DC.