Michael V. Vitiello,1Susan M. McCurry,1and Bruce D. Rybarczyk2
1University of Washington
2Virginia Commonwealth University
The efficacy of cognitive-behavioral therapy for insomnia (CBT-I) to improve both short- and long-term
outcomes in both uncomplicated and comorbid insomnia patients has been repeatedly and conclusively
demonstrated. Further demonstrations of efficacy, per se, in additional comorbid insomnia populations
are likely not the best use of limited energy and resources. Rather, we propose that future CBT-I
research would be better focused on three key areas: (a) increasing treatment efficacy, particularly
for more clinically relevant outcomes; (b) increasing treatment effectiveness and potential for transla-
tion into the community, with a particular focus on variants of CBT-I and alternative delivery modali-
ties within primary healthcare systems; and (c) increasing CBT-I practitioner training and dissemina-
tion. C ?2013 Wiley Periodicals, Inc. J. Clin. Psychol. 00:1–9, 2013.
Keywords: Cognitive Behavioral Therapy; Insomnia; Sleep
Cognitive-behavioral therapy for insomnia (CBT-I) has been consistently demonstrated to be
efficacious in a wide variety of patient populations and settings (Bootzin & Epstein, 2011;
Irwin, Cole, & Nicassio, 2006; Morin et al., 2006; Smith, Huang, & Manber, 2005). This effi-
cacy has been demonstrated in both patients with uncomplicated insomnia and in those whose
insomnia is comorbid with a variety of medical and psychiatric conditions. Specific comor-
bid conditions in which sleep disturbance has been shown to respond to CBT-I in random-
ized clinical trials include chronic pain, breast cancer, chronic obstructive pulmonary disease,
coronary artery disease, osteoarthritis, fibromyalgia, Alzheimer’s disease, depression, alcohol
abuse, and PTSD. Ongoing randomized clinical trials of CBT-I are being conducted in at
least four additional populations, including patients with Parkinson’s disease, with chronic
fatigue syndrome, receiving bone marrow transplants, or undergoing kidney dialysis (see Clin-
icaltrails.gov). In the completed trials for both uncomplicated and comorbid insomnia the
efficacy of CBT-I is generally at least comparable to available pharmacotherapies, with the
advantage of a much lower risk profile. CBT-I has also consistently been demonstrated to
have long-term benefit for up to 2 years posttreatment, which has yet to be established for
Given the richness of the experimental literature supporting the immediate and longer term
efficacy and safety of CBT-I, we believe that research priority should no longer be placed on
continuing to demonstrate its efficacy in additional comorbid populations. Instead, we pro-
pose that future research on CBT-I should focus on three key areas: (a) increasing treatment
efficacy, particularly for more clinically relevant outcomes; (b) increasing treatment effective-
ness and potential for translation into the community, with a particular focus on variants
of CBT-I and alternative delivery modalities within primary healthcare systems; and (c) in-
creasing CBT-I practitioner training and dissemination. Here, we discuss these lines of poten-
tial research in more detail, with special regard for the role of CBT-I in treating comorbid
Please address correspondence to: Michael V. Vitiello, University of Washington, School of
Medicine, Dept. of Psychiatry and Behavioral Sciences, Box 356560, Seattle, WA 98195-6560. E-mail:
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 00(0), 1–9 (2013)
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp).
C ?2013 Wiley Periodicals, Inc.
2 Journal of Clinical Psychology, XXX 2013
Increasing Treatment Efficacy
While the major variants of CBT-I have consistently been shown to be efficacious in numerous
randomized controlled trials, future studies should focus on increasing the efficacy of CBT-
I by determining the most efficacious components of therapy and possibly intensifying these
behavioral and pharmacological therapeutic approaches, enhancing the clinical significance of
treatment outcomes, and testing the usefulness of CBT-I when administered “prophylactically.”
