Offering Brief Behavioral Therapy for insomnia (BBTi) in primary care settings

Authors

Vinicio Delgado, RCT CCSH RPSGT (biography and disclosures)

Disclosures: Co-author of the TranSleep CBTi Workbook and MySleepTutor website. Mitigating potential bias: Recommendations are consistent with current practice guidelines for the treatment of insomnia (American Academy of Sleep Medicine Clinical Practice Guidelines). Access to the https://mysleeptutor.com website is free of charge. The resources are educational in nature and do not promote any specific clinic (including ours, beyond the author’s credit) or any commercial products. Registration data is not used for any promotional purposes.

Wayne Lai, MD (biography and disclosures)

Disclosures: Received payments for participation in commercial clinical trial testing for a device treating sleep apnea. Received an honorarium consulting for Zenneatech (closed down). Co-author of the TranqSleep CBTi Workbook and program and MySleepTutor website (TranSleep clinic). Mitigating potential bias: Recommendations are consistent with current practice guidelines for the treatment of insomnia. Access to the mysleeptutor.com website is free of charge. The resources are educational in nature and do not promote any specific clinic (including ours beyond the author’s credit) or any commercial products. Registration data is not used for any promotional purposes.

What we did before

Insomnia is one of the most commonly reported sleep disorders at our sleep clinic. Despite its prevalence, treating it can be challenging due to its complex and multifactorial nature. A comprehensive and personalized approach to treatment is, therefore, necessary for effective management. However, providing this level of support requires significant time and resources.

These challenges are also evident in general practice settings, where family physicians routinely prescribe behavioural therapies for patients with insomnia. A practice analysis shows that sleep hygiene and relaxation training are the most frequently prescribed behavioural therapies.¹ Yet, although helpful for some patients, these interventions alone are unlikely to be effective for patients with severe insomnia.²

Fortunately, effective treatments are available, such as cognitive behavioural therapy for insomnia (CBTi), which is recommended as the first-line treatment for the disorder.³

What changed our practice

Traditionally, CBTi has been administered by trained psychologists or therapists over six to eight individualized 30- to 50-minute sessions. Given time constraints, this is impractical for general practice settings. The primary barrier to providing effective insomnia treatment reported by family physicians is the limited availability of referral options for behavioural interventions and trained CBTi therapists.¹

To address this challenge, our sleep clinic developed a practical insomnia program based on Brief Behavioral Therapy for Insomnia (BBTi) to assist the physicians in our clinic. BBTi is a brief, structured, evidence-based therapy that encourages the adoption of CBTi techniques in primary healthcare settings.⁴ It can be delivered in collaboration with a nurse practitioner, physician assistant, nurse, or sleep coach with minimal training and has proven to be effective in treating patients with insomnia.⁵

The program consists of 4 sessions lasting 30 to 45 minutes each and includes an educational component that facilitates discussion about conditioning factors involved in perpetuating insomnia, sleep consolidation techniques, relapse prevention, and self-management. Patients are provided with a workbook as a training tool, which contains relevant information about good sleep habits, time-in-bed restriction, stimulus control, self-evaluation, and self-reflection, which are discussed during the sessions. Patients are encouraged to complete workbook exercises between sessions, providing a structure to follow and enhancing their sense of ownership of the treatment process.

Standard behavioural recommendations for insomnia may leave patients feeling disengaged or lacking accountability, especially if they have already tried such recommendations without success. Our program addresses this issue by using the workbook to guide patients through the therapy sessions providing a practical and accessible solution for treating insomnia in primary care or the sleep clinic. The program’s short duration, nurse involvement, and use of a workbook make it an effective and practical solution for treating insomnia.

What we do now

Once patients are referred to our clinic, we conduct a thorough screening and sleep evaluation to rule out other possible sleep disorders such as circadian rhythm disorders, sleep-disordered breathing, and movement disorders. This screening process is crucial to ensure that BBTi therapy is appropriate and effective for patients with insomnia. After screening, the physician presents the appropriate candidates with a step-by-step approach for administering BBTi, using the workbook as a guideline. At our clinic, the program is delivered in collaboration with a sleep coach, who can be a trained nurse in the primary care setting.

