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Evidence-Based Nursing Online First, published on April 12, 2017 as 10.1136/eb-2016-102523
Randomised controlled trial
Cognitivebehavioural therapy for
insomnia is effective, safe and
highly deployable
10.1136/eb-2016-102523
Michael V Vitiello
University of Washington, Seattle, Washington, USA
Correspondence to: Michael V Vitiello, Psychiatry Box 356560,
University of Washington, Seattle, WA 98195-6560, USA; vitiello@uw.edu
Commentary on: Alessi C, Martin JL, Fiorentino L, et al.
Cognitive behavioral therapy for insomnia in older veterans
using nonclinician sleep coaches: randomized controlled trial.
J Am Geriatr Soc 2016;64:18308.
Implications for practice and research
The ability of non-clinician sleep coaches to deliver efcacious cogni-
tivebehavioural therapy for insomnia (CBT-I) was demonstrated, sug-
gesting such coaches can increase the rate and range of deployment of
CBT-I to provide effective rst-line treatment of insomnia into general
medical and healthcare practice.
Similar studies should be conducted to replicate and extend this
nding and explore its likely generalisability beyond the older veteran
population. Such research should explore which patients with insom-
nia respond best to non-clinical sleep coaches and which might
require referral to practitioners with greater clinical expertise.
Context
Insomnia is the most common sleep disorder in older adults, is often
chronic and frequently occurs in association with a wide variety of
comorbid illnesses. Numerous well-conducted, randomised controlled
trials (RCTs) of cognitivebehavioural therapy for insomnia (CBT-I) have
demonstrated that it is efcacious both post-treatment and long term in
a wide variety of patient populations, including those with comorbid
medical or psychiatric disorders.12 Most of these studies have employed
either individual or group face-to-face interventions although other
modalities such as telephone and the internet have been employed and
found to be comparably efcacious.34 CBT-I is now considered the rst-
line treatment for chronic insomnia.5
Methods
One hundred and fty-nine community-dwelling veterans 60 years who
met diagnostic criteria for insomnia of 3 months duration or longer, par-
ticipated in an RCT of CBT-I. Non-clinician sleep coaches delivered a
ve-session manual-based CBT-I programme with weekly telephone
behavioural sleep medicine (BSM) supervision. Control participants
received ve sessions of general sleep education as an attention control.
Primary outcomes, including self-reported sleep onset latency (SOL-D),
wake after sleep onset, total wake time (TWT-D) and sleep efciency
(SE-D), based on a 7-day sleep diary; and Pittsburgh Sleep Quality Index
(PSQI) were measured at baseline, post-treatment, and 6-month and
12-month follow-up assessments.
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Care of the older person
Findings
Intervention participants had signicant (p<0.05) improvement from baseline
relative to controls at post-treatment, 6 months and 12 months, respectively:
SOL-D (23.4, 15.8 and 17.3 min), TWT-D (68.4, 37.0 and 30.9 min),
SE-D (10.5%, 6.7% and 5.4%), PSQI (3.4, 2.4 and 2.1 in total score) and
Insomnia Severity Index (4.5, 3.9 and 2.8 in total score).
Commentary
In an overview of the CBT-I literature, we recently concluded that the ef-
cacy of CBT-I to improve both short-term and long-term outcomes in
patients with uncomplicated and comorbid insomnia has been conclusively
demonstrated and that further demonstrations of efcacy, per se, are likely
not the best use of limited energy and resources.6 Rather, we proposed that
future CBT-I research would be better focused on three key areas: (1)
increasing treatment efcacy; (2) increasing treatment effectiveness and
translation into the community; and (3) increasing CBT-I practitioner train-
ing and dissemination.6 This excellent study by Alessi and colleagues dir-
ectly addresses the second and third of these areas with ndings that have
signicant clinical and research implications for our understanding of the
usefulness of CBT-I and the effective treatment of insomnia.
Alessi and colleagues, in this well-designed RCT with longitudinal
follow-up, found that a manual-based CBT-I treatment programme,
delivered by non-clinician sleep coaches with weekly telephone supervi-
sion by a BSM expert, improved self-reported sleep in older veterans. The
magnitude and duration of the sleep improvements were comparable to
ndings from CBT-I trials in older adults carried out by interventionists
with specialised and formal training in BSM.
This is the rst CBT-I trial that specically used sleep coaches who
did not have healthcare, mental health or BSM backgrounds but rather
were effectively lay sleep coaches. The fact that they effected sleep
changes comparable to trials using more expert interventionists is par-
ticularly noteworthy. Use of such non-clinician sleep coaches is clearly a
step in the right direction as it addresses two important needs regarding
the use of CBT-I: increasingtranslation into the communityand alter-
native delivery modalities; and increasing CBT-I practitioner training and
dissemination.6
This important, innovative approach to CBT-I, pioneered by Alessi
and colleagues, provides an extremely promising option for increasing
access to behavioural treatment for insomnia, in keeping with treatment
guidelines that recommend CBT-I as the rst-line treatment for chronic
insomnia.5
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
References
1. Trauer JM, Qian MY, Doyle JS, et al. Cognitive behavioral therapy for chronic
insomnia: a systematic review and meta-analysis. Ann Intern Med
2015;163:191204.
2. Geiger-Brown JM, Rogers VE, Liu W, et al. Cognitive behavioral therapy in persons
with comorbid insomnia: a meta-analysis. Sleep Med Rev 2015;23:5467.
3. McCurry SM, Guthrie KA, Morin CM, et al. Telephone-based cognitive behavioral
therapy for insomnia in perimenopausal and postmenopausal women with
vasomotor symptoms: a MsFLASH randomized clinical trial. JAMA Intern Med
2016;176:91320.
4. 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;35:76981.
5. Qaseem A, Kansagara D, Forciea MA, et al. Management of chronic insomnia
disorder in adults: a clinical practice guideline from the American College of
Physicians. Ann Intern Med 2016;165:12533.
6. Vitiello MV, McCurry SM, Rybarczyk BD. The future of cognitive behavioral therapy for
insomnia: what important research remains to be done? J Clin Psychol 2013;69:101321.
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Cognitivebehavioural therapy for insomnia

is effective, safe and highly deployable
Michael V Vitiello

Evid Based Nurs published online April 12, 2017

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