Session I5-Tapas
Saturday, October 29, 2011
Implementing Cognitive Behavioral
Therapy for Insomnia in Primary
Care
Christina O. Nash, M.S. & Jacqueline D. Kloss, Ph.D.
Department of Psychology
Drexel University, Philadelphia
Objectives
1.
2.
3.
Briefly review literature on CBT-I in
Primary Care settings
Highlight the additional challenges via a
case vignette while delivering CBT-I in
light of current research
Identify areas for clinical discussion and
pose research questions for future
investigation
Prevalence of Insomnia in Primary Care
Widely recognized that primary care settings serve as the
“front lines” for recognizing and initiating treatment for
insomnia
 Many individuals with Primary Insomnia seek out help with
their general practitioner(Aikens & Rouse, 2005)
 50% of individuals in primary care complain of insomnia,
making insomnia one of the most common complaints at
general practitioner offices (Schochat, Umphress, Israel, &
Ancoli-Israel, 1999; NHLB Working Group on Insomnia)
 Among a sample of 1,935 primary care patients, one third met
criteria for insomnia, more than 50% reported excessive
daytime sleepiness (Alattar, Harringon, Mitchell & Sloane,
2007).

Obstacles and Challenges to the Delivery of
CBT-I in PC Settings
◦ Assessment and recognition of insomnia; differential
diagnosis
◦ Fast-paced setting, yet need for integrated care and
collaborative relationships with behavioral health
consultants
◦ Managing insomnia given a complex health picture and
understanding its comorbidites (e.g., chronic health
conditions)
◦ Despite efficacy of CBT and patient preference for nonpharmacological approaches, prescription medications are
most commonly administered (Chesson, et al, 1999) and
CBT-I is underutilized (Morin, 1999; Espie, 1998)
◦ Health Care Providers are untrained in sleep medicine
Additional Challenges of Delivering CBT-I to
Underserved Populations
◦ Chronic health concerns in general are even more pronounced in lower
SES groups. For example, disparities documented in cancer, diabetes,
cardiovascular disease, HIV, psychiatric comorbidities among
underserved (Winkelby, Jatulis, Frank & Fortmann, 1992)
◦ Sleep quality is inversely related to income, unemployment, education
(Moore, Adler, Williams, Jackson, 2002; Ford and Kamerow, 1989)
◦ Individuals with lower SES as measured by education level were more
likely to experience insomnia while controlling for gender, age, and
ethnicity (Gellis et al., 2005) and those who have dropped out of high
school demonstrated the greatest impairments due to insomnia
◦ Paucity of research on interrelationships between race, ethnicity, SES
and insomnia; For example, perhaps poor sleep may account for the
relationship between low SES and health disparities (Arber, Bote, &
Meadows, 2009; Cauter & Spiegel, 1999)
◦ Shift work more common among low SES, and linked to poorer sleep
quality and poorer health outcomes (Cauter & Spiegel, 1999)
Research Background to CBT-I Delivery
to Underserved in PC Settings



A number of studies have initiated abbreviated CBT
implementation in PC settings with success (e.g, Edinger &
Sampson, 2003; Goodie et al., 2009; Hyrshko-Mullen et al,
2000; and some with primary care nurses (e.g., Espie et al,
2001; 2007; Germain et al., 2006)
However, to our knowledge, little, if any research has been
conducted to examine Sleep Disorders, and specifically
insomnia, among underserved community primary care
patients
One study, McCrae et al. (2007) a 2-day workshop delivered
by service providers (mental health counselor, a provisionally
licensed counselor, and social worker) yielded significant
improvement in a rural setting with elderly population
Translating CBT-I Research to Practice
among Underserved Populations

