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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 [46].”
From Online prenatal trial in mindfulness sleep management (OPTIMISM): Protocol for a pilot randomized controlled trial (2020) · cites this paper as [46]
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“However, the accessibility to cognitive-behavioral therapy for insomnia (CBT-I) in its standard format, that is, through face-to-face sessions delivered by a professional, is extremely limited in primary and routine cancer care mostly because of a lack of expertise and resources.(16,17) Self-administered CBT-I constit…”
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“However, provision of in-person CBT is limited by scarcity of trained therapists, long-wait lists and is costly, culminating in high unmet demands for treatment (Koffel et al., 2018).”
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“Although CBT-I is a prominent nonpharmacological treatment for insomnia, MT differs in mechanism: CBT-I generally focuses on regularizing sleep cycles through implementation of behavioral changes and identifying, challenging, and replacing negative perceptions that impair sleep (42), whereas MT may help an individual…”
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“…to identify scientific evidence for 10 MHAs (19%), this evidence included only one randomized controlled pilot study, and results of this study yielded non-significant group differences between on-site CBT-I paired with a MHA and regular on-site CBT-I on insomnia severity (Koffel et al., 2018b).”
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“For instance, previous research states that a lack of healthcare providers trained in the delivery of CBT-I is a barrier to accessing insomnia treatment (Koffel et al., 2018).”
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“The treatment may be the factor in the stress experienced by patients during CBT-I, directly or indirectly leading to increased anxiety and depressive symptoms during treatment (17).”
BackgroundImplementation of a digital cognitive behavioral therapy for insomnia pathway in primary care
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Self-citationVoice-Activated Cognitive Behavioral Therapy for Insomnia
Starling, C. M., Greenberg, D., Lewin, D. S., Shaw, C., Zhou, E. S., Lieberman, D. Z., Chou, J., & Arem, H. E. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.35011 · Cited by 22
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Koffel, E., Branson, M., Amundson, E. C., & Wisdom, J. P. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2020.1828085 · Cited by 20
“Another barrier to widespread use is that standard CBT-I is inaccessible and inconvenient for many patients (Koffel et al., 2018).”
BackgroundSelf-citationPatient perspectives on facilitators and barriers to equitable engagement with digital CBT-I
Cheng, P., Santarossa, S., Kalmbach, D. A., Sagong, C., Hu, K., & Drake, C. L. (2023) · Sleep Health · doi:10.1016/j.sleh.2023.07.003 · Cited by 19
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“Nevertheless, it is not without drawbacks, including discontinuation risks (Nam et al., 2023), relatively low accessibility (Koffel et al., 2018), and a time-consuming, intricate nature (Chung et al., 2023).”
BackgroundUndercover Dogs: Pet Dogs in the Sleep Environment of Patients with Chronic Pain
Brown, C. A., Wang, Y., & Carr, E. (2018) · Social Sciences · doi:10.3390/socsci7090157 · Cited by 19
“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).”
BackgroundBu, Z., Liu, F.-S., Shahjalal, M., Song, Y.-K., Li, M., Zhuo, R.-E., Zhong, Q., Du, Y.-W., Lu, C.-G., Yang, Z.-H., et al. (2025) · BMJ Evidence-Based Medicine · doi:10.1136/bmjebm-2024-113512 · Cited by 20
“Data were analysed using a random-effects model under the frequentist framework with Stata version 17.”
Tang, Y. W., Teoh, S. L., Yeo, J. H. H., Ngim, C. F., Lai, N. M., Durrant, S. J., & Lee, S. W. H. (2021) · Behavioral Sleep Medicine · doi:10.1080/15402002.2021.1915787 · Cited by 20
“Despite this, CBT-I is not readily available to all individuals, especially those from the socially disadvantaged group, those living in rural settings and in most low-middle income countries due to the high cost, a lack of trained providers or lack of access to online CBT-I packages (Beck et al., 2016).”
