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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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“Researchers have proposed strategies that have the potential to improve the dissemination of evidence-based treatments for insomnia, such as a stepped-care and technology assisted model of cognitive-behavioral therapy delivery (Edinger, 2009; Espie, 2009).”
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Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., Britton, T., Crowe, C., Dijk, D.-J., Espie, C., et al. (2010) · Journal of Psychopharmacology · doi:10.1177/0269881110379307 · Cited by 634
“One approach involving ‘stepped care’ has been suggested (Espie, 2009) where, depending on severity, chronicity and complexity of insomnia, people could be allocated to the various levels, with self-administered CBT (e.”
BackgroundSelf-citation
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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