Several systematic reviews have found that the “big guns” of stimulus control and restricted
time in bed may be the most efficacious components of CBT-I (Epstein, Sidani, Bootzin, &
Belyea, 2012; McCurry, Logsdon, Teri, & Vitiello, 2007; Morin et al., 2006). However, this
possibility needs to be fully tested before these techniques become codified as the principal
studies where the relative efficacy of individual treatment components can be compared. For an
excellent exception to this rule, see the recent paper by Epstein et al. (2012).
Another issue of concern is the need to use high-quality attention control conditions as the
appropriate comparators against which to evaluate CBT-I efficacy. Comparing CBT-I inter-
ventions to waitlist or weak attention controls rather than a credible placebo condition makes
it difficult to discern to what extent observed improvements can be attributable to particu-
lar intervention components versus nonspecific treatment effects such as therapist attention,
treatment expectancy, general patient activation, or simple self-monitoring (Riemann & Perlis,
Earlier work on more efficiently packaging CBT-I, while maintaining its efficacy, emphasized
strategies such as shortening the standard eight-session treatment protocol to two to five ses-
on behavioral components to increase sleep drive and optimize circadian sleep/wake rhythms
(Buysse et al., 2011; Edinger & Samson, 2003; Espie et al., 2007). More recent work examining
ers of advances down this important route (Cheng & Dizon, 2012; Lancee, van den Bout, van
Straten, & Spoormaker, 2012; Palermo, Wilson, Peters, Lewandowski, & Somhegyi, 2009; Riley,
Mihm, Behar, & Morin, 2010; Ritterband et al., 2009; Rybarczyk, Mack, Harris, & Stepanski,
2011; Espie et al., 2012; Morgan et al., in press) Interventions building upon smart phone ap-
plications or web-enabled pedometer/actigraphs such as the FitBitR ?(http://www.fitbit.com/)
that provide 24-hour sleep-wake activity monitoring and personalized feedback on basic sleep
parameters could also eventually replace cumbersome written sleep logs for monitoring CBT-I
treatment response and developing individualized behavioral plans.
treatments to treat insomnia needs to be systematically explored. Although a few excellent
studies exist comparing the relative efficacy of a combination of behavioral and pharmacologic
therapies versus single therapies, (Morin, Colecchi, Stone, Sood, & Brink, 1999; Morin et al.,
2009) many questions remain unanswered. There is no clear protocol for determining which
treatment (behavioral or pharmacological) to initiate first, nor whether treatments should be
started concurrently. Issues of patient preferences, treatment cost/availability, and treatment
duration all must be considered (Morin, 2006). Particularly, these issues need to be pursued
when insomnia is comorbid with other disorders, such that the appropriateness and impact of
these therapeutic options can be assessed not only for insomnia but for the comorbid illnesses
As noted above, excellent progress has been made with regards to using CBT-I to treat in-
somnia that is comorbid with a variety of psychological and medical comorbidites (Belleville,
Cousineau, Levrier, & St-Pierre-Delorme, 2011; Riemann et al., 2011; Rybarczyk, Lopez,
Benson, Alsten, & Stepanski, 2002; Rybarczyk et al., 2011; Smith et al., 2005). There has also
been a wave of recent research testing the possible synergistic effects of combining CBT-I with
The Future of Cognitive Behavioral Therapy for Insomnia3
of CBT-I Combined with another Treatment
Tx combined with
Civilian assualt victims
with PTSD and
PTSD with nightmares
PTSD with or without
nightmares in veterans
Obstructive Sleep Apnea
Krakow et al., 2001a,
Krakow et al, 2001b
University of New
Durham VA Medical
Richmond, Virginia VA
Medical Center, Sleep
Houston VA Medical
Ulmer et al., 2011IRT
Margolies et al., 2012,
see Ong & Crisostomo,
2012 for pilot study
Vitiello, McCurry and
Von Korff, study in
Beck & Brown, study in
Gardner, study in
Manber, study in
CBT for Chronic Pain
Osteoarthritis in older
PTSD with nightmares
Obesity in adults
Behavioral weight loss
Stanford Medical Center
Depression in adults
sertraline (Zoloft) or
Stanford Medical Center
Depression in adultsCarney, study in
Harvey, study in
Perlis, study in progress,
Depression in teens and
CBT for DepressionUniversity of California
Cancer Survivors with
Armodafinil (Nuvigil) Abramson Cancer
Center of the
Yale University School
Cigarette Smokers Fucito, study in
CBT for Smoking
Note. CBT-I = Cognitive behavioral therapy for insomnia; PTSD = Posttraumatic Stress Disorder; OSA =
CBT = Cognitive behavioral therapy
effects for both treatments. Table 1 provides a list of recent studies testing these combination
approaches as well as ongoing studies listed at clinicaltrials.gov. There is as yet little systematic
research combining traditional CBT-I or insomnia medication with alternative nonpharmaco-
logical strategies such as biofeedback, acupuncture/acupressure, or what has become known
as the “third-wave” behavioral therapies, which focus on mindfulness and acceptance; however,
there is increasing interest in treatment of insomnia by adherents of these alternative approaches
(Ong, Shapiro, & Manber, 2009).
