Cited by 391Sleep and related disordersHealth Policy Implementation ScienceObstructive Sleep Apnea Research

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

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Koffel, Erin, Bramoweth, Adam D., Ulmer, Christi S.·2018·Journal of General Internal Medicine

DOI 10.1007/s11606-018-4390-1PMC PMC5975165

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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.

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“83 .”
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Background
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Use of Insomnia Treatments and Discussions About Sleep with Health Professionals Among Australian Adults with Mental Health Conditions
Russell, D. I., Reynolds, A. C., Appleton, S., Adams, R., Correia, H., Bowman, J., Gill, T. K., & Metse, A. P. (2023) · Nature and Science of Sleep · doi:10.2147/nss.s412468 · Cited by 1
“Lastly, it is worth mentioning that the availability of health professionals trained in CBTi can be a potential barrier for consumers seeking first line treatment.(24,38) However, this specific barrier was not included as an option in the survey, and therefore, its impact on treatment access and utilisation was not di…”
Background
Global trend of nondrug and nonsedativehypnotic treatment forinsomnia: a bibliometric study.
Lei, H., Xu, G., Zepeng, W., Ling, Z., & Fan-rong, L. (2024) · PubMed Central · doi:10.19852/j.cnki.jtcm.20240408.002 · Cited by 1
Harnessing the Power of Integrated Behavioral Health to Enhance Insomnia Intervention in Primary Care
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“Patients report numerous external pressures, such as work schedules or childcare, that make it difficult to modify sleep routines, habits, and schedules [21].”
BackgroundInfluential
Perceptions and Effectiveness of a Fully Automated Brief Behavioral Insomnia Therapy, Delivered by a Virtual Companion, in Older and Young Adults
Sagaspe, P., Sánchez-Ortuño, M. M., Dupuy, L., Pécune, F., Coelho, J., Micoulaud‐Franchi, J., Levavasseur, Y., de Sevin, É., Chanteclair, A., Philip, P., et al. (2024) · Innovation in Aging · doi:10.1093/geroni/igae086 · Cited by 1
“Nonetheless, access to a sleep specialist in CBT-I is restricted for many patients in need, and most primary care physicians are not sufficiently trained to perform CBT-I (Espie, 2009; Koffel et al., 2018).”
Preliminary feasibility and efficacy of a brief behavioural treatment for insomnia after acquired brain injury: A case series
Gardani, M., Baylan, S., & Zouhar, V. (2025) · Journal of Sleep Research · doi:10.1111/jsr.14441 · Cited by 1
Effects of happy sensation training group on the symptom of anxiety, depression and sleep structure: a randomized controlled trial
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Prevention of Pain Interference in Insomnia Patients via Digital Cognitive-Behavioral Therapy for Insomnia
Jennings, M. B., Kalmbach, D. A., Reffi, A. N., Miller, C. B., Roehrs, T., Drake, C. L., & Cheng, P. (2025) · Behavioral Sleep Medicine · doi:10.1080/15402002.2025.2500519 · Cited by 1
“Given the lack of qualified CBT-I providers across the U.S. (Koffel et al., 2018; Thomas et al., 2016). dCBT-I could expand access to an unprecedented number of patients, especially those at multidisciplinary pain treatment centers with co-occurring insomnia.”
Influential
Novel active-feedback device improves sleep quality in insomnia disorder: a randomized placebo-controlled trial
Ypsilanti, A., van de Werken, M., Robson, A., Examilioti, P., & Lazuras, L. (2025) · Frontiers in Sleep · doi:10.3389/frsle.2025.1452213 · Cited by 1
Treatment Preferences in Patients With Insomnia and Medical Comorbidity: Associated Factors and Impact on Treatment‐Outcome
Rauwerda, N. L., Pot, I., Braamse, A. M. J., van Straten, A., Nieuwkerk, P. T., Boss, M., Rikkert, M., & Knoop, H. (2025) · Journal of Sleep Research · doi:10.1111/jsr.70115 · Cited by 2
“However, not all patients are willing to participate in CBT-I, nor do they always have access to it (Buenaver et al. 2019; Koffel et al. 2018).”
