Is it Time to Step Up to Stepped Care with our Cognitive-Behavioral Insomnia Therapies?

Dr. Edinger has indicated no financial conflicts of interest. WORLDWIDE, CHRONIC INSOMNIA IS A HIGHLY PREVALENT AND OFTEN DEBILITATING CONDITION THAT REDUCES QUALITY OF LIFE, INCREASES RISKS FOR serious psychiatric and medical disorders, and enhances healthcare costs for affected individuals and society at large. A number of currently available pharmacotherapies have proven effective for the management of insomnia and some of these have demonstrated continued efficacy for extended periods of continuous treatment.1 However, there are no data demonstrating the sustained benefit of such therapies long after active treatment is discontinued. In contrast, cognitive-behavioral insomnia therapy (CBT) is a well-tested and well-proven alternative therapy that teaches patients sufficient insomnia management skills such that they appreciate continued sleep benefits long after completing active therapy.2–4 Furthermore, many patients prefer this form of treatment over pharmacotherapy when given the choice between these two forms of intervention.5 As such, CBT should have a prominent place at the “insomnia treatment table” whenever and wherever insomnia patients present for treatment. Despite the extensive body of literature supporting the efficacy and durability of CBT for insomnia, accessibility to this form of treatment remains spotty at best. Providers who have training in CBT are sorely limited. In fact, within the US, one can traverse entire states and not find one practitioner who has expertise in this form of treatment. Notwithstanding the challenge that CBT faces purely as a function of paid advertising for the medicinal insomnia remedies, the practical matter of not being able to access this treatment keeps CBT as one of our best kept secrets in the sleep medicine world. This issue's article by Colin Espie, entitled “‘Stepped care’: a health technology solution for delivering Cognitive Behavioral Therapy as a first line insomnia treatment,” is a nicely written, reflective paper that offers one possible solution to this problem.6 Specifically, this article describes the use of a stepped care model to assure greater dissemination of CBT for insomnia. Dr. Espie discusses a range of issues related to the difficulty of CBT dissemination and the potential patient demand for this therapy. He also considers a range of CBT delivery methods that could be employed in an integrated manner to efficiently address the needs of the insomnia population at large. Although theoretical rather empirical in nature, this paper provides a timely, thoughtful, and certainly pertinent discussion of a potentially interesting methodology for greater CBT dissemination. Admittedly aspects of this paper are provocative, particularly to those wishing to protect the guild of well-trained and qualified CBT practitioners. To promote the widest CBT dissemination, Dr. Espie envisions the population of insomnia sufferers as a diverse group who vary in their treatment needs. Some, he postulates, can benefit from minimal self-help or abbreviated CBT protocols, whereas others need various levels of progressively more intensive and time-consuming therapies. Given this postulate, Dr. Espie advocates the systematic assignment of patients to the level of care they need with the caveat that those initially miss-assigned to a lower level of care than required could be “stepped up” to a higher level of care as needed. He also advocates for the use of non-traditional providers, including nurses, pharmacists, and even PSG staff in the cadre of healthcare providers who can be considered for CBT delivery under the guidance/supervision of a clinical psychologist with CBT expertise. As these opinions diverge somewhat from other recently published opinions regarding the dissemination of CBT,7 it is useful to consider the critical and more provocative aspects of Espie's model. First and foremost, we need to consider what is the least intensive CBT method that can be expected to be effective for at least a portion of those patients with chronic insomnia problems. Clearly it makes no sense to consider “interventions” in this model if they have no proven efficacy. Although widely disseminated newspapers and magazines are ripe with stories about good sleep hygiene and CBT-based recommendations, there is no evidence that such information serves as effective treatment for insomnia patients. If we peruse the insomnia literature, it appears that structured forms of bibliotherapy8 (with or without telephone visits by a CBT therapist) as well as internet based CBT delivery mechanisms are the “least restrictive or intensive therapies that have shown efficacy for at least some insomnia sufferers.9,10 However, virtually nothing is known about who does and who does not benefit from these forms of interventions, which makes it difficult at this juncture to confidently assign selected patients to this entry-level treatment and have a reasonable expectation for their success. Moreover, we know little about short-term and, perhaps more importantly, longer-term outcomes of insomnia patients who might become disillusioned and stop seeking treatment entirely if such a low level intervention proves inadequate for their needs. These considerations are not necessarily arguments against Espie's stepped model, but they do highlight some challenges that need to be addressed in its implementation. The main point is that we need to identify