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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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Background
A randomized controlled trial of digital cognitive behavioral therapy for insomnia in pregnant women
Kalmbach, D. A., Cheng, P., O'Brien, L. M., Swanson, L. M., Sangha, R., Sen, S., Guille, C., Cuamatzi-Castelan, A., Henry, A. L., Roth, T., et al. (2020) · Sleep Medicine · doi:10.1016/j.sleep.2020.03.016 · Cited by 154
“Not only do pregnant women face the same access barriers as insomnia patients in the broader population [29,30], but pregnant women also have additional unique logistical barriers including managing other recurring prenatal health appointments, reserving medical leave for other prenatal and postnatal appointments, and…”
Background
Depression prevention via digital cognitive behavioral therapy for insomnia: a randomized controlled trial
Cheng, P., Kalmbach, D. A., Tallent, G., Joseph, C. L. M., Espie, C. A., & Drake, C. L. (2019) · SLEEP · doi:10.1093/sleep/zsz150 · Cited by 166
“One barrier has been the accessibility of CBT-I, which has been severely limited by several factors including a scarcity of certified providers, geographic distance to providers, and the requirement of 6–8 weeks of direct patient contact [26, 27].”
Background

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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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