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Implications for practice and research
The ability of non-clinician sleep coaches to deliver efficacious cognitive–behavioural therapy for insomnia (CBT-I) was demonstrated, suggesting such coaches can increase the rate and range of deployment of CBT-I to provide effective first-line treatment of insomnia into general medical and healthcare practice.
Similar studies should be conducted to replicate and extend this finding and explore its likely generalisability beyond the older veteran population. Such research should explore which patients with insomnia 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 cognitive–behavioural therapy for insomnia (CBT-I) have demonstrated that it is efficacious both post-treatment and long term in a wide variety of patient populations, including those with comorbid medical or psychiatric disorders.1–2 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 efficacious.3–4 CBT-I is now considered the first-line treatment for chronic insomnia.5
Methods
One hundred and fifty-nine community-dwelling veterans ≥60 years who met diagnostic criteria for insomnia of 3 months duration or longer, participated in an RCT of CBT-I. Non-clinician ‘sleep coaches’ delivered a five-session manual-based CBT-I programme with weekly telephone behavioural sleep medicine (BSM) supervision. Control participants received five 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 efficiency (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.
Findings
Intervention participants had significant (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 efficacy 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 efficacy, 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 efficacy; (2) increasing treatment effectiveness and translation into the community; and (3) increasing CBT-I practitioner training and dissemination.6 This excellent study by Alessi and colleagues directly addresses the second and third of these areas with findings that have significant 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 supervision by a BSM expert, improved self-reported sleep in older veterans. The magnitude and duration of the sleep improvements were comparable to findings from CBT-I trials in older adults carried out by interventionists with specialised and formal training in BSM.
This is the first CBT-I trial that specifically 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 particularly 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: “increasing…translation into the community…and alternative 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 first-line treatment for chronic insomnia.5
Footnotes
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.