Behavioral treatment of insomnia: a proposal for a stepped-care approach to promote public health

Abstract

Chronic insomnia is a highly prevalent condition that has psychological and medical consequences for those who suffer from it and financial consequences for both the individual and society. In spite of the fact that nonpharmacologic treatment methods have been developed and shown to be as or more effective than medication for chronic insomnia, these methods remain greatly underutilized due to an absence of properly trained therapists and a general failure in dissemination. A stepped-care model implemented in a primary-care setting offers a public health solution to the problem of treatment accessibility and delivery of behavioral treatments for insomnia. Such a model would provide graduated levels of cognitive behavioral intervention, with corresponding increases in intensity and cost, including self-help, manualized group treatment, brief individual treatment, and finally, individualized behavioral treatment provided by a specialist. To provide such a systematic approach, future research would need to confirm several aspects of the model, and a cadre of professionals would need to be trained to administer manualized care in both group and individualized formats.

Keywords: chronic insomnia; cognitive behavioral therapy; primary care; stepped care.

Figure 1

A proposed model for an insomnia clinical pathway in primary care. Abbreviation: CBT-I, cognitive behavioral therapy for insomnia.

Figure 2

A model for stepped-care treatment for chronic insomnia in primary care indicating how patients might move through the cognitive-behavioral treatment levels. As treatments become progressively more individualized and intense, they also become more costly to the individual and the health care system. Abbreviation: CBT-I, cognitive behavioral therapy for insomnia.