Improve accessibility to evidence-based treatment for insomnia disorder

Abstract

The Society of Behavioral Medicine supports increasing access to evidence-based treatment of insomnia by addressing barriers at the patient, provider, and systemic levels including support from government agencies to raise awareness about sleep and sleep disorders, health payors providing fair reimbursement for evidence-based insomnia assessment and therapy consistent with standard of care recommendations, and relevant training programs (e.g. psychologists, nurses, physicians, social workers, licensed professional counselors) to prioritize sleep health education.

Problem Being Addressed

Insomnia disorder is highly prevalent in the general population, with estimates ranging from 5% to 15% [1–3]. Insomnia disorder is even more common in older adults [1, 4], individuals from minoritized or marginalized groups [5], and individuals with medical and psychiatric co-morbidities [6–8]. In addition to considerable health repercussions (e.g. cardiovascular disease) [9], symptoms of insomnia are associated with significant economic consequences, such as increased healthcare costs, loss of productivity, and absenteeism.

Although cognitive-behavioral therapy for insomnia (CBT-I) is the first-line recommendation for evidence-based treatment by numerous organizations, access to proper assessment and treatment of insomnia disorder is insufficient. These organizations include:

• American Academy of Sleep Medicine [10]

• American College of Physicians [11]

• European Sleep Research Society [12]

• NIH Consensus State-of-the-Science Conference [13]

• Veteran Affairs/Department of Defense clinical practice guidelines [14]

Current Policy Statement

Insufficient access to evidence-based insomnia treatment—including CBT-I—is related to barriers at the patient, provider, and systemic levels [15].

1. At the patient level: a lack of public health knowledge about evidence-based treatments, the stigma associated with mental health treatment, and trivialization of the impact of sleep problems may limit their ability to self-advocate and seek help [16, 17]. Existing federal legislation addressing the specific solutions proposed here are limited with none directly relevant to the current policy statement.

2. At the provider level: a lack of training in assessment and evidence-based treatment options may serve as a bottleneck to appropriate diagnosis, referral, and treatment [18, 19]. Requirements from accrediting bodies of behavioral health provider training programs (e.g. for psychologists, nurses, physicians, counselors) about the type, duration, and quality of sleep health education are either entirely absent or severely limited.

3. At the systemic level: limited access to CBT-I providers [20] and inconsistent insurance reimbursement of non-physician providers (e.g. psychologists, nurses, social workers, masters-level mental health providers) for evidence-based treatment of insomnia. Although some health systems have adopted approaches to increasing accessibility to evidence-based treatment (e.g. developing self-guided insomnia treatment programs), many have not done so. Additionally, providers of evidence-based insomnia treatment who are not physicians often have insurance claims rejected (from all major health payors) on the grounds that insomnia diagnosis is a medical code, despite their qualifications to deliver the front-line treatment (i.e. CBT-I). Furthermore, insurance reimbursement for mental health codes has declined over the past two decades when factoring in inflation, prompting many mental health professionals to only accept private pay.

Proposed Solutions

Solutions must occur at the patient, provider, and systemic levels to promote accessibility to evidence-based treatment for those with insomnia.

1. At the patient level: increased public health messaging about overall sleep health, insomnia, and evidence-based treatment can reduce patient stigma and encourage treatment-seeking behavior.

2. At the provider level: solutions include increased training opportunities in the assessment and treatment of insomnia for providers of evidence-based treatment, including psychologists, nurses, physicians, masters-level mental health providers. Additionally, health system educational initiatives are needed to educate all healthcare providers on the extant evidence base, available care options, and referral pathways for evidence-based insomnia treatment.

3. At the systemic level: solutions include increased hiring of appropriately trained providers of evidence-based insomnia treatment (e.g. certified by Board of Behavioral Sleep Medicine [BBSM]), incorporation of evidence-based treatment into multidisciplinary and primary care settings through mandates about access to care, and a consistent reimbursement process by healthcare payors for evidence-based treatment by qualified providers including psychologists, nurses, social workers, and masters-level mental health providers.

Relevance

Sleep health is a biological necessity which is behaviorally modifiable and intersects with almost every aspect of medical and mental health. The consideration of sleep and circadian rhythms is fundamental to understanding interactions between our behavior, physical health, and mental health. By increasing access to safe, effective, front-line evidence-based insomnia treatment, we can improve the health and well-being of individuals, families, communities, and populations across many dimensions.

Recommendations

Legislative recommendations

#1: Legislators need to allocate funding to support public health campaigns to educate patients on sleep health, and sleep training programs to increase the number of qualified providers. Subsequently, government agencies, such as the Centers for Disease Control and Prevention (CDC) and Department of Health and Human Services (HHS), should carry out these campaigns.

#2: Public and private health payors need to consistently and fairly reimburse non-physician providers who are trained in CBT-I (e.g. psychologists, nurses, social workers, counselors) who bill for providing evidence-based assessment and treatment for insomnia disorder.

Systems-level recommendations

• #1: Training programs in behavioral health disciplines (e.g. nursing, medicine, psychology, social work) must develop and implement formal educational opportunities for students that focus on overall sleep health, and sleep disorders assessment and treatment.

• #2: Accrediting bodies (e.g. Commission on Collegiate Nursing Education, American Psychological Association) must develop training competencies and provide training opportunities that encourage the implementation of education and clinical rotations in the field of sleep medicine.

• #3: Professional organizations, such as the American Psychological Association, should join the Society of Behavioral Sleep Medicine in supporting the American Academy of Sleep Medicine Behavioral Insomnia Clinical Practice Guidelines and develop policies for healthcare organizations to encourage institution-wide adoption of education among all health care providers on screening for sleep disorders and the evidence-based treatment of insomnia disorder.

• #4: Health care systems need to support access to behavioral sleep medicine care by prioritizing hiring of BBSM certified providers, providing insomnia-specific continuing education opportunities for providers in multiple disciplines and specialties (e.g. www.cbtiweb.org), and ensuring access to evidence-based front-line treatments including cognitive-behavioral therapy for insomnia.

Endorsements

• American Academy of Sleep Medicine

• Association for Behavioral and Cognitive Therapies

• Society of Behavioral Sleep Medicine

Conflict of interest statement. The authors report no conflicts of interest.

Funding

Dr. Dietch’s work on this project was supported by the National Heart, Lung, and Blood Institute under Grant HL157698. Dr. Zhou has received grant funding from Jazz Pharmaceuticals and Harmony Biosciences, and consulting fees from MindUP and Samsung for work unrelated to the content of this manuscript. Dr. Dietch is a co-developer of the CBTIweb.org platform.

Transparency Statement

There is no study registration. There is no analytic code. There is no data. There are no additional materials.

References