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“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 [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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“Stepped-care approaches have been recommended for cognitive-behavioural therapy for insomnia (CBTI; Espie, 2009), and early evidence supports the scalability of CBTI for insomnia (Manber, Simpson, & Bootzin, 2015).”
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Buysse, D. J., Germain, A., Moul, D. E., Franzen, P. L., Brar, L. K., Fletcher, M. E., Begley, A. E., Houck, P. R., Mazumdar, S., Reynolds, C. F., et al. (2011) · Archives of Internal Medicine · doi:10.1001/archinternmed.2010.535 · Cited by 562
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BackgroundA meta-analysis of group cognitive behavioral therapy for insomnia
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“The stepped-care model is a population health service approach to providing people with insomnia with access to evidence-based care (Espie, 2009; Espie et al., 2013).”
Hyperarousal and sleep reactivity in insomnia: current insights
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“CCBT-I can be considered as an acceptable form of low-intensity therapy for patients with chronic insomnia in a stepped care model [66, 67] .”
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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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“Pharm acological sleep treatments have been found to produce short-lived improvements in sleep but are not recommended for longer-term sleep problems due to poor efficacy [28] and concer ns about dependence and other adverse”
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Cunnington, D., Junge, M. F., & Fernando, A. T. (2013) · The Medical Journal of Australia · doi:10.5694/mja13.10718 · Cited by 223
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Self-citationBi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)
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The evidence base of sleep restriction therapy for treating insomnia disorder
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Lancee, J., van Straten, A., Nexhmedin Morina, B., Kaldo, V., & Kamphuis, J. H. (2015) · SLEEP · doi:10.5665/sleep.5344 · Cited by 180
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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).”
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“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
“However, using a stepped care approach, with lower intensity methods of delivering care as the starting point may help to reduce access problems [9].”
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“[87] Espie CA.”
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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
“through stepped care models (Espie, 2009; Vincent & Walsh, 2013) has the potential to”
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“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].”
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Moloney, M. E., Konrad, T. R., & Zimmer, C. R. (2011) · American Journal of Public Health · doi:10.2105/ajph.2010.300014 · Cited by 136
“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
“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).”
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“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).”
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“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
“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
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“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., Dogas, Z., Bassetti, C., Berg, S., Grote, L., Jennum, P., Levy, P., Mihăicuţă, S., Nobili, L., Riemann, D., et al. (2012) · Journal of Sleep Research · doi:10.1111/j.1365-2869.2011.00987.x · Cited by 98
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We know CBT-I works, now what?
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“Espie (2009)150, for example, proposed a stepped care approach to insomnia care that begins with self-administered CBT-I (via book or online).”
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“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 88
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The Delivery of Behavioral Sleep Medicine to College Students
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“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
“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 71
Insomnia Patients' Help-Seeking Experiences
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“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
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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 69
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 71
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 75
“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 68
“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
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 72
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 70
“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
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
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 70
“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 65
“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 65
Sweetman, A., Putland, S., Lack, L. C., McEvoy, R. D., Adams, R., Grunstein, R. R., Stocks, N. P., Kaambwa, B., Ryswyk, E. V., Gordon, C. J., et al. (2020) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2020.101404 · Cited by 69
Qing, W., Zhang, W., & An, S. (2023) · Internet Interventions · doi:10.1016/j.invent.2023.100690 · Cited by 78
“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
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
BJORVATN, B., FISKE, E., & PALLESEN, S. (2011) · Scandinavian Journal of Psychology · doi:10.1111/j.1467-9450.2011.00902.x · Cited by 60
“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
“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 59
Rybarczyk, B. D., Lund, H. G., Shamaskin‐Garroway, A., & Mack, L. (2012) · Clinical Gerontologist · doi:10.1080/07317115.2012.731478 · Cited by 60
“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
“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
“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
“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
“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
“[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
Haycock, J., Grivell, N., Redman, A., Saini, B., Vakulin, A., Lack, L. C., Lovato, N., Sweetman, A., Zwar, N. A., Stocks, N. P., et al. (2021) · BMC Family Practice · doi:10.1186/s12875-021-01510-z · Cited by 55
Waters, F., Chiu, V., Janča, A., Atkinson, A., & Ree, M. J. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.00990 · Cited by 55
“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
“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
“, 2008), there is a shortfall in the clinical workforce required to provide this to the population (Espie, 2009).”
Background
Metadata
- 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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