Another aspect of increasing treatment efficacy has to do with increasing the clinical sig-
nificance and potency of our interventions. Although insomnia treatments consistently report
4 Journal of Clinical Psychology, XXX 2013
statistically significant and reproducible changes on self-report and objectively measured sleep
parameters, the bigger question is the extent to which these changes are considered meaningful
in insomnia outcomes, although a variety of strategies have been proposed, including changes
in outcome based upon predetermined criteria, decreases below cutoff scores of validated in-
struments or improvement/remission of insomnia symptoms (Morin, 2003). The definition of
clinically significant improvement is particularly complex in the instance of comorbid insom-
nia, where symptomatology of the comorbid condition may confound perceived improvements
in sleep. Future research is needed to both explore the extent to which treatment effects can
be enhanced and examine issues of clinical significance assessment in the context of complex
A final way of potentially enhancing efficacy is to determine if some format of CBT-I de-
livered “prophylactically” to at-risk preinsomniac medical and psychiatric populations results
in decreased development of insomnia and potentially even in improved medical or psychiatric
status. The development of chronic insomnia has been linked to a series of compensatory strate-
gies (e.g., sleeping in when an eventual good night of sleep occurs, going to bed earlier, directing
more cognitive focus and effort towards achieving good sleep) that individuals make when expe-
riencing acute insomnia (Spielman, Caruso, & Glovinsky, 1987). Therefore, it stands to reason
that educating individuals on how and why to avoid making these adjustments in their approach
to sleep would serve to prevent at least some of them from developing chronic insomnia. Such
interventions could presumably be delivered to individuals who are at-risk for developing in-
somnia due to cognitive/personality characteristics, lifestyle factors (e.g., shift work), and/or
thepresence ofcommoncomorbidconditions.Forexample, would prophylacticCBT-Idecrease
development of comorbid insomnia and depression, or would it decrease, or delay, development
of sleep and circadian rhythm disturbances in persons with progressive dementing illnesses? Pre-
vention research is challenging to conduct: it requires long follow-up periods, large sample sizes,
and generous research budgets. Nevertheless, from a public health perspective, the cost/benefit
of reducing the incidence of insomnia particularly in at-risk comorbid populations could be
Increasing Treatment Effectiveness
In addition to improving the efficacy of CBT-I as detailed above, it is important that the
based samples. The past decade has seen a huge increase in the discussion around how best to
increase the translation of medical research findings into practice. Several guiding models have
evolved out of this dialogue, including the framework developed by the Treatment Fidelity
Workgroup of the NIH Behavioral Change Consortium (BCC; Bellg et al., 2004) to ensure
that interventions in research studies are delivered as intended, and the RE-AIM framework
(Glasgow, Vogt, & Boles, 1999), developed to ensure that proposed research study outcomes
have maximum generalizability and relevance to community providers. Regardless of the size of
one’s clinical trial, CBT-I researchers increasingly need, from the earliest stages of design and
implementation, to be considering how to measure the components of such models, with an eye
towards developing and testing interventions that have potential for real-world implementation
if efficacy is demonstrated in the RTC.
