“Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment
Open accessAbstract
There is a large body of evidence that Cognitive Behavioral Therapy for insomnia (CBT) is an effective treatment for persistent insomnia. However, despite two decades of research it is still not readily available, and there are no immediate signs that this situation is about to change. This paper proposes that a service delivery model, based on "stepped care" principles, would enable this relatively scarce healthcare expertise to be applied in a cost-effective way to achieve optimal development of CBT services and best clinical care. The research evidence on methods of delivering CBT, and the associated clinical leadership roles, is reviewed. On this basis, self-administered CBT is posited as the "entry level" treatment for stepped care, with manualized, small group, CBT delivered by nurses, at the next level. Overall, a hierarchy comprising five levels of CBT stepped care is suggested. Allocation to a particular level should reflect assessed need, which in turn represents increased resource requirement in terms of time, cost and expertise. Stepped care models must also be capable of "referring" people upstream where there is an incomplete therapeutic response to a lower level intervention. Ultimately, the challenge is for CBT to be delivered competently and effectively in diversified formats on a whole population basis. That is, it needs to become "scalable". This will require a robust approach to clinical governance.
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Non-pharmacological sleep interventions can be successfully delivered in a variety of relatively low-cost formats.
“Non-pharmacological sleep interventions can be successfully delivered in a variety of relatively low-cost formats [28], therefore providing these as a treatment option for people with depression has the potential to be cost-effective.”
From The effect of non-pharmacological sleep interventions on depression symptoms: a meta-analysis of randomised controlled trials (2019) · cites this paper as [28]
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“In contrast, cognitive–behavioral therapy for insomnia (CBT-I) provides greater long-term efficacy and fewer side effects than hypnotics; however, availability remains restricted.(8) Meanwhile, the primary treatment option for SDB, continuous positive airway pressure (CPAP), significantly reduces SDB symptoms when use…”
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“Here we propose a simplification of the model proposed by Espie (2009) and Espie et al. (2013), which could be adapted for use within a given national health system.”
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“Even though CBT for insomnia is broadly considered treatment of choice, few patients suffering from insomnia receive CBT due to a lack of trained therapists (Edinger, 2009; Espie, 2009; Larsson, Kaldo, & Broberg, 2010).”
BackgroundKoffel, E., Kuhn, E. R., Petsoulis, N., Erbes, C. R., Anders, S. L., Hoffman, J. E., Ruzek, J. I., & Polusny, M. A. (2016) · Health Informatics Journal · doi:10.1177/1460458216656472 · Cited by 153 · see citing works
Understanding and Treating Insomnia
Bootzin, R. R., & Epstein, D. R. (2011) · Annual Review of Clinical Psychology · doi:10.1146/annurev.clinpsy.3.022806.091516 · Cited by 150 · see citing works
Schwartz, D. R., & Carney, C. E. (2012) · Clinical Psychology Review · doi:10.1016/j.cpr.2012.06.006 · Cited by 137 · see citing works
“Although CBT-I and pharmacotherapy demonstrate comparable efficacy in the treatment of insomnia (Morin, Colecchi, Stone, Sood, & Brink, 1999; Morin et al., 2009), CBT-I has been recommended as a first line treatment given its long-term efficacy (Espie, 2009).”
Ree, M., Junge, M., & Cunnington, D. (2017) · Sleep Medicine · doi:10.1016/j.sleep.2017.03.017 · Cited by 145 · see citing works
“However, using a stepped care approach, with lower intensity methods of delivering care as the starting point may help to reduce access problems [9].”
Sadler, P., McLaren, S., Klein, B., Harvey, J. T., & Jenkins, M. (2018) · SLEEP · doi:10.1093/sleep/zsy104 · Cited by 147 · see citing works
Sleep and Antidepressant Treatment
Wichniak, A., Wierzbicka, A., & Jernajczyk, W. (2012) · Current Pharmaceutical Design · doi:10.2174/138161212803523608 · Cited by 142 · see citing works
“[87] Espie CA.”