BackgroundInfluentialSleep Deficiency in the Elderly
Pappas, J. A., & Miner, B. (2022) · Clinics in Chest Medicine · doi:10.1016/j.ccm.2022.02.005 · Cited by 17
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Mapping the insomnia patient journey in Europe and Canada
O'Regan, D. J., Garcı́a-Borreguero, D., Gloggner, F., Wild, I., Leontiou, C., & Ferini‐Strambi, L. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1233201 · Cited by 19
The function of sleep and the treatment of primary insomnia
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The new science of sleep: From cells to large-scale societies
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“Of these, the most studied is the relationship between impaired sleep, Alzheimer’s disease, and the glymphatic system [89].”
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“However, because of the limited number of trained therapists, high costs, and time-intensive nature of in-person CBT for insomnia (CBT-I), millions of patients still do not have access to this effective treatment to improve their sleep outcomes [11].”
A closer look at yoga nidra- early randomized sleep lab investigations
Sharpe, E., Butler, M. P., Clark-Stone, J., Soltanzadeh, R., Jindal, R. D., Hanes, D. A., & Bradley, R. D. (2023) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2023.111169 · Cited by 16
Wake Up America: National Survey of Patients’ and Physicians’ Views and Attitudes on Insomnia Care
Benca, R. M., Bertisch, S. M., Ahuja, A., Mandelbaum, R., & Krystal, A. D. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12072498 · Cited by 16
“This contrasts with other studies reporting that referrals for CBT-I or psychological treatment are uncommon (5–10%) [8,20], which is consistent with our finding that 8% of PWTS reported currently receiving CBT-I therapy.”
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“…model, and clinical psychologists (Meaklim et al., 2021), who could be expected to work on later steps in the model, and may be an important reason why sleep problems are handled quite differently between individual healthcare professionals but rarely according to guidelines (Koffel et al., 2018).”
BackgroundMolla, A., & Wondie, T. (2021) · Sleep Disorders · doi:10.1155/2021/6611338 · Cited by 19
“The trained CBT-I providers can identify and challenge thoughts, feelings, and behaviors of individuals with sleep problem [56, 57].”
BackgroundYang, B., Nie, Q., & Yang, Y. (2021) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2021.110483 · Cited by 17
Guo, W., Nazari, N., & Sadeghi, M. (2024) · PeerJ · doi:10.7717/peerj.17491 · Cited by 15
“Moreover, CBT-I may not be accessible to all patients because of the limited availability of qualified therapists, low treatment acceptance, and poor adherence ( Lovato et al., 2014 ; Koffel, Bramoweth & Ulmer, 2018 ).”
BackgroundShergis, J. L., Hyde, A. J., Meaklim, H., Varma, P., Costa, C. D., & Jackson, M. L. (2020) · Complementary Therapies in Medicine · doi:10.1016/j.ctim.2020.102657 · Cited by 17
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“However, stand-alone DMHIs may have particular public health utility when they offer services that are difficult to access in the community (eg, specialty treatments such as cognitive behavior psychotherapy for insomnia [82]).”
Effectiveness of an App-Based Short Intervention to Improve Sleep: Randomized Controlled Trial
Vollert, B., Müller, L. K., Jacobi, C., Trockel, M., & Beintner, I. (2022) · JMIR Mental Health · doi:10.2196/39052 · Cited by 13
“However, reach and access to face-to-face, therapist-delivered CBT-I is limited [41-43], due to both structural and attitudinal barriers.”
Meaklim, H., Meltzer, L. J., Rehm, I. C., Junge, M. F., Monfries, M. M., Kennedy, G. A., Bucks, R. S., Graco, M., & Jackson, M. L. (2023) · SLEEP · doi:10.1093/sleep/zsad169 · Cited by 16
“…providers in sleep and circadian rhythms management [ 60– 80 ], A second barrier to CBT-I dissemination is that our mental healthcare providers lack general sleep and insomnia knowledge due to the limited sleep education taught within university-based healthcare training programs [52–54, 81, 93].”
BackgroundUsing Cannabis and CBD to Sleep: An Updated Review
Lavender, I., Garden, G., Grunstein, R. R., Yee, B. J., & Hoyos, C. M. (2024) · Current Psychiatry Reports · doi:10.1007/s11920-024-01564-7 · Cited by 16
“Cognitive behavioural therapy for insomnia (CBTi) faces obstacles to scalability [62, 63] and suffers issues with attrition in digital forms [64].”
Metadata
- 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
- 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 (medical) › 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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