those measurable patient factors that make patients best suited for the types of minimal entry level CBT treatments we offer. These considerations herald broader challenges that need to be faced in the allocation of various levels of CBT intervention to the patients seeking insomnia treatment. On the one hand, it makes sense to allocate patients to the least restrictive and least expensive effective treatments whenever possible. Simply put, why do major surgery when two weeks of physical therapy will do the trick? Yet we must admit our limited knowledge of patients' characteristics that predict treatment needs and outcomes is not confined to the briefer and lower intensity insomnia interventions. Rather, there is a general dearth of data to guide us in matching insomnia patients to any level of behavioral or pharmacologic treatment per se. Whereas factors such as current cognitive deficits, the presence of complicating psychiatric or medical comorbidities, coexisting sleep disorders (e.g., obstructive sleep apnea), and low levels of sleep-related self-efficacy may all argue for more intensive CBT models, data demonstrating that these sorts of factors are useful in matching CBT interventions to patients is lacking. Thus, it would seem that such information would be needed before we can effectively implement the stepped care model proposed. Additionally, we need not only allocate patients to various levels of intervention in Espie's stepped care model, but we also need to discern which types of providers should be assigned to each step so as to maximize treatment outcomes while minimizing treatment costs. To date, various provider types have shown to be effective therapists in the delivery of cognitive and behavioral insomnia therapies—these include licensed clinical psychologists,11–13 clinical psychology graduate students,14,15 primary care nurses and nurse practitioners,16–18 and physicians.19 Whether Espie's suggestion that pharmacists and PSG staff could be added to the mix at some level of care remains an empirical question. However, given the high comorbidity between insomnia and mental disorders, it would seem most prudent to position such providers at lower levels in the stepped care model wherein they encounter the least complicated patients. Even if we assume that we can eventually effectively allocate patients and providers to appropriate steps in Espie's model, certain pragmatics will remain as challenges to its implementation. We first need to ascertain where such a model could be implemented. Healthcare reform efforts aside, it would likely be very difficult to implement stepped care at the broader societal level in a country like the USA, given its complex, free-market based healthcare system. However, it would seem possible to implement it within selected, relatively closed health maintenance organizations, wherein a finite patient population of health plan enrollees is tracked closely via current-day computer technology. Likewise it may be possible to implement it in countries like the United Kingdom that have a socialized, government-managed, and centralized healthcare system. Secondly, it will be necessary to determine who would perform the massive triage operation of assigning patients to their initial, presumably best-suited levels of care, tracking their outcomes, and then reassigning those non-responders to a higher level of care. This activity, of course, presumes that we are able to identify those patient factors best suited for treatment matching. But assuming we do that, who will screen the insomnia patients seeking treatment and decide which interventions they are assigned initially in the step care pyramid? Given the potential volume of such patients to be screened and the complexity of this task, we need to institute careful thought and assure that adequate personnel and resources are devoted to this challenging triage endeavor. Lastly, we will need to consider what will be used as our basis of comparison to determine if this stepped care protocol actually enhances management of an identified population of insomnia patients who are subject to it. If we are to address this question through some form of treatment effectiveness study, it would seem that we could employ a naturalistic control group of those undergoing care as usual as the mark to beat. Specifically, we should investigate how treatment-seeking insomnia patients access the different levels in the stepped care pyramid on their own accord, and then determine if an orchestrated stepped care protocol that guides patients to the most appropriate treatment actually produces better outcomes. A variety of outcomes could be scrutinized, but such considerations as insomnia response and remission rates, speed of recovery, and overall costs to the patient and healthcare system seem paramount. Positive findings in regard to such metrics would certainly enhance the appeal of Dr. Espie's model. So is it time to step up to stepped care in providing CBT to our insomnia patients? Notwithstanding the various challenges mentioned herein, perhaps it is. Or at least, perhaps we can take some of the preparatory steps mentioned towards this objective. Dr. Espie provides compelling rationale for implementing this approach, and with my added thoughts toward its realization, we may be ready to at least conduct an empirical test of its effectiveness and utility. Who knows—we may learn something about insomnia management and surprise ourselves and our patients in the process.