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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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“Patients not responding to basic levels of CBT-I are then referred upstream to insomnia psychotherapy that is progressivelymore specialised through a ‘stepped care’ approach as proposed by Espie (2009).”
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“It lies at the heart of the personalised behavioural medicine approach that I believe will be the future of insomnia stepped care (Espie, 2009; Espie et al., 2013, 2014).”
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“Espie (2009) highlighted the need for a stepped-care approach, where less complicated cases may be treated by non-specialist health-care personnel and those with complicated issues or recalcitrant cases are progressed to receive specialized treatment by sleep psychologists.”
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“, 2018), we focused on sleeping problems as a low-threshold and rather psychoeducational approach that are considered suitable for a stepped care approach (Espie, 2009).”
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“Based on the stepped care model of health care delivery with two fundamental features [24,25], the pure self-help or guided self-help CBT-I app and its dashboard could serve as the “least restrictive” therapy with evidence-based, entry-level treatment to achieve significant health gains using a…”
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Steinmetz, L., Simon, L., Feige, B., Riemann, D. W., Johann, A. F., Ell, J., Ebert, D. D., Baumeister, H., Benz, F., & Spiegelhalder, K. (2024) · Clinical Psychology Review · doi:10.1016/j.cpr.2024.102507 · Cited by 48
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“While psychological options for treating insomnia are becoming more available in primary care (Edinger and Sampson, 2003; Espie, 2009), the lack of research in modified support for those with insomnia and long-term medical conditions is likely to reflect the lack of such treatment available in…”
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The Insomnia Patient Perspective, A Narrative Review
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“Similarly, in response to the lack of resources and expertise to implement cognitive behavioral 380 CHEUNG ET AL. therapy for insomnia (CBT-I), Espie (2009) proposed a stepped care approach.”
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Buenaver, L. F., Townsend, D. R., & Ong, J. C. (2019) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2019.01.008 · Cited by 38
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“Digital sleep therapies have been proposed as entry treatments in stepped-care models, group sleep therapies have been proposed as mid-level treatments, and individualized sleep therapies have been proposed as the most intensive treatments (Espie, 2009).”
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“…not a sufficient standalone intervention for chronic insomnia, and would not qualify as the entry level treatment in a stepped- care service model (Espie, 2009; Chung et al., 2018), sleep hygiene is typically integrated within evidence- based CBT programmes and is referenced in clinical…”
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Cheung, J. M. Y., Bartlett, D. J., Armour, C. L., & Saini, B. (2015) · Behavioral Sleep Medicine · doi:10.1080/15402002.2014.981818 · Cited by 37
“The premise of stepped care is to deliver resources that reflect the patient’s actual needs (Espie, 2009).”
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Cape, J. D., Leibowitz, J., Whittington, C. J., Espie, C. A., & Pilling, S. (2015) · Psychological Medicine · doi:10.1017/s0033291715002561 · Cited by 34
“The majority of insomnia patients are treated with pharmacotherapy for sleep (Sivertsen et al. 2009; Espie, 2009).”
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“Go! to Sleep”: A Web-Based Therapy for Insomnia
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“GTS incorporates a stepped-care approach to be used by primary care providers, allowing them to treat as many insomnia patients as possible with the least intensive treatment needed to achieve clinically significant outcomes, reserving more intensive resources for those who require enhanced care.(19,20)”
Persuasive strategies in mobile insomnia therapy: alignment, adaptation, and motivational support
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“These therapies are targeted at large user groups, easy accessible, and cost-effective [13, 23, 42].”
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Insomnien – Stand der Forschung
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“A stepped-care model using both digital and face-to-face CBT-I has been suggested, 13 with access to face-to-face treatment available for complex cases and dCBT-I treatment failures.”
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“With respect to this, Espie (2009) has proposed a service delivery model, based on “stepped care” principles, to achieve optimal development and availability of CBT-I services.”
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“Overall, these studies suggest a stepped-care model may sufficiently target sleep reactivity to attenuate risk of chronic insomnia disorder and comorbid health conditions (Espie, 2009).”
BackgroundFord, M. E., Geurtsen, G. J., Groet, E., Mishre, R. R., van Bennekom, C. A. M., & Someren, E. J. W. V. (2022) · Journal of Sleep Research · doi:10.1111/jsr.13629 · Cited by 26
“Also, with better access to treatment, better utilisation of trained therapists, reduced time investment and cost (Espie, 2009), the eCBT-I has additional benefits.”
BackgroundIs it Time to Step Up to Stepped Care with our Cognitive-Behavioral Insomnia Therapies?