How do we translate and deliver our
well-established CBT-I approaches not
only within a fast-paced PC setting in an
abbreviated modality with care
professionals who likely have limited sleep
knowledge, but also to populations with
complex health histories, impoverished
environments, and with limited resources?
Observations from Community Health Center
Ethnicity/Race: Latino and African-American patients
 Over 98% of patients are 200% below the poverty line
 Potential for comorbidity
◦ 24.3% of patients met criteria for Major Depressive Disorder (MDD)
◦ 26% met criteria for Generalized Anxiety Disorder (GAD)
◦ 28.5% met criteria for Post-traumatic Stress Disorder (PTSD)
◦ In a study of a sample of 288 patients conducted in 2003, 46% of
patients met criteria for a DSM-IV-TR diagnosis, 14% met criteria for 2
diagnoses, and 11% met criteria for 3 diagnoses.
 Of 9057 adult patients seen during the last year, 158 were diagnosed with
Psychophysiological Insomnia, 2 with Insomnia, Unspecified
◦ Over half of these patients reported symptoms of insomnia during their
medical visit
◦ 120 of these patients with diagnosed insomnia are currently prescribed
Zolpidem (i.e., Ambien)
◦ Of 9057 patients, 125 were seen by Behavioral Health for screening
and/or consultation

Observations from the Community
Health Center
Language barriers
 Literacy
 Legal status
 Unemployment/Lack of a daytime routine
 Patients sleeping in shelters/Homeless
 Impoverished sleep environments may lead
to poor sleep hygiene (e.g., noise, fear, bed
availability, curtains, temperature)
 Limited access to sleep education and sleep
specialists

Case Vignette
History of
Domestic
Unemployed and Violence Diagnosed with
lacks a daytime
MDD, GAD &
routine
PTSD
Safety Concerns
in Neighborhood
Rosa
Did not
graduate high
school
English as a
One bed for four second
language
people
Chronic
Medical
Conditions
Nightmares
Treatment Implementation
Behavioral Health Consultation
Delivery of CBT-I
Consult 1
“Warm-handoff” by PCP. Gathered patient history and provided psychoeducation on
sleep hygiene. Sleep diaries were distributed.
Consult 2
Assess sleep diaries and implement Stimulus Control procedures. Progressive muscle
relaxation strategies are introduced to help patient cope with her anxiety at bedtime.
Consult 3
Patient reports difficulty with Stimulus Control. Strategies are discussed and
implementation is encouraged. PMR is reviewed.
Consult 4
Patient reports she is engaging in stimulus control and has been “sleeping better.” Sleep
Restriction is introduced and the continuation of Stimulus Control strategies is
recommended.
Consult 5
Patient reports she has been having difficulty with Sleep Restriction and her sleep
restriction schedule is reviewed.
Consult 6
Patient is a “no show” for her scheduled appointment.
Consult 7
Patient reports that she has been sleeping with less nighttime awakenings and has been
falling asleep in less than 30 minutes. She is encouraged to continue utilizing CBT-I
strategies.
Consult 8
Patient’s self-report of insomnia severity is below the threshold for insomnia. Patient
wishes to discontinue behavioral health consultation at this time and promises to
contact DVCH if she is having sleep difficulties again. She is encouraged to continue
engaging in CBT-I.
Rosa Sleep Diary Data*
SOL
WASO
TST
TIB
Consult 1
(Baseline)
1.5 hrs
2.5 hrs
4hrs
8 hrs
Consult 2
1.25hrs
2.5hrs
4hrs
7.75 hrs
Consult 3
Missing
Consult 4
Consult 5
1hr
Missing
Missing
2hrs
Missing
Missing
5.75hrs
Missing
Missing
7.75 hrs
Missing
Consult 6
45 min
30 min
6.25hrs
6.65hrs
Consult 7
40 min
45 min
7.25 hrs
7.65hrs
Consult 8
25 min
30 min
7.25 hrs
8.70hrs
*Weekly Averages
Insomnia Severity
Practices and Pitfalls of CBT-I in the
Community Health Center
Method of Treatment
Delivery
“Practices”
“Pitfalls”
Self-administered CBT
“Cold calls” vs. “warm hand-offs”
Having proper screening devices;
collaborative relationships;
knowledge and training; efficacy
of self-help treatments?
Language barriers and Literacy
Small Group manualized brief
CBT delivered by a trained
therapist
Where available, can be ideal, e.g.,
graduate student training model
Limited resources; rural settings;
adequate training care providers,
consulting BSM specialists
Individual or small group CBT
delivered by a graduate
psychologist
Availability of these training
models
Need for supervision, BSM
specialist consultation; need
research on efficacy; volume
outweighs staff
Individual, tailored CBT delivered
by a clinical psychologist or
Expert CBT-I delivered by a BSM
Specialist
Limited research on efficacy of
abbreviated models and limited
availability
Cost, volume, accessibility;
Follow-up
Adapted from Espie’s Stepped Care Model (2009)
Future Research and Clinical Considerations
◦ Epidemiological studies on the links between SES and insomnia (e.g.,
understanding the mechanisms that link insomnia and SES, education,
and health); studies on incidence, prevalence, and
presentation/manifestation of insomnia
◦ Additional efficacy studies on abbreviated CBT approaches specifically
with underserved populations (e.g., in rural settings, at community
health centers, varied educational levels); Does one size fit all?
◦ Psychometrically sound screening and assessment measures (e.g.,
Kroenke et al, 1999; PHQ-9)
◦ How effectively can “in house” care providers deliver CBT-I? Under
what conditions? How do we best access BSM specialists and provide
adequate supervision and training?
◦ How do we foster collaborative relationships into an integrative care
system with the use of behavioral health consultants and/or BSMtrained practitioners?
◦ Consider complex comorbidities (physical and mental health problems)
◦ Enhance decision-making about pharmacotherapy
Where do we go from here?
Stepped Care Model (Espie, 2009)
 Meta-analyses demonstrated self-help
tools (books, internet) to have a small to
moderate effect size (Straten & Cuijpers,
2009)
 Tele-health, Internet and Telephone
Consultations (e.g.,Vincent& Lewycky,
2009; Bastien et al, 2004)
 Group CBT-I
 Implementation of Training Models