BackgroundSavard, J., Ivers, H., Savard, M.-H., & Morin, C. M. (2014) · Sleep · doi:10.5665/sleep.3918 · Cited by 136 · see citing works
Benz, F., Knoop, T., Ballesio, A., Bacaro, V., Johann, A. F., Rücker, G., Feige, B., Riemann, D., & Baglioni, C. (2020) · Clinical Psychology Review · doi:10.1016/j.cpr.2020.101873 · Cited by 142 · see citing works
“through stepped care models (Espie, 2009; Vincent & Walsh, 2013) has the potential to”
MethodChan, J. S. M., Ho, R. T. H., Chung, K.-F., Wang, C.-W., Yao, T.-J., Ng, S.-M., & Chan, C. L. W. (2014) · Evidence-Based Complementary and Alternative Medicine · doi:10.1155/2014/106048 · Cited by 138 · see citing works
“In light of the efficacy, acceptability, low cost, and accessibility of Qigong exercise, it should be tested in future studies as an entry-level treatment in a stepped care model for insomnia [41].”
BackgroundThe medicalization of sleeplessness: a public health concern
Moloney, M. E., Konrad, T. R., & Zimmer, C. R. (2011) · American Journal of Public Health · doi:10.2105/ajph.2010.300014 · Cited by 136 · see citing works
“With greater awareness and training, clinicians might utilize more nondrug treatments.(43,44) Patients, in turn, require more information about the deleterious health effects of long-term sleep loss and the benefits of behavioral therapies.”
Lancee, J., van den Bout, J., van Straten, A., & Spoormaker, V. I. (2012) · Behaviour Research and Therapy · doi:10.1016/j.brat.2011.09.012 · Cited by 131 · see citing works
“To bridge the gap between the high prevalence of insomnia and the low accessibility of trained therapists, self-help CBT has been proposed as a first option in a stepped care model (Espie, 2009).”
BackgroundAshworth, D. K., Sletten, T. L., Junge, M., Simpson, K., Clarke, D., Cunnington, D., & Rajaratnam, S. M. W. (2015) · Journal of Counseling Psychology · doi:10.1037/cou0000059 · Cited by 131 · see citing works
The insomnia and suicide link: toward an enhanced understanding of this relationship
Woznica, A. A., Carney, C. E., Kuo, J. R., & Moss, T. G. (2014) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2014.10.004 · Cited by 124 · see citing works
Integrating psychology and medicine in CPAP adherence – New concepts?
Crawford, M., Espie, C. A., Bartlett, D. J., & Grunstein, R. R. (2013) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2013.03.002 · Cited by 112 · see citing works
Non-pharmacological Approaches for Management of Insomnia
Chan, N. Y., Chan, J. W. Y., Li, S. X., & Wing, Y. K. (2021) · Neurotherapeutics · doi:10.1007/s13311-021-01029-2 · Cited by 117 · see citing works
Sleep problems in cancer patients: prevalence and association with distress and pain
Sharma, N., Hansen, C. H., O’Connor, M. J., Thekkumpurath, P., Walker, J., Kleiboer, A. M., Murray, G. D., Espie, C. A., Storey, D. J., & Sharpe, M. (2011) · Psycho-Oncology · doi:10.1002/pon.2004 · Cited by 107 · see citing works
Lancee, J., van den Bout, J., Sorbi, M. J., & van Straten, A. (2013) · Behaviour Research and Therapy · doi:10.1016/j.brat.2013.09.004 · Cited by 104 · see citing works
“To increase CBT-I outreach while restraining care expenses, CBT-I delivered through the internet is proposed as a first option within a stepped-care model (Espie, 2009).”
MethodMatthews, E. E., Berger, A. M., Schmiege, S. J., Cook, P. F., McCarthy, M. S., Moore, C. M., & Aloia, M. S. (2014) · Oncology Nursing Forum · doi:10.1188/14.onf.41-03ap · Cited by 103 · see citing works
“Effectiveness studies are needed to validate the therapies implemented by nurses (Espie, 2009).”
Backgroundas the Sleep Disturbance Expert Panel on behalf of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer, Howell, D., Oliver, T. K., Keller-Olaman, S., Davidson, J. R., Garland, S. N., Samuels, C. H., Savard, J., Harris, C. A., Aubin, M., et al. (2013) · Supportive Care in Cancer · doi:10.1007/s00520-013-1823-6 · Cited by 100 · see citing works
“evidence; these included reviews, information summaries, consensus statements, or guidelines that offered best practice advice, but were not necessarily cancer-focused or evidencebased [13,16,34–59].”
