Practical guide to implement CBT-I in primary care

The components of CBT-I include stimulus control therapy, sleep restriction therapy, and/or relaxation therapy in addition to cognitive restructuring of dysfunctional thoughts related to sleep.20Patient education about side effects of long-term hypnotic use should also be included as part of the behavioral strategy to limit medication use.Table 1.1summarizes all components of CBT-I for providers.

Table 1.1. Components of CBT-I

Patient education on side effects of hypnotics

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  • Psychomotor impairment
  • Unknown long-term side effects
  • Withdrawal, dependence, tolerance, rebound effects
  • Improved sleep quality on discontinuation of hypnotics
Relaxation training

  • Progressive relaxation
  • Deep breathing
  • Imagery
  • Meditation
Cognitive Behavioral Therapy

Any combination of stimulus control therapy, sleep restriction therapy, patient education about medication side effects, and sleep hygiene in combination with behavioral therapy.

Stimulus control therapy

  • The bedroom is for sleep and sex only
  • Wake up and go to bed at a consistent time every day
  • Do not nap
  • Only go to bed when sleepy
  • Get out of bed if not asleep within 15 minutes of going to bed
Sleep hygiene

  • Wake up and go to bed at the same time every day, including weekends
  • Exercise at least four hours before bedtime
  • Avoid caffeine at least six hours before bedtime.
  • Avoid alcohol within three to four hours before bedtime.
  • Keep the bedroom cool, dark, and quiet
  • Do not eat a large meal before bedtime
  • Avoid watching TV or other stimulating activities in the bedroom.
Sleep restriction therapy

  • Limit the time in bed to the actual time sleeping only
  • Schedule sleep according to each patient’s total average sleep time
Cognitive therapy

  • Identify dysfunctional thought processes that interfere with sleep
  • Reinforce accurate beliefs about sleep
  • Challenge patients’ misconceptions about sleep with action: for example, the patient should be encouraged to exercise instead of nap during the day to demonstrate that one is still capable of functioning with a lack of sleep.
  • Identify other common inaccurate beliefs, including the false common assumption that hypnotics are more effective than behavioral therapy
Adapted from Espie CA, MacMahon KM, Kelly HL, et al. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep. 2007;30(5):574-584; Morin CM, Bootzin RR, Buysse DJ, et al. Psychological and behavioral treatment of insomnia: update of the recent evidence (1998-2004). Sleep. 2006;29(11):1398-1414; and National Guideline Clearinghouse (NGC). Clinical practice guidelines for the management of insomnia in primary care. 2013.

Who benefits from CBT?

The optimal treatment of patients with long-term insomnia should be considered on a case-by-case basis, because every patient’s comorbidities, degree of motivation, and other lifestyle factors vary considerably. Some patients may respond to simple behavioral interventions, while patients with more complex psychologic comorbidities may need referrals to specialists in sleep medicine or psychiatry. Before initiating treatment, the primary care provider should first obtain a thorough history to identify possible comorbidities and current sleep hygiene practices.

The provider should then administer the ISI tool and determine the severity of sleep symptoms, daytime symptoms, and distress.16Although the cutoff for insomnia severity is considered 14 on the ISI, all patients may benefit from behavioral therapy as a first-line treatment.17

Despite studies showing the superior efficacy of cognitive behavioral therapy, hypnotics are warranted in several types of patients: those with short-term insomnia, individuals who lack motivation to try an intensive behavioral regimen, and patients with comorbid conditions including depression.2

Online resources

Promising evidence supports the effectiveness of CBT-I when administered online.23,24Some websites that have demonstrated improvements in sleep severity scores and in daytime functioning include

It is important to consider the patient’s motivation, access and comfort level with technology, and willingness to invest time prior to referring him or her to a time-intensive online-guided program. Further research is warranted regarding the efficacy of online-based CBT-I programs, compared with in-office programs. Offering online-based CBT for insomnia may be an effective strategy in patients who are not compliant with regular office visits, or in cases in which the primary care provider is unable to perform abbreviated CBT-I due to practice constraints.24

Discontinuation of hypnotics

The discontinuation of hypnotics such as zolpidem is a challenge in primary care because many patients present with a history of chronic hypnotic use and psychologic and/or physiologic dependence. Although it is safe to discontinue chronic treatment with benzodiazepine-like hypnotics such as zolpidem when the patient is taking a recommended dosage,25withdrawal and rebound effects may still occur and can be minimized by gradual tapering of dose and frequency.16

It is important to address behavioral strategies to sustain improved sleep after discontinuation of hypnotic medications.2Behavioral strategies, including sleep hygiene, relaxation strategies, and brief cognitive behavioral therapy interventions, are all effective, widely available, and feasible interventions to administer in the primary care setting.

It is important that all primary care providers focus on behavioral interventions that produce enduring positive effects in patients with insomnia who have chronic hypnotic use. Pharmacologic therapies may also be necessary in combination with behavioral strategies in some cases, but behavioral interventions should be targeted for the most sustainable effects in improving sleep quality.2

Sabrina Brem, DNP, FNP-BC, is a family nurse practitioner and an Instructor of Nursing at Columbia University School of Nursing in New York City. 


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