Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

Abstract

The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.

The European Academy for Cognitive Behavioural Therapy for Insomnia: An initiative of the European Insomnia Network to promote implementation and dissemination of treatment

“…However, as Morin () in his editorial about the European guideline (Riemann, Baglioni, et al, ) noted, the central challenge is the implementation of these clinical practice guidelines for the management of chronic insomnia within the various healthcare systems of Europe. Data from different sources indicate that at present, CBT‐I is offered only to a very small proportion of patients suffering from chronic insomnia (e.g., Koffel, Bramoweth, & Ulmer, ). Furthermore, pharmacotherapy is still by far the most prevalent intervention for insomnia in routine healthcare worldwide.…”

“…Thus, GPs have a pivotal role in treating patients with insomnia. Despite this, available data indicate that GPs rarely prescribe or are able to offer CBT‐I to patients with insomnia (e.g., Everitt et al, ; Koffel et al, ). In the Netherlands, according to national GP standards, GPs should offer certain aspects of CBT‐I.…”

The effect of mindfulness meditation on sleep quality: a systematic review and meta‐analysis of randomized controlled trials

“…While effective, they have the potential for abuse, cross‐reactivity with other medications, and side effects, including memory loss, abnormal thoughts, behavioral changes, and headaches . Alternatively, behavioral treatments, such as cognitive behavioral therapy for insomnia (CBT‐I), can be expensive and inaccessible . While the risks are attenuated with CBT‐I, some of the therapeutic components, such as intensive sleep restriction, may exacerbate comorbid psychiatric symptoms and thus compromise adherence .…”

“…8,9 Alternatively, behavioral treatments, such as cognitive behavioral therapy for insomnia (CBT-I), can be expensive and inaccessible. 10 While the risks are attenuated with CBT-I, some of the therapeutic components, such as intensive sleep restriction, may exacerbate comorbid psychiatric symptoms and thus compromise adherence. [11][12][13] Taken together, there is a need for complementary health interventions, which increase patient choice and may be offered as a second-line treatment option when first-line treatments are not viable or are intolerable.…”

Undercover Dogs: Pet Dogs in the Sleep Environment of Patients with Chronic Pain

“…However, ongoing use of sleep medication can contribute to a range of negative side-effects and insomnia management guidelines recommend short term use only (Riemann et al 2017). While cognitive-behavioral therapies (CBT) are regarded as first-line interventions (Riemann et al 2017) this form of treatment is not always acceptable to patients nor readily available (Koffel et al 2018). Beyond CBT, few studies exist specific to development and testing of pragmatic and accessible non-pharmacological sleep strategies for persons with pain and research is much needed.…”