BackgroundRandomized Controlled Trial of Telephone-Delivered Cognitive Behavioral Therapy for Chronic Insomnia
Arnedt, J. T., Cuddihy, L. J., Swanson, L. M., Pickett, S. M., Aikens, J. E., & Chervin, R. D. (2013) · SLEEP · doi:10.5665/sleep.2448 · Cited by 98 · see citing works
Bartlett, D. J., WONG, K. K. H., Richards, D., Moy, E., Espie, C. A., Cistulli, P. A., & Grunstein, R. R. (2013) · SLEEP · doi:10.5665/sleep.3118 · Cited by 94 · see citing works
Thorndike, F. P., Ritterband, L. M., Gonder-Frederick, L. A., Lord, H. R., Ingersoll, K. S., & Morin, C. M. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.22032 · Cited by 95 · see citing works
“Despite the strong efficacy supporting CBT-I, it is not widely available to patients due to a lack of trained clinicians, poor geographical distribution of knowledgeable professionals, and expense (Edinger & Means, 2005; Espie, 2009).”
BackgroundStandard procedures for adults in accredited sleep medicine centres in Europe
FISCHER, J. H., Đogaš, Z., Bassetti, C. L., BERG, S., Grote, L., Jennum, P., Levy, P. A., Mihaicuta, S. D., Nobili, L., Riemann, D. W., et al. (2011) · Journal of Sleep Research · doi:10.1111/j.1365-2869.2011.00987.x · Cited by 93 · see citing works
Natsky, A. N., Vakulin, A., Chai-Coetzer, C. L., Lack, L., McEvoy, R. D., Lovato, N., Sweetman, A., Gordon, C. J., Adams, R. J., & Kaambwa, B. (2020) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2020.101351 · Cited by 91 · see citing works
We know CBT-I works, now what?
Muench, A., Vargas, I., Grandner, M. A., Ellis, J. G., Posner, D. A., Bastien, C., Drummond, S. P. A., & Perlis, M. L. (2022) · Faculty Reviews · doi:10.12703/r/11-4 · Cited by 91 · see citing works
“Espie (2009)150, for example, proposed a stepped care approach to insomnia care that begins with self-administered CBT-I (via book or online).”
BackgroundWagley, J. N., Rybarczyk, B., Nay, W. T., Danish, S., & Lund, H. G. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.21927 · Cited by 85 · see citing works
Taylor, D. J., Peterson, A. L., Pruiksma, K. E., Young‐McCaughan, S., Nicholson, K. L., & Mintz, J. (2017) · SLEEP · doi:10.1093/sleep/zsx075 · Cited by 87 · see citing works
Sleep in PTSD: Treatment approaches and outcomes
Miller, K. E., Brownlow, J. A., & Gehrman, P. R. (2020) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2019.08.017 · Cited by 87 · see citing works
Ho, F. Y., Chung, K., Yeung, W., Ng, T. H., & Cheng, S. K.-W. (2014) · Behaviour Research and Therapy · doi:10.1016/j.brat.2014.10.002 · Cited by 86 · see citing works
“Faced with the limitations of CBT-I, a stepped care model has been proposed (Espie, 2009).”
MethodCheung, J. M. Y., Jarrin, D. C., Ballot, O., Bharwani, A. A., & Morin, C. M. (2018) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2018.11.001 · Cited by 84 · see citing works
Redeker, N. S., Yaggi, H. K., Jacoby, D. L., Hollenbeak, C. S., Breazeale, S., Conley, S., Hwang, Y., Iennaco, J. D., Linsky, S., Nwanaji-Enwerem, U., et al. (2021) · SLEEP · doi:10.1093/sleep/zsab252 · Cited by 83 · see citing works
The Delivery of Behavioral Sleep Medicine to College Students
Kloss, J. D., Nash, C. O., Horsey, S. E., & Taylor, D. J. (2010) · Journal of Adolescent Health · doi:10.1016/j.jadohealth.2010.09.023 · Cited by 78 · see citing works
Rosenberg, R. P., Citrome, L., & Drake, C. L. (2021) · Neuropsychiatric Disease and Treatment · doi:10.2147/ndt.s297504 · Cited by 77 · see citing works
Savard, J., Ivers, H., Savard, M., Morin, C. M., Caplette‐Gingras, A., Bouchard, S., & Lacroix, G. (2021) · SLEEP · doi:10.1093/sleep/zsab166 · Cited by 74 · see citing works
“This led us and others to conclude that self-administered CBT-I would be better used as part of a stepped care model [17, 18].”