There has already been a research shift towards examining the efficacy of CBT-I in primary
care settings, and including patients in clinical trials with common psychiatric or medical mor-
bidities (Buysse et al., 2011; Edinger & Samson, 2003; Espie et al., 2007; Manber et al., 2012).
However, these studies typically enroll participants who respond to an advertisement or medical
referral, so it is unknown how willing persons in the population-at-large would be to participate,
how effective treatment would be for the population as a whole, or how representative people
who do consent to treatment are of the larger group.
One model for addressing these limitations is found in a large (n = 367) randomized trial
of older adults with comorbid insomnia and osteoarthritis pain that combined features of
The Future of Cognitive Behavioral Therapy for Insomnia5
efficacy and effectiveness (Von Korff et al., 2012). Our recently completed “Lifestyles” trial
compared a combination CBT intervention for osteoarthritis pain and insomnia (CBT-PI) to
a CBT intervention for osteoarthritis pain alone (CBT-P) and an education only control. The
education only condition controlled for information and nonspecific effects, such as therapist
attention and group participation. Both research interviewers and participants in the Lifestyles
trial were blinded to whether the participant was assigned to an active intervention or to
a control condition. Participant screening and recruitment was population-based, employing
electronic health care records at a large Seattle health maintenance organization (Group Health
were delivered in study participants’ primary care clinics, enhancing the relevance of the trial
to dissemination in general health care settings. Last, the education-only control allows for the
differentiation of the efficacy of the CBT-PI and CBT-P interventions from the nonspecific
effects of participation in a support group that presents basic information about osteoarthritis
pain and insomnia. Results from this study will thus provide valuable insight into the potential
relevance and impact of CBT-I on pain, insomnia, and functional outcomes in a representative
primary care population of older adults.
Another model that has potential for increasing the effectiveness of CBT-I is the stepped-
care approach. In the stepped health care delivery model, treatment is initiated using the least
and then it is “stepped up” for persons either who do not benefit or for whom it can be predicted
intensity of services are guided by treatment algorithms; patient preference, treatment history,
and response; and existing institutional resources. One of the best-known examples of stepped
care is IMPACT (Improving Mood: Providing Access to Collaborative Treatment or Late-Life
Depression; Un¨ utzer, Powers, Katon, & Langston, 2005), which over the past 15 years has
successfully moved depression treatment for older adults from efficacy testing through multisite
Insomnia, like depression, lends itself to a stepped care intervention model; it is highly prevalent
in the population, and treatment can be delivered at varying levels ranging from low-intensity
CBT-I by a behavioral sleep medicine specialist (Espie, 2009).
Regardless of the model followed, increasing the future effectiveness of CBT-I requires
examining many pragmatic issues that determine broad-based acceptance of evidence-based
treatments in the community. These include systematic evaluation of the short- and long-term
cost-effectiveness of treatment in terms of subsequent healthcare utilization and related costs,
including comparisons with pharmacotherapy. Little is known about the factors that facilitate
physicians and patients in choosing among insomnia treatment options, including CBT-I, phar-
macotherapy, a combination of both, neither, or some alternative treatment approach. Further,
it is important to test the effectiveness of CBT-I within usual health care delivery systems. In
the real world, there would be few a priori restrictions on who would be considered eligible to
receive a CBT-I intervention. Presumably, compliance with sleep monitoring and homework
would be less than among research protocol participants. Providers would have considerable
freedom in how they delivered the various intervention components and what outcomes they
measured. Treatment dropouts would be high. In light of this expected dilution in treatment
delivery and evaluation, how impactful and durable might CBT-I be? What components are ab-
solutely necessary for inclusion, and how flexible can their delivery be? What systemic changes
in how CBT-I is administered will allow it to be more widely deployable in health care delivery
systems while still maintaining its efficacy/effectiveness?