Edinger, J. D. (2009) · SLEEP · doi:10.1093/sleep/32.12.1539 · Cited by 26
Insomnia (primary) in older people: non-drug treatments.
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“In the adult insomnia literature, a “stepped care” model has been proposed as a means of increasing access to sleep-related care (Espie, 2009).”
BackgroundBonnar, D., Hwu, M., Lee, S., Gradisar, M., Suh, S. A., & Kahn, M. (2023) · Journal of Electronic Gaming and Esports · doi:10.1123/jege.2022-0023 · Cited by 26
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Can a meditation app help my sleep? A cross-sectional survey of Calm users
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“, specialist time) [37], suggesting that apps such as Calm may be useful as adjunctive components to more intensive treatments, an early component in a stepped-care framework, or an as-needed aid for fluctuating symptoms or intermittent periods of sleep difficulty [38].”
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“It is argued that insomnia should be treated within a stepped-care model and Internet-delivered treatment for insomnia is proposed as a good first option (Espie, 2009).”
BackgroundBehavioral Treatments for Pediatric Insomnia
Zhou, E. S., & Owens, J. A. (2016) · Current Sleep Medicine Reports · doi:10.1007/s40675-016-0053-0 · Cited by 25
“This notion of a stepped-care model for insomnia treatment has been discussed in the adult literature [109] and warrants further research in pediatric patients as well [110].”
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“One route of disseminating education to patients about the benefits of behavioral sleep interventions could be educational brochures about the harms and hazards of hypnotics (with CBT-I as a safer alternative) provided in waiting rooms of primary care settings (Silverstein et al., 2016).”
Zhou, E. S., Partridge, A. H., & Recklitis, C. J. (2016) · Psycho-Oncology · doi:10.1002/pon.4096 · Cited by 24
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“Internet-based therapy might be a solu-tion for this; in addition, face-to-face treatment could be administered through a stepped-care approach, as recently proposed by Espie.”
Telemedicine and the Management of Insomnia
Hsieh, C. G., Rezayat, T., & Zeidler, M. R. (2020) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2020.05.004 · Cited by 24
Buntrock, C., Lehr, D., Smit, F., Horvath, H., Berking, M., Spiegelhalder, K., Riper, H. M., & Ebert, D. D. (2021) · Journal of Medical Internet Research · doi:10.2196/25609 · Cited by 22
“Internet-based CBT intervention for insomnia (iCBT-I) has been touted as a solution that can bridge this gap in health care [14].”
BackgroundCognitive Behavioral Therapies for Insomnia and Hypnotic Medications
Cheung, J. M. Y., Ji, X., & Morin, C. M. (2019) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2019.01.006 · Cited by 25
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Sleep Disturbances in Patients with Medical Conditions
Kamath, J., Prpich, G., & Jillani, S. (2015) · Psychiatric Clinics of North America · doi:10.1016/j.psc.2015.07.011 · Cited by 21
Comparing the Effects of Single‐ and Multiple‐Component Therapies for Insomnia on Sleep Outcomes
Sidani, S., Epstein, D. R., Fox, M. T., & Collins, L. J. (2019) · Worldviews on Evidence-Based Nursing · doi:10.1111/wvn.12367 · Cited by 25
“Accordingly, the SCT and SRT are viable single component therapies that nurses can be trained to implement in primary care settings, as suggested by Espie (2009).”
BackgroundMijnster, T., Boersma, G. J., Meijer, E., & Lancel, M. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12071070 · Cited by 24
A Tailored Intervention for PAP Adherence: The SCIP-PA Trial
Sawyer, A. M., King, T. S., Weaver, T. E., Sawyer, D. A., Varrasse, M., Franks, J., Watach, A. J., Kolanowski, A. M., & Richards, K. C. (2017) · Behavioral Sleep Medicine · doi:10.1080/15402002.2016.1276018 · Cited by 21
“This approach, from an intervention design perspective, is closely aligned with stepped care models, wherein measurable, emergent patient-specific data guides “next steps” (Bower & Gilbody, 2005; Espie, 2009).”
BackgroundMethodPatient Perceptions of Treatment Delivery Platforms for Cognitive Behavioral Therapy for Insomnia
Cheung, J. M. Y., Bartlett, D. J., Armour, C. L., Laba, T., & Saini, B. (2017) · Behavioral Sleep Medicine · doi:10.1080/15402002.2017.1293539 · Cited by 21
“Since the application of stepped care in the insomnia care pathway, there has been a proliferation of abbreviated CBT-I programs that fall within the lower tiers of the treatment hierarchy (Espie, 2009).”