MethodBothelius, K., Kyhle, K., Espie, C. A., & Broman, J. (2013) · Journal of Sleep Research · doi:10.1111/jsr.12067 · Cited by 71 · see citing works
“The aim of this study was to investigate the clinical effectiveness of protocol-driven CBT for insomnia delivered by ordinary primary care personnel (primary care nurses and social workers) in general medical practice with unselected patients, in line with a ‘stepped care’ approach (Espie, 2009).”
BackgroundUnderstanding the Sleep-Wake Cycle: Sleep, Insomnia, and the Orexin System
Krystal, A. D., Benca, R. M., & Kilduff, T. S. (2013) · The Journal of Clinical Psychiatry · doi:10.4088/jcp.13011su1c · Cited by 69 · see citing works
Insomnia Patients' Help-Seeking Experiences
Cheung, J. M. Y., Bartlett, D. J., Armour, C. L., Glozier, N., & Saini, B. (2014) · Behavioral Sleep Medicine · doi:10.1080/15402002.2013.764529 · Cited by 68 · see citing works
“Those not responding to the less intensive therapy are then referred upstream to specialist care where necessary (Espie, 2009).”
BackgroundInsomnia in Patients With Chronic Kidney Disease
Lindner, A. V., Novák, M., Bohra, M., & Mucsi, I. (2015) · Seminars in Nephrology · doi:10.1016/j.semnephrol.2015.06.007 · Cited by 68 · see citing works
Davy, Z., Middlemass, J., & Siriwardena, A. N. (2013) · Health Expectations · doi:10.1111/hex.12119 · Cited by 68 · see citing works
Song, P., Lin, H., Li, S., Wang, L., Liu, J., Li, N., & Wang, Y. (2019) · Sleep Medicine · doi:10.1016/j.sleep.2019.01.007 · Cited by 67 · see citing works
Darden, M., Espie, C. A., Carl, J. R., Henry, A. L., Kanady, J. C., Krystal, A. D., & Miller, C. B. (2020) · SLEEP · doi:10.1093/sleep/zsaa223 · Cited by 67 · see citing works
Bassetti, C. L., Ferini‐Strambi, L., Brown, S. A., Adamantidis, A., Benedetti, F., Bruni, O., Cajochen, C., Dolenc‐Grošelj, L., Ferri, R., Gais, S., et al. (2015) · European Journal of Neurology · doi:10.1111/ene.12781 · Cited by 68 · see citing works
“The use of internet-based methods within a stepped care framework would allow this at minimal cost [44] and will help to evaluate whether early insomnia treatment is capable of preventing consequences like cardiovascular disease, depression/suicidality and cognitive dysfunction.”
MethodMurawski, B., Plotnikoff, R. C., Rayward, A. T., Oldmeadow, C. J., Vandelanotte, C., Brown, W. J., & Duncan, M. J. (2019) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2019.05.009 · Cited by 66 · see citing works
“This is important considering the high percentage of the population with poor sleep quality, but without a clinical sleep disorder and limited access to practitioner-based treatment.(57,58) PSQI scores <5 indicate remission of sleep problems,(59) and despite the magnitude of improvement observed in the intervention gr…”
ResultCasault, L., Savard, J., Ivers, H., & Savard, M. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.02.003 · Cited by 65 · see citing works
Digital Delivery of Cognitive Behavioral Therapy for Insomnia
Luik, A. I., van der Zweerde, T., van Straten, A., & Lancee, J. (2019) · Current Psychiatry Reports · doi:10.1007/s11920-019-1041-0 · Cited by 69 · see citing works
The Cost of Insomnia and the Benefit of Increased Access to Evidence-Based Treatment
Reynolds, S. A., & Ebben, M. R. (2017) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2016.10.011 · Cited by 65 · see citing works
“Most patients would be triaged to self-administered CBT-I as the first step, which can be made readily available for anyone who needs it, and sessions with trained providers and behavioral specialists would be arranged for those who self-administered care is not suitable or has not yielded adequate improvement.(55) St…”
Backgroundde Bruin, E. J., van Steensel, F. J. A., & Meijer, A. M. (2016) · SLEEP · doi:10.5665/sleep.6024 · Cited by 66 · see citing works
Pigeon, W. R., Funderburk, J. S., Bishop, T. M., & Crean, H. F. (2017) · Journal of Affective Disorders · doi:10.1016/j.jad.2017.04.003 · Cited by 65 · see citing works
Garland, S. N., Rowe, H. L., Repa, L. M., Fowler, K., Zhou, E. S., & Grandner, M. A. (2018) · Sleep Health · doi:10.1016/j.sleh.2018.01.003 · Cited by 63 · see citing works
“The increase observed in individuals reporting good and fair/poor mental health supports the need for increased access to evidence-based sleep interventions alongside more traditional mental health services.(43,44) We found an increased prevalence of insomnia symptoms in individualswith higher levels of education comp…”
BackgroundCognitive behavioural therapy for insomnia disorder: Extending the stepped care model
Baglioni, C., Espie, C. A., Altena, E., Gavriloff, D., Jernelöv, S., Holzinger, B., Schlarb, A. A., & Riemann, D. W. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14016 · Cited by 64 · see citing works
“Based on the SCM proposed by Espie (2009) and Espie et al. (2013), a large number of patients with insomnia can be efficiently treated at lower levels using high-quality evidence-based CBT-I self-help programmes, including those provided by digital CBT-I (dCBT-I), booklets or audio resources.”