Increasing Dissemination and Training
about CBT-I and increase the availability of training for practitioners. Only when primary care
physicians appreciate that CBT-I is effective, accept the importance of treating insomnia, and
have access to well-qualified practitioners to whom they can refer, will the potential effect of
6 Journal of Clinical Psychology, XXX 2013
CBT-I to improve patient well-being and quality of life and decrease healthcare utilization and
related costs be realized in the broader healthcare arena (Morgan, Dixon, Mathers, Thompson,
& Tomeny, 2003).
It is unclear exactly what level of expertise and training a CBT-I practitioner might be
expected to have to provide a quality intervention. The field of behavioral sleep medicine is
relatively new. The American Board of Sleep Medicine currently offers a certification process by
which postdoctoral individuals can demonstrate that they have the skills and knowledge that are
essential to deliver excellent patient care. However, the numbers of individuals who realistically
will be able to afford the time, cost, and educational training needed to get such certification is
far outstripped by the need and demand for competent practitioners.
Following the stepped care approach, it might well be that less training is required for delivery
of some CBT-I treatment components, but there are as yet no good guidelines for determining
who should be trained for which components. We also need better screening tools to identify
be particularly important for persons with significant psychiatric or medical comorbidities, or
when withdrawal and dependence factors need to be addressed and expert assistance in tapering
and terminating complex hypnotic and other medication regimens is required. For example, a
paper included in this current issue of JCLP (Mack et al., 2012) demonstrated that individuals
with stronger beliefs about the necessity of using hypnotics in certain situations were less likely
to benefit from self-help interventions.
Other important research work on training issues includes whether practitioners without
extensive backgrounds in behavioral interventions need additional fundamental training in
cognitive-behavioral principles to achieve proficiency in CBT-I, and what type of continuing
supervision and reinforcement of skills is needed after an initial intensive training in CBT-I, as
such skills may gradually erode over time if not sufficiently practiced. Considerations related
to the ultimate widespread dissemination of CBT-I also include what types of reimbursement
changes are needed across the different disciplines to make such treatments financially feasible
to make a “pitch” for CBT-I to their patients when hypnotics are requested. Some persuasive
skills are often required to counteract the cultural tendency to look for a “magic pill” solution
to health problems and to offset the pervasive media advertising by pharmaceutical companies
reinforcing this belief in an easy solution for chronic sleep problems.
Last, work is still needed to demonstrate that implementation of CBT-I in large health care
systems does indeed reduce health care utilization and costs. A number of studies have shown
that the economic burden of untreated insomnia from factors such as health care consultations,
medication and alcohol use, and work absenteeism is high (Alonso et al., 2011; Daley, Morin,
LeBlanc, Gergoire, & Savard, 2009). However, there are currently almost no data on the cost
offsets of CBT-I (for an exception see Morgan et al., 2003), or what types of patient populations
or health care services for which CBT-I would be most cost effective. For example, the cost
benefits of collaborative care management of depression have been shown to vary depending
did produce significant reductions in per-person outpatient health costs (Katon et al., 2012),
illustrating the potential additive benefits of targeting individuals with comorbid conditions. We
look forward to seeing the results from similar work in the future examining the cost effect of
systematically implemented CBT-I in health care delivery systems.
It is a very exciting time in the evolution of CBT-I. The efficacy of CBT-I to improve both
short- and long-term outcomes in both uncomplicated and comorbid insomnia patients has
been repeatedly and conclusively demonstrated. Further demonstrations of efficacy, per se, in
additional comorbid insomnia populations are likely not the best use of limited energy and
resources. Rather, refining CBT-I techniques and methods of delivery to further increase both
The Future of Cognitive Behavioral Therapy for Insomnia7
their efficacy and their effectiveness should be key goals for the field. Expanded training and
dissemination of CBT-I to a larger and wider cadre of practitioners throughout the health care
system is another important and worthy goal. As researchers in the field move towards reaching
these crucial goals they will be better positioned to elucidate the potential additive benefits that
CBT-I may have for enhancing quality of life in patients through not only improved sleep but
also the effect of such improved sleep on comorbid conditions. The wider availability of CBT-I
will also allow for better testing of its potential affect on healthcare utilization and related costs.
CBT-I has come a long way, but much remains to be done. Exciting times, indeed!
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