"Stepped care": a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment

Abstract

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.

Figure 1

The CBT feasibility agenda.

Figure 2

A generic stepped care model illustrating incremental levels (steps) of intervention complexity. The most efficient service will ensure maximal throughput by stepping patients according to need, matching interventions to needs, and making best use of available expertise.

Figure 3

Methods of delivery of CBT: Interacting domains reflect levels of resource intensity in CBT.

Figure 4

An evidence-based stepped care model for CBT (c. 2009) illustrating how patients might be allocated to resources in relation to assessed need, to achieve optimal service provision. Arrows represent self-correcting referral movements.