References

Alattar, M., Harrington, J.J., Mitchell, M.,, & Sloane, P. (2007). Sleep problems in primary care: a North Carolina family
practice research network (NC-FP-RN) study. JABFM, 20, 365-374.

Arber, S., Bote, M. & Meadows, R. (2009). Gender and socio-economic patterning of self-reported sleep problems in
Britain. Social Science & Medicine, 68, 281-289.

Espie, C.A. (2009). “Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line
insomnia treatment. SLEEP, 32(12), 1549-1558.

Espie, C.A., Inglis, S.J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic
insomnia: implementation and evaluation of a sleep clinic in general practice. Behaviour Research and Therapy, 39, 45-60.

Ford, D.E., & Kamerow, K.B. (1989). Epidemiologic study of sleep disturbances and psychiatric disorders. Journal of the
American Medical Association, 262, 1479-1484.

Gellis, L. A., Lichstein, K. L., Scarinci, I.C., Durrence, H.H., Taylor, D.J., & Bush, A.J. (2005). Socioeconomic status and
insomnia. Journal of Abnormal Psychology, 114(1), 111-118.

Germain, A., Moul, D.E., Franzen, P.L., Miewald, J.M., Reynolds, C.F., Monk, T.H., & Buysse, D.J. (2006). Effects of a brief
behavioral treatment for late-life insomnia: preliminary findings. Journal of Clinical Sleep Medicine, 2(4), 403-406.

Goodie, J.L. , Isler, W.C., Hunter, C., & Peterson, A.L. (2009). Using behavioral health consultants to treat insomnia in
primary care: a clinical case series. Journal of Clinical Psychology, 65(3), 294-304.

McCrae, C.S., McGovern, R., Lukefahr, R., & Stripling, A.M. (2007). Research evaluating brief behavioral sleep treatments
for rural elderly (RESTORE): a preliminary examination of effectiveness.

Moore, J.P., Adler, N.E., Williams, D.R., & Jackson, J.S. (2002). Socioeconomic status and health. The role of sleep.
Psychosomatic Medicine, 64, 337-344.

Winkelby, M.A., Jatulis, D.E., Frank, E. & Fortmann, S.P. (1992). Socioeconomic status and health: How education,
income, and occupation contribute to risk factors of cardiovascular disease. Journal of Public Health, 82(6), 816-820.
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