Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review
Open accessAbstract
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.
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Despite the high prevalence of sleep disturbance during pregnancy, effective behavioral treatments are largely inaccessible because of time, cost, and insufficient numbers of trained therapists.
“Despite the high prevalence of sleep disturbance during pregnancy, effective behavioral treatments are largely inaccessible because of time, cost, and insufficient numbers of trained therapists [46].”
From Online prenatal trial in mindfulness sleep management (OPTIMISM): Protocol for a pilot randomized controlled trial (2020) · cites this paper as [46]
The Patient Barriers section reports time constraints as a barrier to CBT-I, and the System Barriers section says demand for CBT-I specialists exceeds supply. The review does not establish these barriers specifically during pregnancy or identify treatment cost as an access barrier; its discussion of economic costs concerns insomnia itself. (LLM, conf=0.88)
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- Authors
- Koffel, E., Bramoweth, A. D., & Ulmer, C. S.
- Affiliations
- University of Minnesota (US)
- VA Pittsburgh Healthcare System (US)
- Duke University (US)
- Corresponding author
- Koffel, Erin
- Venue
- Journal of General Internal Medicine
- Published
- 2018-04-04
- Volume
- 33
- Issue
- 6
- Pages
- 955-962
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC5975165
- OpenAlex
- W2795657325
- Cited by
- 391
- References
- 82
- Citations by year
- 2026: 66 · 2025: 70 · 2024: 69 · 2023: 62 · 2022: 49 · 2021: 27 · 2020: 32 · 2019: 11 · 2018: 4 · 2017: 1
- FWCI
- 2.95
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- www.springer.com/tdm (tdm)
- Locations
- Journal of General Internal Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Veterans Affairs
- University of Minnesota
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Health Sciences › Medicine › Physiology › Obstructive Sleep Apnea Research
- Keywords
- cognitive behavioral therapy for insomnia, insomnia, barriers to treatment access, primary care referral, behavioral sleep medicine, sleep screening, patient engagement, treatment beliefs, implementation research, guideline-concordant care, hypnotic dependence
- MeSH terms
- Health Services Accessibility, Humans, Sleep Initiation and Maintenance Disorders, Patient Acceptance of Health Care, Primary Health Care, Cognitive Behavioral Therapy
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