A Scoping Review of Large Language Models in Personal Sleep Wellness
Mansoor, H. (2025) · Mayo Clinic Proceedings Digital Health · doi:10.1016/j.mcpdig.2025.100301 · Cited by 1
Circadian Rhythm Sleep-Wake Disorders (CRSWDs) in Older Adults: A Narrative Review
Alshiban, A., Fields, C., & Salas, R. M. E. (2025) · Current Geriatrics Reports · doi:10.1007/s13670-025-00437-y · Cited by 1
“Unfortunately, real-world challenges hinder the delivery of this treatment, including limited knowledge and motivation among both clinicians and patients to refer to and adopt this model [ 66, 67 ].”
Sleep health in the primary care setting
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“In line with a previous literature review [74], interviewed HCPs and patients expressed limited knowledge about CBT-I and its potential benefits.”
Time to take the Declaration of Helsinki seriously? A systematic review of comparison conditions in clinical trials on internet-delivered cognitive behavioral therapy for insomnia
Grolig, L., Brückner, H., Heimes, H., Buntrock, C., Hempeler, C., Spiegelhalder, K., & Lehr, D. (2025) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2025.102224 · Cited by 2
Effect of acupuncture on fatigue in cancer survivors with chronic pain: a secondary analysis
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“However, implementing exercise in daily clinical practice remains challenging, particularly due to low treat-ment adherence rates [39–41].”
Patterns of insomnia and its treatment in North Central London: using primary care data to establish unmet needs and health inequalities
Waterman, L. Z., Harrison, F., Osuagwu, U., & Dougan, S. (2023) · BJPsych Open · doi:10.1192/bjo.2025.10861 · Cited by 1
Mind-Body Interventions for Comorbid Sleep and Gastrointestinal Concerns
Thakur, E. R., Tran, T., Duarte, B. A., Horrigan, J. M., Lampe, E. W., Said, H., & Salwen‐Deremer, J. K. (2025) · Current Sleep Medicine Reports · doi:10.1007/s40675-025-00348-6 · Cited by 2
“First, demand for CBT-I providers drastically exceeds availability [70], and access is further complicated by issues related to feasibility of screening and referral within medical settings.”
The Study in Outpatient Medicine using Nudges to Improve Sleep (SOMNUS): study protocol for an 18-month factorial, cluster-randomized trial to increase guideline-concordant treatment of insomnia in primary care
Cloughesy, J. N., Linder, J. A., Knight, T. K., Persell, S. D., Sullivan, M. D., Meeker, D., Brown, T., Lee, J. Y., Stewart, E. A., Fox, C. R., et al. (2025) · Trials · doi:10.1186/s13063-025-09385-6 · Cited by 1
“…barriers, which include lack of knowledge of non-phar-maceutical options, reluctance to engage with CBT-I, and trivialization of insomnia symptoms, can also result in, respectively, demand for Z-drugs, non-compliance with nonpharmacological therapies, and underdiagnosis or undertreatment [14].”
Influential
Digital Cognitive Behavioral Therapy for Chronic Insomnia in South Korea: Cost-Effectiveness Analysis Using Decision Tree and Markov Modeling Based on a Secondary Analysis of a Randomized Clinical Trial
Kim, J. H., Sohn, M., Woo, J., Shin, J., & Han, E. (2026) · JMIR mhealth and uhealth · doi:10.2196/71750 · Cited by 1
Factors influencing the implementation of general practice nurse-delivered models of care for chronic conditions: a mixed-methods systematic review to inform models of care for chronic sleep disorders
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“…OSA assessment and management, insufficient trained providers of CBTi, and inequities in access to sleep health care for individuals living in rural and remote areas and/or on low income, make accessing assessment and treatment of OSA and chronic insomnia a challenge for some individuals [30–35].”
