EDITORIAL

The Future of Insomnia Treatmentthe Challenge of Implementation

Brge Sivertsen, PhD1,2; ystein Vedaa, PsyD1,2; Tine Nordgreen, PhD2,3
1 3

http://dx.doi.org/10.5665/sleep.2432

Commentary on Arnedt et al. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. SLEEP 2013;36:353-362.
Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; 2Faculty of Psychology, University of Bergen, Bergen, Norway; Department of Psychiatry, Haukeland University Hospital, Bergen, Norway

In this issue of SLEEP, Arnedt and colleagues provide support for telephone-delivered cognitive behavioral therapy for insomnia (CBTI).1 The authors conducted a small randomized controlled trial comparing 15 patients with chronic insomnia who received telephone-delivered CBTI with an equal sized control group who received a CBTI-based information pamphlet (IPC) without therapist support. Both groups improved significantly on most sleep measures with effect sizes ranging from 1.0 to 1.8, but no significant group differences were found. For the daytime functioning measures CBTI yielded overall better results than the IPC condition. The effect of individual in-person CBTI across age cohorts and comorbidities is well documented, and the sleep medicine community is now facing the next frontierhow to provide a broader and more rapid dissemination of this treatment. Despite being highly effective, individual CBTI is both expensive and time-consuming, and perhaps even more importantly, it is not available for the majority of the population. Although the number of accredited sleep specialists delivering CBTI is growing both in the US and Europe, there are far too few to provide CBTI beyond major metropolitan areas. Therefore, the results of Arnedt et al. are important, as they provide support for the beneficial effects of a non-face-to-face therapy treatment modality for insomnia. Until now the only study examining the effect of telephone-delivered CBTI versus other active treatments was conducted by Bastien et al.,2 who found CBTI delivered by brief phone therapy consultations to be equally effective as that delivered in a group therapy format and individual face-to-face therapy. In contrast to the report by Bastien et al.2 the report by Arnedt et al.1 in this issue of SLEEP included a passive control group (i.e., information pamphlet control [IPC]). This allows us to discern whether the observed changes after CBTI delivered by phone were any greater than changes without treatment, which is important to rule out regression to the mean as an explanation for improvements over time. Surprisingly, the IPC treatment yielded equally strong effect sizes as the CBTI on all sleep measures. As discussed by the authors, the content in the pamphlet may have had some overlap with the CBTI intervention, making it more therapeutic than intended. This unexpected finding clearly needs to be
Submitted for publication January, 2013 Accepted for publication January, 2013 Address correspondence to: Brge Sivertsen, PhD, Norwegian Institute of Public Health, Christiesgt 12, Bergen 5012, Norway; Tel: 4755588876; Fax: 4755589877; E-mail: borge.sivertsen@psykp.uib.no
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replicated in a larger sample, and with actigraphic or polysomnographic outcomes. The findings of Arnedt et al.1 are also important from a cost-effectiveness perspective, suggesting that it is possible to reduce expensive face-to-face therapy sessions, as well as transportation costs, without reducing the efficacy of CBTI, as long as the core treatment modules are present. However, the telephone sessions in the Arnedt et al. study were provided by experienced sleep therapists in 4-8 sessions, which each lasted up to 60 minutes, indicating that if or when implemented, such treatment still requires sleep specialists, making it not very dissimilar from regular face-to-face treatments in terms of costs beyond transportation. As such, telephone CBTI is not guaranteed to be as low-cost an intervention as self-help based treatments with no-to-minimal professional guidance. The discussion of whether CBTI therapists support should be included to reduce attrition and improve outcomes from self-help interventions is both important and controversial.3 Whereas some claim that human support is an essential component of effective self-help Internet interventions, such statements have mainly been based on studies on depression and anxiety, not insomnia.4 In fact, all five published randomized controlled trials (RCT) investigating Internet-based self-help interventions based on CBT for insomnia have used fully automated programs without any human support during treatment, but with positive outcomes.4-8 Also, findings from Andersson and colleagues9 have shown that therapist involvement (via telephone contact) in the treatment of headache does not appear to moderate outcome, and it adds little to the prediction of who will drop out. However, the rise of Internet interventions for insomnia does not eliminate the need for other treatment modalities beyond individual face-to-face therapy. Effect sizes in the Arnedt study were notably high, and also higher than typically found for Internet interventions. Another important aspect is that of patient preference, as not everyone will be satisfied with interacting with only a computer, no matter how personalized and tailored the web program might be. Although 95% of all American households have access to high-speed broadband, there are today still 14 million Americans without such terrestrial broadband infrastructure.9 As such, there is clearly a need to further investigate and refine ways of delivering CBTI between the extreme ends of the spectrum of therapist involvement (i.e., individual face-toface therapy to fully automated Internet interventions). The economic costs of insomnia are very high,10,11 and its prevalence is a major public health concern. We now have knowledge of how to behaviorally treat insomnia. CBTI is efEditorialSivertsen et al

fective, and we believe the right future direction is to develop a wide range of CBTI treatment modalities to improve public dissemination and implementation. Future studies should seek to test a stepped-care model, in which assessment together with an information pamphlet may be a first step, followed by a fully automated web program or brief telephone-based intervention, and finally individual in-person, telephone or Skype CBTI sessions. Given the high prevalence of insomnia and continued scarcity of insomnia therapists, this treatment model reserves individual CBTI sessions to those who do not benefit from lower-intensity interventions. CITATION Siversten B; Vedaa ; Nordgreen T. The future of insomnia treatmentthe challenge of implementation. SLEEP 2013;36(3):303-304. DISCLOSURE STATEMENT The authors have indicated no financial conflicts of interest. REFERENCES
1. Arnedt J, Cuddihy L, Swanson L, Pickett S, Aikens J, Chervin R. Randomized controlled trial of telephone-delivered cognitive-behavioral therapy for chronic insomnia. Sleep 2013;36:353-62. 2. Bastien CH, Morin CM, Ouellet MC, Blais FC, Bouchard S. Cognitivebehavioral therapy for insomnia: comparison of individual therapy, group therapy, and telephone consultations. J Consult Clin Psychol 2004;72:653-9.

3. Ritterband LM, Thorndike FP. The further rise of internet interventions. Sleep 2012;35:737-8. 4. Spek V, Cuijpers P, Nyklicek I, Riper H, Keyzer J, Pop V. Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: a meta-analysis. Psychol Med 2007;37:319-28. 5. Espie CA, Kyle SD, Williams C, et al. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. Sleep 2012;35:769-81. 6. Ritterband LM, Bailey ET, Thorndike FP, Lord HR, Farrell-Carnahan L, Baum LD. Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. Psychooncology 2012;21:695-705. 7. Ritterband LM, Thorndike FP, Gonder-Frederick LA, et al. Efficacy of an Internet-based behavioral intervention for adults with insomnia. Arch Gen Psychiatry 2009;66:692-8. 8. Strom L, Pettersson R, Andersson G. Internet-based treatment for insomnia: a controlled evaluation. J Consult Clin Psychol 2004;72:113-20. 9. Federal Communications Comission (FCC). National Broadband Plan: Current State of the Ecosystem, 2013 http://www.broadband.gov/plan/3current-state-of-the-ecosystem/. 10. Kessler RC, Berglund PA, Coulouvrat C, et al. Insomnia and the performance of US workers: results from the America Insomnia Survey. Sleep 2011;34:1161-71. 11. Sivertsen B, Lallukka T, Salo P. The economic burden of insomnia at the workplace. An opportunity and time for intervention? Sleep 2011;34:1151-2.

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