BackgroundKatofsky, I., Backhaus, J., Junghanns, K., Rumpf, H., Hüppe, M., von Eitzen, U., & Hohagen, F. (2012) · Sleep Medicine · doi:10.1016/j.sleep.2011.12.008 · Cited by 20
“Several meta-analyses or reviews could have confirmed that CBT caused improvements that persisted at least six months after completing therapy [9–11].”
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“The non-responders will proceed to the more intensive and individualized levels upstream until satisfactory improvements are manifested (Espie, 2009; Mack & Rybarczyk, 2011).”
BackgroundCrönlein, T., Langguth, B., Geisler, P., Wetter, T. C., & Eichhammer, P. (2014) · Psychotherapy and Psychosomatics · doi:10.1159/000360706 · Cited by 20
Leveraging Technology: Creating and Sustaining Changes for Health
Teyhen, D. S., Aldag, M., Edinborough, E., Ghannadian, J. D., Haught, A., Kinn, J. T., Kunkler, K. J., Levine, B. A., McClain, J. J., Neal, D. T., et al. (2014) · Telemedicine Journal and e-Health · doi:10.1089/tmj.2013.0328 · Cited by 19
Koffel, E., Branson, M., Amundson, E. C., & Wisdom, J. P. (2020) · Behavioral Sleep Medicine · doi:10.1080/15402002.2020.1828085 · Cited by 20
“These patient preferences align with stepped care models for insomnia treatment that start with less intensive treatment options to maximize access and resources (Espie, 2009).”
BackgroundKhalsa, S. B. S., & Goldstein, M. R. (2021) · Journal of Clinical Sleep Medicine · doi:10.5664/jcsm.9320 · Cited by 23
“…of the current study suggestthatyogamayserveasanadjuncttoCBT-Iorevenanini-tial treatment option within the context of a stepped care approach 41 involving minimal burden of instructor time or required insomnia treatment expertise to improve sleep efficiency while simultaneously increasing…”
Psychological Interventions for Late-Life Insomnia: Current and Emerging Science
Dzierzewski, J. M., Griffin, S. C., Ravyts, S. G., & Rybarczyk, B. D. (2018) · Current Sleep Medicine Reports · doi:10.1007/s40675-018-0129-0 · Cited by 20
Vincent, N., Walsh, K., & Lewycky, S. (2013) · Behavioral Sleep Medicine · doi:10.1080/15402002.2012.700662 · Cited by 18
Gardner, D. M., Turner, J. P., Magalhaes, S., Rajda, M., & Murphy, A. L. (2024) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2024.2731 · Cited by 19
Improving sleep health management in primary care: A potential role for community nurses?
Basheti, M. M., Bawa, Z., Grunstein, R. R., Grivell, N., Saini, B., & Gordon, C. J. (2023) · Journal of Advanced Nursing · doi:10.1111/jan.15577 · Cited by 24
“However, given the rising prevalence of insomnia, there is a clear demand– supply imbalance, with not enough CBTI-specialized providers (Espie, 2009 ).”
Savard, M., & Savard, J. (2017) · Current Sleep Medicine Reports · doi:10.1007/s40675-017-0067-2 · Cited by 17
Kaldo, V., Bothelius, K., Blom, K., Lindhé, M., Larsson, M., Karimi, K., Melder, S., Bondestam, V., Ulfsparre, C., Sternbrink, K., et al. (2019) · Journal of Sleep Research · doi:10.1111/jsr.12881 · Cited by 18
“To meet the demands, an increased availability of CBT‐i has been requested (Kraus & Rabin, 2012) and a “stepped care” delivery model has been proposed (Espie, 2009).”
BackgroundYang, Y., Luo, X., Paudel, D., Zhang, J., Li, S. X., & Zhang, B. (2019) · BMJ Open · doi:10.1136/bmjopen-2019-033457 · Cited by 17
Management of insomnia in primary care
Ng, L., & Cunnington, D. (2021) · Australian Prescriber · doi:10.18773/austprescr.2021.027 · Cited by 17
Culturally Adapted CBTI for Chinese Insomnia Patients: a One-Arm Pilot Trial
Birling, Y., Wang, J., Li, G., Wu, E., Yu, Z., Feng, Y., & Wu, Y. (2018) · International Journal of Behavioral Medicine · doi:10.1007/s12529-017-9710-z · Cited by 17
“In 2009, Espie [16] proposed a stepped caremodel for CBTI, and there is now evidence of efficacy for various treatment modalities as self-help treatment [17, 18], group therapy [19, 20], and individual therapy [21].”
