A systematic review of cognitive behavioral therapy for insomnia implemented in primary care and community settings

Abstract

The advent of stepped-care and the need to disseminate cognitive behavioral therapy for insomnia (CBT-I) has led to novel interventions, which capitalize on non-specialist venues and/or health personnel. However, the translatability of these CBT-I programs into practice is unknown. This review evaluates the current state of CBT-I programs that are directly implemented in primary care and/or community settings. A literature search was conducted through major electronic databases (N = 840) and through snowballing (n = 8). After removing duplicates, 104 full-texts were extracted and evaluated against our initial inclusion criteria. Twelve studies including data from 1625 participants were subsequently evaluated for its study design and methodological quality. CBT-I program components varied across studies and included cognitive therapy (n = 6), relaxation (n = 7), sleep restriction therapy (n = 9), stimulus control therapy (n = 11) and sleep psychoeducation (n = 12). The respective interventions produced small to moderate post-treatment weighted effect sizes for the Insomnia Severity Index (0.40), Pittsburgh Sleep Quality Index (0.37), sleep efficiency (0.38), sleep onset latency (0.38), and wake time after sleep onset (0.46) but total sleep time (0.10) did not reach statistical significance. While non-specialist community settings can potentially address the demands for CBT-I across clinical contexts, intervention heterogeneity precluded the full impact of the 12 CBT-I programs to be evaluated.

Keywords: Cognitive behavioral therapy for insomnia; Community care; Insomnia; Primary care; Stepped-care.