Insomnia and Anxiety (Series in Anxiety and Related Disorders) (16 page)

Treatment Delivery Issues

CBT originally evolved as a treatment that is delivered via individual therapy

using four to eight therapy sessions. Moreover, a review of the available efficacy

studies showed that this has been the most popular form of treatment delivery used

Treatment Delivery Issues

57

in these investigations over the past two decades. However, to improve the cost

effectiveness of CBT and accessibility, a number of alternative delivery methods

have been developed. Not surprisingly, the most common alternative CBT delivery

format that has been used thus far is group therapy. Although one meta-analytic

review (Morin, Culbert, & Schwartz, 1994) suggested a slight superiority of indi-

vidually-administered CBT over a group delivery format, several studies have

shown that group CBT models involving six to eight sessions produce significant

improvements in sleep and global insomnia symptoms (Backhaus, Hohagen,

Voderholzer, & Riemann, 2001; Espie et al., 2007; Espie, Inglis, Tessier, et al.,

2001; Morin et al., 1999; Morin, Kowatch et al., 1993). Yet, studies directly com-

paring the relative benefits of individual versus group formats have been extremely

limited. Nonetheless, one recent study (Bastien, Morin, Ouellet, Blias, &

Bouchard, 2004) did show similar outcomes for insomnia patients assigned to

either group or individualized CBT therapy, so this finding in conjunction with the

others mentioned suggest that group CBT can and should be considered a viable

treatment approach.

Inasmuch as CBT is a psychological treatment, it was originally intended for

use by trained and licensed psychologists. However, the number of such indi-

viduals who are experts in CBT for insomnia is currently very limited. Moreover,

the majority of treatment seeking insomnia patients present in primary care

settings (Richardson, 2000) where direct access to psychologist providers is

usually limited. Hence, in such settings, the use of nontraditional therapists to

deliver this insomnia intervention might be considered. Several studies utilizing

nontraditional therapists have found that family physicians (Baillargeon,

Demers, & Ladouceur, 1998) and nurses (Epstein & Dirksen, 2007; Espie et al.,

2007; Espie, Inglis, Tessier, et al., 2001), rural mental health clinic staff, such as

mental health counselors and social workers (McCrae, McGovern, Lukefabr, &

Stripling, 2007), and primary care counselors (Morgan, 2003) can effectively

administer treatments such as stimulus control and multicomponent CBT in

general practice settings. In several of these trials, the therapists received training/

supervision from a clinician experienced with CBT for insomnia, so the nontra-

ditional therapists could be considered specialist provider “extenders.” This

model in which the CBT specialist assumes a trainer/consultant role may repre-

sent a reasonable alternative for optimal dissemination when access to the

CBT specialist may be limited.

Of course, many people with insomnia may wish to initiate treatment on their

own, thus we need to consider the effectiveness of home-based self-help renditions

of CBT. In an effort to address this question, Mimeault and Morin (Mimeault &

Morin, 1999) tested a booklet of self-help CBT instructions, used independently

or with the assisted phone consultations with a therapist. Compared to the wait-list

control condition, those treated with the self-help therapy showed greater sleep

improvements, and these improvements persisted at a 3-month follow up.

Telephone consultations with a therapist conferred some short-term advantage

over the self-help booklet, but these benefits disappeared by follow up. Similarly,

Currie et al. (Currie, Clark, Hodgins, & El-Guebaly, 2004) compared individual

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4 Cognitive Behavior Therapy for Insomnia: Treatment Considerations

CBT, treatment with a self-help manual, and a waiting list condition for ameliorating

insomnia in those recovering from alcohol addiction. Results showed treated

patients achieved significantly greater improvements than controls, but no signifi-

cant differences were noted between the in-person therapy and home-administered

self-help program. It should also be noted that Bastien et al. (Bastien et al., 2004)

found comparable effectiveness of CBT provided in individual, group, and tele-

phone formats. Finally, Rybarczyk et al. (Rybarczyk et al., 2005) found a home-

based video CBT program superior to no treatment (wait-list condition), but less

effective than CBT delivered face-to-face in a classroom setting among older

adults with insomnia with comorbid medical conditions. Considered collectively,

these findings suggest that self-administered behavioral insomnia treatments are

promising although some form of contact with a therapist may be needed to obtain

the most optimal results.

There have been a few published attempts to deliver CBT via mass media

dissemination. In perhaps the largest and most unique study to date, Oosterhuis

and Klip tested an insomnia therapy provided via a series of 8, 15-min educa-

tional programs broadcast on radio and television in the Netherlands (Oosterhuis

& Klip, 1997). Over 23,000 people ordered the accompanying course material,

and data from a random subset of these showed sleep improvements and reduc-

tions in hypnotic use, medical visits, and physical complaints were achieved

program participants. Unfortunately, the single group nature of their design

makes it difficult to discern how these results compare to more conventional

treatment. More recently, investigators (Ritterband et al., 2009; Strom, Pettersson,

& Andersson, 2004) have begun testing self-help interactive CBT programs

delivered via the Internet. The initial venture (Strom et al., 2004) found that

those who were treated achieved significantly greater reductions in maladaptive

sleep-related beliefs than did those assigned to a wait-list condition, but treat-

ment and control groups otherwise did not differ on study outcome measures,

including measures of sleep changes. However, in a later study, Ritterband et al.

(Ritterband et al., 2009) found that those who received an internet-delivered CBT

appreciated significantly greater improvements in sleep diary measures and in

their global insomnia symptoms than did those in a wait-list condition. Although

these studies provide a mixed view of internet-based CBT interventions, the

promising findings in the latter trial encourage more tests of this form of treat-

ment delivery.

It should be understood that the best-tested and well-established forms of CBT

delivery are the individual and group therapy protocols directed by those with

extensive training both psychotherapy in general and CBT insomnia therapy

specifically. Treatment delivery approaches that diverge from that paradigm

through their use of alternative providers or self-help vehicles currently have less

empirical support. This does not mean that they are not effective for some insomnia

sufferers. However, the bulk of the data supporting CBT efficacy/effectiveness

comes from the studies of traditional individual and group delivery methods

employed by well-trained CBT therapists. Thus, this form of treatment delivery

would seem preferred and recommended when feasible.

References

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