SleepPathfinder: A Socratic Questioning and Self-Decision–Based Chatbot to Support User Engagement in Digital CBT-I: Usability and Feasibility Study
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“Difficulties in meaning-making, motivational alignment, and sustained engagement during treatment practice have been associated with reduced adherence and inconsistent long-term use in real-world dCBT-I settings [25,26].”
Comparative effectiveness and safety of acupuncture treatments for primary insomnia: a systematic review and network meta-analysis of randomized trial
Fang, T., Cao, X., Liu, L., & Lu, S. (2026) · Frontiers in Neurology · doi:10.3389/fneur.2026.1750474 · Cited by 1
“While CBT-I is suggested as the dominant treatment, its accessibility and adherence remain limited (8).”
Predictors and moderators of treatment outcomes from cognitive behavioural interventions for insomnia in adults: A systematic review
Smith, M. L., Oldenhof, E., Byrne, J. E. M., McNeill, I. M., Sweetman, A., & Staiger, P. K. (2026) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2026.102269 · Cited by 1
Cost-Effectiveness of Pharmacopuncture Versus Conventional Acupuncture for Insomnia: An RCT-Based Economic Evaluation with a Markov Model
Cho, E., Lee, J.-E., Lim, J. H., Lee, J.-H., Kwon, C., & Kim, B.-K. (2026) · Neurology and Therapy · doi:10.1007/s40120-026-00936-w · Cited by 1
“I is recommended as first‑line but underuti‑ lized because of limited trained providers and low patient awareness [6]; however, pharmacotherapy has safety concerns, including cognitive decline, fall risk, and dependence [7].”
Dose–response relationship between physical activity and subjective sleep quality in patients with insomnia: a systematic review and Bayesian meta-analysis of randomized controlled trials
Huang, Z., Zhang, Y., & Xu, W. (2026) · International Journal of Behavioral Nutrition and Physical Activity · doi:10.1186/s12966-026-01905-0 · Cited by 1
Bidirectional Associations between Daily Symptoms of Perfectionism and Poor Sleep: The Mediating Role of Stress
Oh, S. Y., Meaklim, H., Nicholas, C. L., Cunnington, D., Patrick, C. J., Schenker, M. T., & Phillips, L. (2026) · Behavioral Sleep Medicine · doi:10.1080/15402002.2026.2657920 · Cited by 2
“Such interventions may be helpful in preventing the worsening of sleep difficulties, particularly while waiting for access to limited behavioral sleep medicine providers and specialist sleep therapy resources, such as cognitive behavioral therapy for insomnia (Koffel et al., 2018).”
Efficacy of repetitive transcranial magnetic stimulation for insomnia disorder: a systematic review and meta-analysis of randomized controlled trials
Cao, Z., Shi, Q., Shi, Z., Yuan, D., & Zeng, S. (2026) · Frontiers in Neuroscience · doi:10.3389/fnins.2026.1816963 · Cited by 1
“However, the dissemination of CBT-I is limited by a shortage of practitioners and financial barriers, which reduce its accessibility and acceptance among most patients with chronic insomnia, hindering its widespread adoption (Koffel et al., 2018).”
Innovative Approaches to Advancing Equitable Access to Insomnia Interventions
Oliver, S., Dombek, K., Milner, A. E., & Harvey, A. G. (2026) · Current Sleep Medicine Reports · doi:10.1007/s40675-026-00385-9 · Cited by 1
“This shift reflects longstanding evidence that behavioral sleep medicine services remain insufficient relative to population need, with research docu - menting a limited number of clinicians trained in CBT-I and uneven availability across care settings [29–31].”
