Trouble Sleeping

Insomnia Assessment and Treatment is an Essential Competency for Health Psychologists

Jessee R. Dietch, PhD
Jessee R. Dietch, PhD

Jessee R. Dietch, PhD
Assistant Professor
School of Psychological Science, Oregon State University

Insomnia is one of the most common sleep disorders, and its prevalence may be on the rise (Pandey & Phillips, 2015). Insomnia symptoms are experienced by between 30-50% of the general population (Ellis et al., 2012). The prevalence of chronic insomnia, defined by difficulty falling asleep, staying asleep, and associated daytime functioning impairments occurring at least 3 nights per week for at least 3 months, is estimated between 5 – 15% (Morin et al., 2006; Ohayon, 2002, 2009). Emerging evidence suggests insomnia prevalence may have increased in the context of the COVID-19 pandemic (Li et al., 2020).

            As a health psychologist or other behavioral medicine provider, the chances that a patient with insomnia will walk through your door (or join your virtual waiting room) are high. One estimate suggests 50% of patients presenting to primary care report occasional insomnia, and  additional 19% report chronic insomnia (Shochat et al., 1999). Further, insomnia has a high rate of co-occurrence with medical and psychiatric disorders and symptoms. For example, up to 67% of people with major depression also meet criteria for chronic insomnia (Franzen & Buysse, 2008). Not only can untreated insomnia worsen the course of major depression (Trivedi et al., 2005), but there is evidence that intervening on insomnia can enhance depression treatment outcomes (Manber et al., 2008). Further, insomnia is one of the most common residual symptoms following depression treatment, even in the context of depression remission, with 44-53% of patients reporting residual insomnia (Carney et al., 2007; Nierenberg et al., 1999). Although the co-occurrence of depression and insomnia has perhaps received the most attention in the research literature, similar patterns are also seen for posttraumatic stress disorder (Belleville et al., 2011; López et al., 2019; Pruiksma et al., 2016; Zayfert & DeViva, 2004) and other disorders (Harvey et al., 2015). Insomnia is a persistent condition which is unlikely to remit on its own without targeted treatment (Morin et al., 2020).

            Cognitive-behavioral therapy for insomnia (CBTI) is the frontline evidence-based treatment for insomnia as recommended by, among others, the American Academy of Sleep Medicine (Edinger et al., 2021), the American College of Physicians (Qaseem et al., 2016), the European Sleep Research Society (Riemann et al., 2017), the NIH Consensus State-of-the-Science Conference (Dolan-Sewell et al., 2005), and the VA/DoD clinical practice guidelines (Mysliwiec et al., 2020). CBTI is effective in a wide variety of populations, including those with comorbid conditions (Geiger-Brown et al., 2015; Trauer et al., 2015; Wu et al., 2015), and across delivery formats including group (Koffel et al., 2015) and telemedicine (Arnedt et al., 2021). The long-term effects and side effect profile of CBTI are superior to pharmacotherapy (Mitchell et al., 2012), yet medications are still the most common treatment offered for insomnia.

One reason that the frontline treatment for insomnia is not the most commonly offered treatment is the limited awareness and training of providers in the assessment and treatment of insomnia and related sleep disorders.  A recent study revealed actively practicing clinical psychologists (N =200) received a median of 10 hours of didactic sleep training, with 95% reporting no clinical sleep training during graduate school, internship, or postdoctoral fellowship (Zhou et al., 2020). Further, the majority of respondents endorsed insomnia treatment approaches that were inconsistent with empirical guidelines, and over 99% expressed a desire for additional training in sleep (Zhou et al., 2020). Providers trained to deliver CBTI and related behavioral sleep medicine interventions are inconsistently distributed across the country, and only 10% of accredited sleep medicine centers in the US employ a PhD sleep specialist (Thomas et al., 2016). Although the increase in the availability of telehealth may have slightly eased the geographical constraints, the overall shortage of trained providers evidenced by expanding waitlists is still a factor which limits access to CBTI.

To address the shortage in trained providers, a Department of Defense-funded study (W81XWH-17-1-0165; PI: Taylor) sought to develop a web-based provider training platform for the assessment and treatment of insomnia with CBTI, entitled CBTIweb. This training launched on April 1, 2020, and in the first 10 months trained over 1200 clinicians to deliver CBTI. Pilot testing demonstrated CBTIweb resulted in equivalent knowledge gains in comparison to a typical 8-hour in-person CBTI workshop provided by leaders in the field (Taylor et al., 2021). This training is available for free or at a low cost (if APA CEs are desired) at cbtiweb.org, along with resources for seeking consultation in CBTI (see below for additional resources). Health psychologists now have ready access to a convenient, brief, effective training for evidence-based insomnia assessment and treatment.

In sum, insomnia is a serious psychological health problem which is certain to be common among patients treated by health psychologists, no matter the setting. Insomnia is a 24-hour problem which impacts psychological and physical health functioning and warrants independent, targeted, evidence-based assessment and treatment. At a minimum, every clinician should be familiar with evidence-based assessment and the principles of CBTI in order to ensure that patients with insomnia are detected, referred, and treated in line with evidence-based guidelines.

Resources:

Assessment: The Structured Clinical Interview for Sleep Disorders, Revised (Taylor et al., 2019; Taylor et al., 2018) is available along with the training manual for free at: insomnia.arizona.edu/SCISD

Treatment: Visit cbtiweb.org for free or low-cost (for APA CEs) training in sleep assessment and CBTI. Open source treatment manual for insomnia is available at: insomnia.arizona.edu/cbti-m

Consultation: All providers who are new to CBTI should seek consultation to ensure fidelity to evidence-based treatment. Consultation resources are available at: insomnia.arizona.edu/content/21

–Learn more about behavioral sleep medicine and find certified providers at the Society of Behavioral Sleep Medicine behavioralsleep.org

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