BackgroundDigitale Behandlungsangebote für Insomnie – eine Übersichtsarbeit
Spiegelhalder, K., Acker, J. G., Baumeister, H., Büttner‐Teleagă, A., Danker‐Hopfe, H., Ebert, D. D., Fietze, I., Frase, L., Klein, S., Lehr, D., et al. (2020) · Somnologie - Schlafforschung und Schlafmedizin · doi:10.1007/s11818-020-00238-9 · Cited by 18
Nordfjærn, T., Bjerkeset, O., Moylan, S., Berk, M., & Gråwe, R. W. (2013) · Addictive Behaviors · doi:10.1016/j.addbeh.2013.06.010 · Cited by 15
Spiegelhalder, K., Baumeister, H., Al-Kamaly, A., Bader, M., Bauereiß, N., Benz, F., Braun, L., Buntrock, C., Burkhardt, M., Cuijpers, P. J., et al. (2022) · BMJ Open · doi:10.1136/bmjopen-2021-058212 · Cited by 16
Deng, W., van der Kleij, R., Shen, H., Wei, J., Brakema, E. A., Guldemond, N., Song, X., Li, X., van Tol, M., Aleman, A., et al. (2022) · Journal of Medical Internet Research · doi:10.2196/39250 · Cited by 18
“The observed effects suggest that eHealth-based psychosocial interventions for insomnia could be applicable to a broad range of populations and are well suited to be integrated into a stepped-care approach [88,89].”
BackgroundJernelöv, S., & Blom, K. (2023) · Journal of Sleep Research · doi:10.1111/jsr.14024 · Cited by 18
“…CBT-I should be administered in steps, where the initial step may be to guide patients to high-quality self-help treatments that do not require much therapist support, and the highest step may be individual face-to-face CBT-I delivered by behavioural sleep medicine (BSM) specialists (Espie, 2009).”
BackgroundMethodMorin, C. M., Edinger, J. D., Krystal, A. D., Buysse, D. J., Beaulieu‐Bonneau, S., & Ivers, H. (2016) · Trials · doi:10.1186/s13063-016-1242-3 · Cited by 16
“In addition, they are less widely available than medications despite recent efforts to facilitate their implementation through abbreviated therapy protocols [44], self-help interventions [45], and Internet-based programs [46, 47].”
BackgroundDissemination of CBT for Insomnia
Manber, R., & Simpson, N. S. (2016) · Current Sleep Medicine Reports · doi:10.1007/s40675-016-0048-x · Cited by 16
Online Delivery of Cognitive Behavioral Therapy-Insomnia
Drerup, M. L., & Ahmed, S. (2019) · Sleep Medicine Clinics · doi:10.1016/j.jsmc.2019.02.001 · Cited by 16
Time to Disseminate Cognitive Behavioral Treatment of Insomnia
Neylan, T. C. (2011) · Archives of Internal Medicine · doi:10.1001/archinternmed.2010.526 · Cited by 16
CBT-I Cannot Rest Until the Sleepy Teen Can
Gradisar, M., & Richardson, C. E. (2015) · SLEEP · doi:10.5665/sleep.5220 · Cited by 18
Psychological and Behavioral Treatments for Insomnia II
Edinger, J. D., Leggett, M. K., Carney, C. E., & Manber, R. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-24288-2.00086-6 · Cited by 17
Stepped care management of insomnia co-occurring with sleep apnea: the AIR study protocol
Eldridge-Smith, E. D., Manber, R., Tsai, S. C., Kushida, C. A., Simmons, B., Johnson, R. E., Horberg, R., Depew, A., Abraibesh, A., Simpson, N. S., et al. (2022) · Trials · doi:10.1186/s13063-022-06753-4 · Cited by 15
“Nonetheless, given the putative scalability and apparent efficacy of this intervention approach, OCBT-I could represent a first stage intervention in a broader stepped care model that allocates more intensive and less assessable therapist-delivered CBT-I only to those who show an inadequate response to lower intensity…”
Background‘CBT-I in Cancer: We Know It Works, so Why Are We Waiting?’
Fleming, L., & Macmahon, K. (2015) · Current Sleep Medicine Reports · doi:10.1007/s40675-015-0021-0 · Cited by 16
Sadler, P., McLaren, S., Klein, B., Jenkins, M., & Harvey, J. T. (2015) · Trials · doi:10.1186/s13063-015-1066-6 · Cited by 17
“Since previous research has suggested that comorbid insomnia is often misunderstood and inadequately treated [18, 40, 62], education and training play a vital role to address this disparity between research and clinical practice.”
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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