Self-Directed vs Clinician-Delivered Cognitive Behavioral Therapy for Chronic Pain
Heapy, A. A., Driscoll, M., Edmond, S. N., LaChappelle, K. M., Buta, E., Halat, A. M., Krein, S. L., Martino, S., DeBar, L., Murphy, J. L., et al. (2026) · JAMA · doi:10.1001/jama.2026.7861 · Cited by 1
Management of Insomnia Disorder
Carlson, G. E., Zeidler, M. R., & Martin, J. L. (2022) · Respiratory medicine · doi:10.1007/978-3-030-93739-3_13 · Cited by 1
The Future of Sleep Medicine: A Patient-Centered Model of Care
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A Systematic Review and Meta-Analysis Protocol to Establish How Common Clinical Acupoint Stimulation-Related Therapies Should Be Used for Managing Insomnia
Guo, P., Xu, M., Pan, J., Lin, J., Hu, T.-N., Wei, Y., Chen, Y., & Guo, Y. (2023) · Journal of Pain Research · doi:10.2147/jpr.s394328 · Cited by 1
“Secondly, the high cost of treatment and the lack of behavioral sleep medicine specialists restrict access of CBT-I to many patients.(26,27) Third, CBT-I is ineffective in 20–30% of insomnia patients.”
Background
Navigating Alcohol Use Disorder in Adults: A Case Report
Threet, C., Tan, R. A., & Serafica, R. C. (2023) · The Journal for Nurse Practitioners · doi:10.1016/j.nurpra.2023.104721 · Cited by 1
Sleep Treatment Education Program for Young Adult Cancer Survivors (STEP-YA): Protocol for an Efficacy Trial
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“To make CBTI widely available to YACS, several barriers need to be resolved, including the shortage of trained CBTI providers [32,33], the patient burden of standard CBTI regimens [34-36], and the lack of CBTI interventions specifically targeting the needs of YACS.”
Background
Focus Group Study of Heart Failure Nurses’ Perceptions of the Feasibility of Cognitive Behavioral Therapy for Insomnia
O’Connell, M., Feder, S. L., Nwanaji-Enwerem, U., & Redeker, N. S. (2023) · Nursing Research · doi:10.1097/nnr.0000000000000706 · Cited by 1
“The lack of trained providers (Koffel et al., 2018) is a barrier to access.”
Background
Pain in your day? Get sleep treatment anyway! The role of pain in insomnia treatment efficacy in women veterans
Erickson, A. J., Ravyts, S. G., Dzierzewski, J. M., Carlson, G. E., Kelly, M. R., Song, Y., McGowan, S. K., Mitchell, M. N., Washington, D. L., Yano, E. M., et al. (2024) · Journal of Sleep Research · doi:10.1111/jsr.14147 · Cited by 1
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Increasing Restorative Sleep Among Adults With Depressive Symptoms: A Quality Improvement Project
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“…recommended that the ﬁ rst-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBT-I) rather than the more commonly used and risky prescribing of hypnotic medications, available by prescription or over the counter, to induce sleep (Koffel et al., 2018; Qaseem et al., 2016).”
Robotic Cognitive Behavioural Therapy: rCBT
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“A ruffled mind makes a restless pillow”: reducing depression incidence and severity with dCBT-I
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Music, Arts and Cognitive Behavioural Therapy to Treat Sleep Disorders
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“Due to significant clinical benefits, cognitive behavioural therapy has not only become an important approach in the realm of sleep medicine: the American College of Physicians (ACP) even calls it the first-line treatment for insomnia, and ‘CBT-I’ has become a label [9].”
Background
The Intersection of Insomnia Disorder and Major Depressive Disorder: A Clinical Perspective
Bachu, A. K., Yadav, G., Ansari, M. I., Kochhar, H., Cabrera, T., & Chopra, A. (2023) · Psychiatric Annals · doi:10.3928/00485713-20231024-01 · Cited by 1
CONQUERING INSOMNIA: COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA (CBT-I) -WORKSHOP FOR COMMUNITY MENTAL HEALTH CARE PROVIDERS
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A digital cognitive behavioural therapy programme for insomnia and anxiety in older adults: feasibility and preliminary efficacy.
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Digital medicine for insomnia
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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
ORCID: Koffel, Erin
Bramoweth, Adam D.
Ulmer, Christi S.
Venue: Journal of General Internal Medicine
Publisher: Springer Science and Business Media LLC
Published: 2018-04-04
Volume: 33
Issue: 6
Pages: 955-962
ISSN: 0884-8734 (ISSN-L)
1525-1497
DOI: 10.1007/s11606-018-4390-1
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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Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

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