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SLEEP, Vol. 36, No. 3, 2013 303 EditorialSivertsen et al

In this issue ofSLEEP, Arnedt and colleagues provide support

for telephone-delivered cognitive behavioral therapy for insom-

nia (CBTI).1 The authors conducted a small randomized con-

trolled trial comparing 15 patients with chronic insomnia who

received telephone-delivered CBTI with an equal sized control

group who received a CBTI-based information pamphlet (IPC)

without therapist support. Both groups improved signicantly

on most sleep measures with effect sizes ranging from 1.0 to

1.8, but no signicant group differences were found. For the

daytime functioning measures CBTI yielded overall better re-sults than the IPC condition.

The effect of individual in-person CBTI across age cohorts

and comorbidities is well documented, and the sleep medicine

community is now facing the next frontierhow to provide a

broader and more rapid dissemination of this treatment. Despite

being highly effective, individual CBTI is both expensive and

time-consuming, and perhaps even more importantly, it is not

available for the majority of the population. Although the num-

ber of accredited sleep specialists delivering CBTI is growing

both in the US and Europe, there are far too few to provide

CBTI beyond major metropolitan areas.

Therefore, the results of Arnedt et al. are important, as theyprovide support for the benecial effects of a non-face-to-face

therapy treatment modality for insomnia. Until now the only

study examining the effect of telephone-delivered CBTI versus

other active treatments was conducted by Bastien et al., 2 who

found CBTI delivered by brief phone therapy consultations to

be equally effective as that delivered in a group therapy format

and individual face-to-face therapy. In contrast to the report by

Bastien et al.2 the report by Arnedt et al.1 in this issue ofSLEEP

included a passive control group (i.e., information pamphlet

control [IPC]). This allows us to discern whether the observed

changes after CBTI delivered by phone were any greater than

changes without treatment, which is important to rule out re-

gression to the mean as an explanation for improvements over

time. Surprisingly, the IPC treatment yielded equally strong ef-

fect sizes as the CBTI on all sleep measures. As discussed by

the authors, the content in the pamphlet may have had some

overlap with the CBTI intervention, making it more therapeu-

tic than intended. This unexpected nding clearly needs to be

EDITORIAL

http://dx.doi.org/10.5665/sleep.2432

The Future of Insomnia Treatmentthe Challenge of ImplementationCommentary on Arnedt et al. Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. SLEEP2013;36:353-362.

Brge Sivertsen, PhD1,2; ystein Vedaa, PsyD1,2; Tine Nordgreen, PhD2,3

1Division of Mental Health, Norwegian Institute of Public Health, Bergen, Norway; 2Faculty of Psychology, University of Bergen, Bergen, Norway;3Department of Psychiatry, Haukeland University Hospital, Bergen, Norway

Submitted for publication January, 2013

Accepted for publication January, 2013

Address correspondence to: Brge Sivertsen, PhD, Norwegian Institute

of Public Health, Christiesgt 12, Bergen 5012, Norway; Tel: 4755588876;

Fax: 4755589877; E-mail: borge.sivertsen@psykp.uib.no

replicated in a larger sample, and with actigraphic or polysom-

nographic outcomes.

The ndings of Arnedt et al.1 are also important from a

cost-effectiveness perspective, suggesting that it is possible

to reduce expensive face-to-face therapy sessions, as well as

transportation costs, without reducing the efcacy of CBTI, as

long as the core treatment modules are present. However, the

telephone sessions in the Arnedt et al. study were provided by

experienced sleep therapists in 4-8 sessions, which each lasted

up to 60 minutes, indicating that if or when implemented, suchtreatment still requires sleep specialists, making it not very dis-

similar from regular face-to-face treatments in terms of costs

beyond transportation. As such, telephone CBTI is not guaran-

teed to be as low-cost an intervention as self-help based treat-

ments with no-to-minimal professional guidance.

The discussion of whether CBTI therapists support should

be included to reduce attrition and improve outcomes from

self-help interventions is both important and controversial.3

Whereas some claim that human support is an essential com-

ponent of effective self-help Internet interventions, such state-

ments have mainly been based on studies on depression and

anxiety, not insomnia.4

In fact, all ve published randomizedcontrolled trials (RCT) investigating Internet-based self-help

interventions based on CBT for insomnia have used fully auto-

mated programs without any human support during treatment,

but with positive outcomes.4-8 Also, ndings from Andersson

and colleagues9 have shown that therapist involvement (via

telephone contact) in the treatment of headache does not appear

to moderate outcome, and it adds little to the prediction of who

will drop out.

However, the rise of Internet interventions for insomnia does

not eliminate the need for other treatment modalities beyond in-

dividual face-to-face therapy. Effect sizes in the Arnedt study

were notably high, and also higher than typically found for In-

ternet interventions. Another important aspect is that of patient

preference, as not everyone will be satised with interacting with

only a computer, no matter how personalized and tailored the

web program might be. Although 95% of all American house-

holds have access to high-speed broadband, there are today still

14 million Americans without such terrestrial broadband infra-

structure.9 As such, there is clearly a need to further investigate

and rene ways of delivering CBTI between the extreme ends of

the spectrum of therapist involvement (i.e., individual face-to-

face therapy to fully automated Internet interventions).

The economic costs of insomnia are very high,10,11 and its

prevalence is a major public health concern. We now have

knowledge of how to behaviorally treat insomnia. CBTI is ef-

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SLEEP, Vol. 36, No. 3, 2013 304 EditorialSivertsen et al

fective, and we believe the right future direction is to develop

a wide range of CBTI treatment modalities to improve public

dissemination and implementation. Future studies should seek

to test a stepped-care model, in which assessment together with

an information pamphlet may be a rst step, followed by a fully

automated web program or brief telephone-based intervention,

and nally individual in-person, telephone or Skype CBTI ses-

sions. Given the high prevalence of insomnia and continued

scarcity of insomnia therapists, this treatment model reserves

individual CBTI sessions to those who do not benet from low-

er-intensity interventions.

CITATION

Siversten B; Vedaa ; Nordgreen T. The future of insom-

nia treatmentthe challenge of implementation. SLEEP

2013;36(3):303-304.

DISCLOSURE STATEMENT

The authors have indicated no nancial conicts of interest.

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