BackgroundMethodStepped Care for Insomnia: An Evaluation of Implementation in Routine Practice
Vincent, N., & Walsh, K. (2013) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.2484 · Cited by 63 · see citing works
Sweetman, A., Putland, S., Lack, L. C., McEvoy, R. D., Adams, R., Grunstein, R. R., Stocks, N., Kaambwa, B., Ryswyk, E. V., Gordon, C. J., et al. (2020) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2020.101404 · Cited by 65 · see citing works
Wang, Q., Zhang, W., & An, S.-B. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100690 · Cited by 51 · see citing works
“This aligns with recommendations from researchers like Espie (2009), who advocated for evidence-based online interventions as the primary accessible step for most individuals, reserving in-person services for those requiring intensified support.”
BackgroundSavard, J., & Savard, M. (2013) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2013.04.006 · Cited by 61 · see citing works
McCurry, S. M., Shortreed, S. M., Von Korff, M., Balderson, B. H., Baker, L. D., Rybarczyk, B. D., & Vitiello, M. V. (2014) · Sleep · doi:10.5665/sleep.3402 · Cited by 60 · see citing works
BJORVATN, B., FISKE, E., & PALLESEN, S. (2011) · Scandinavian Journal of Psychology · doi:10.1111/j.1467-9450.2011.00902.x · Cited by 60 · see citing works
“If this still does not lead to clinical improvement the patient should be referred to a sleep disorders specialist (Espie , 2009).”
Predictors of dropout from internet-based self-help cognitive behavioral therapy for insomnia
Yeung, W., Chung, K., Ho, F. Y., & Ho, L. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.07.008 · Cited by 59 · see citing works
“With benefits of low cost and easy accessibility, self-help CBT-I has been used as an efficacious and acceptable entry-level treatment in a stepped-care delivery model of CBT-I (Espie, 2009; Ho et al., 2015).”
MethodThe Future of Cognitive Behavioral Therapy for Insomnia: What Important Research Remains to Be Done?
Vitiello, M. V., McCurry, S. M., & Rybarczyk, B. D. (2013) · Journal of Clinical Psychology · doi:10.1002/jclp.21948 · Cited by 57 · see citing works
Rybarczyk, B. D., Lund, H. G., Shamaskin‐Garroway, A., & Mack, L. (2012) · Clinical Gerontologist · doi:10.1080/07317115.2012.731478 · Cited by 58 · see citing works
“supporting the efficacy of abbreviated and self-help CBT-I, there have been calls for the implementation of a stepped care approach to insomnia treatment in order to increase access and reduce cost (Edinger, 2009; Espie, 2009).”
MethodFeasibility of a self‐help treatment for insomnia comorbid with cancer
Savard, J., Villa, J., Simard, S., Ivers, H., & Morin, C. M. (2010) · Psycho-Oncology · doi:10.1002/pon.1818 · Cited by 58 · see citing works
“However, based on a stepped care model [25], our goal was to develop a widely accessible intervention that would be effective for as many patients as possible.”
BackgroundFuller, J. M., WONG, K. K. H., Krass, I., Grunstein, R. R., & Saini, B. (2011) · Patient Education and Counseling · doi:10.1016/j.pec.2011.05.004 · Cited by 58 · see citing works
“Certainly there is evidence suggesting that nonpsychologists such as nurses and physiotherapists can effectively provide such interventions [62,63], and thus in this situation, advantage can be taken of the convenience and relative ease of access to community pharmacy.”
