Can primary care personnel deliver effective CBTi?

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By Dr. Simon Kyle

While several studies have demonstrated that Cognitive-Behavioral Therapy (CBT) is an effective treatment for insomnia, these studies have tended to be under ideal conditions (e.g. recruiting highly selected patients, delivery of CBT by specialist clinical psychologists). Up to 20% of primary care patients report chronic sleep disturbance, and typically derive little benefit from hypnotic use. With a shortage of trained CBTi practitioners, it is of important interest to develop and assess treatments that can be delivered by non-sleep experts within primary care settings.

In a recent study published in the Journal of Sleep Research, a research team from Uppsala University sought to investigate whether CBTi delivered by nurses and social workers can improve sleep in general practice patients. Sixty-six primary care patients were randomized to small group CBT, over five biweekly sessions, or to a waitlist control. CBTi was delivered using standardized manuals, by nurses and social workers, who had no specific training in CBT but attended a 2-day workshop on insomnia management. Participants were assessed at baseline, post-treatment (9 weeks) and at 18 months follow-up. Exclusion criteria were limited to mimic reality of clinical practice as much as possible. Sleep and daytime functioning was assessed through sleep diaries and questionnaires probing insomnia severity, fatigue, sleepiness and anxiety and depression.

The main findings were that, post-treatment, patients in the CBT group had significantly reduced insomnia severity, sleep latency and wakefulness during the night, relative to wait-list controls. Almost half of the CBT group evidenced a clinically-relevant improvement in sleep versus just 6% of the waitlist control group. However, there were no consistent and robust effects for daytime functioning measures, and improvements in sleep (while still significant) tended to weaken at 18 months follow-up. Nevertheless, results indicate that sleep can be improved to a moderate degree using manualised CBTi delivered by primary-care personnel. Such an approach may be a cost-effective way of reaching the large number of primary care patients with chronic sleep disturbance, with those who don’t response requiring more specialist intervention.

Bothelius, K., Khyie, K., Espie, C.A., Broman, J.E. (2013). Manual-guided cognitive-behavioral therapy for insomnia delivered by ordinary primary care personnel general medical practice: a randomized controlled effectiveness trial. Journal of Sleep Research, 22(6), 688-696.

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