BackgroundChiu, V., Ree, M. J., Janča, A., & Waters, F. (2015) · Psychiatric Quarterly · doi:10.1007/s11126-015-9415-x · Cited by 58 · see citing works
“Cognitive-behaviour therapy for insomnia (CBT-I) is recommended as a first line of treatment for insomnia in the general population [12], and applications to schizophrenia and psychosis are increasinly being explored [13, 14].”
BackgroundNorell‐Clarke, A., Jansson‐Fröjmark, M., Tillfors, M., Holländare, F., & Engström, I. (2015) · Behaviour Research and Therapy · doi:10.1016/j.brat.2015.09.005 · Cited by 56 · see citing works
“CBT-I in group is efficient for primary insomnia (for a review see Koffel, Koffel, & Gehrman, 2015) and its potential for easy dissemination in healthcare has led it to be advocated as the first clinician-led step (after self-help) in a stepped care model of insomnia treatment (Espie, 2009).”
MethodLancee, J., van den Bout, J., van Straten, A., & Spoormaker, V. I. (2012) · Depression and Anxiety · doi:10.1002/da.22004 · Cited by 53 · see citing works
“[5, 6] Cognitive-behavioral therapy can effectively treat insomnia (CBT-I),[7–11] but current waiting lists may only be shortened by less intensive approaches such as self-help therapy.[12] A meta-analysis found smallto-moderate effects of self-help CBT-I on subjective insomnia complaints.”
BackgroundSavard, J., Ivers, H., Savard, M., & Morin, C. M. (2016) · SLEEP · doi:10.5665/sleep.5634 · Cited by 53 · see citing works
Haycock, J., Grivell, N., Redman, A., Saini, B., Vakulin, A., Lack, L. C., Lovato, N., Sweetman, A., Zwar, N. A., Stocks, N., et al. (2021) · BMC Family Practice · doi:10.1186/s12875-021-01510-z · Cited by 53 · see citing works
Waters, F., Chiu, V., Janča, A., Atkinson, A., & Ree, M. J. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.00990 · Cited by 52 · see citing works
“While CBT-I is recommended by the American Academy of Sleep Medicine as a first-line treatment for insomnia (Espie, 2009), few studies has been published in people with psychosis.”
BackgroundSwift, N., Stewart, R. J., Andiappan, M., Smith, A. B., Espie, C. A., & Brown, J. S. L. (2011) · Journal of Sleep Research · doi:10.1111/j.1365-2869.2011.00940.x · Cited by 52 · see citing works
“Espie (2009) has recently proposed a fivetier stepped-care model for delivering CBT-I, which aims to optimise resources and clinical care.”
BackgroundResultSpontaneous adverse event reports associated with zolpidem in Australia 2001-2008
BEN-HAMOU, M., Marshall, N. S., Grunstein, R. R., Saini, B., & Fois, R. A. (2011) · Journal of Sleep Research · doi:10.1111/j.1365-2869.2011.00919.x · Cited by 51 · see citing works
“, 2008), there is a shortfall in the clinical workforce required to provide this to the population (Espie, 2009).”
Background
- Authors
- Espie, C. A.
- Affiliations
- Southern General Hospital (GB)
- Corresponding author
- Espie, Colin A.
- ORCID
- Espie, Colin A.
- Venue
- SLEEP
- Publisher
- Oxford University Press (OUP)
- Published
- 2009-12
- Volume
- 32
- Issue
- 12
- Pages
- 1549-1558
- ISSN
- 0161-8105 (ISSN-L)
- 1550-9109
- PMC
- PMC2786038
- OpenAlex
- W1215988363
- Cited by
- 422
- References
- 61
- Citations by year
- 2026: 17 · 2025: 22 · 2024: 32 · 2023: 28 · 2022: 35 · 2021: 28 · 2020: 21 · 2019: 29 · 2018: 26 · 2017: 22 · 2016: 19 · 2015: 39 · 2014: 29 · 2013: 29 · 2012: 18
- FWCI
- 2.27
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- SLEEP (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- ENLIGHTEN (Jurnal Bimbingan dan Konseling Islam) (acceptedVersion)
- Funders
- Wellcome Trust
- Cancer Research UK
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Sleep and related disorders
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- stepped care, cognitive behavioral therapy for insomnia, insomnia treatment, service delivery models, manualized intervention, referral, scalability, clinical governance, cost-effectiveness
- MeSH terms
- Humans, Sleep Initiation and Maintenance Disorders, Patient Care Management, Cognitive Behavioral Therapy, Biomedical Technology
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