The first session is an introduction to the program where we provide all the necessary materials such as the workbook and sleep diary forms, along with instructions on how to complete them. We also discuss healthy sleep practices and the reasoning behind BBTi. Sessions two and three focus on the implementation of time-in-bed restriction strategies and education about sleep, including sleep drive and biological factors that regulate sleep, nocturnal awakenings, sleep as we age, diary tabulation, and discussion of stimulus control. The fourth and final session is done together with the physician and involves reviewing results and discussing self-management techniques. We then recommend a follow-up appointment in three to six months.

At our sleep clinic, we have found that implementing BBTi has been highly effective in improving patient outcomes for insomnia, including reducing overall insomnia severity. Patients report a greater sense of control over their sleep and an improved quality of life.

Insomnia screening and BBTi program delivery tips

Screening and sleep evaluation are crucial for the proper diagnosis and treatment of insomnia. It is essential to identify insomnia and rule out other sleep disorders to ensure the appropriate therapy is prescribed. Certain individuals may have underlying medical or psychological conditions that need to be addressed before treating insomnia.

Screening tools:

1. Sleep disorders questionnaire. Alberta Medical Association. Accessed July 17, 2023. View PDF actt.albertadoctors.org
2. Insomnia severity index. Oncology Nursing Society. Accessed July 17, 2023. View PDF ons.org

BBTi delivery:

In order to facilitate the adoption of BBTi and encourage efficient insomnia treatment in primary care, we have created a complimentary training program designed for clinicians. Our aim is to provide nurses with the necessary skills and knowledge through the Primary Care Networks, enabling them to seamlessly incorporate the treatment of insomnia patients into the primary care setting in partnership with family physicians. Currently, the free clinician training program is in the initial planning phase and we will provide further details on accessing this training once more information becomes available.

Alternatively, family physicians may choose a stepped-care approach by providing patients with access to the self-guided BBTi program. The BBTi program is free and is available at MySleepTutor CBTi website mysleeptutor.com. It includes a copy of a workbook for managing insomnia that patients can complete at their convenience, along with how-to videos and a digital sleep diary that calculates sleep averages. While therapist-guided interventions have shown better results, unguided internet CBTi has been found to have sustained effects on sleep, daytime functioning, and beliefs about sleep for up to 18 months after the intervention period.⁶

Offering a self-help intervention as a complement to care can help reach patients who might not otherwise receive CBTi or refuse onsite treatment. Patients can download a copy of the workbook to complete on their own and use the program website, which contains helpful resources.

Resources

1. Wei L, Delgado V. TranqSleep BBTi insomnia program. Updated 2023. Accessed July 17, 2023. (View MySleepTutor.com)
2. Management of chronic insomnia tool. Centre for Effective Practice. Accessed July 17, 2023. (View cep.health)
3. Davison J. Treating chronic insomnia in primary care – early recognition and management. Canadian Sleep Society. 2012. Accessed July 17, 2023. (View PDF css-scs.ca)
4. Insomnia — self-help online CBTi courses. Kelty’s Key Online Therapy. Accessed July 17, 2023. (View keltyskey.com)
5. Virtual CBT skills groups for BC residents. The CBT Skills Groups Society. Accessed July 17, 2023. (View cbtskills.ca)
6. Insomnia CBT-I coach app. Central Okanagan Pathways. Accessed July 17, 2023. (View central-okanagan.pathwaysbc.ca)
7. Therapy for sleep disorders: insomnia – CBTi help guide. HelpGuide.org. Accessed July 17, 2023. (View helpguide.org)

References

1. Crain J, Raj M, Garland S, Jones S, Farah B. Current Practice Analysis: Interventions for Insomnia Disorder. Ottawa: CADTH; 2017 Jun. (CADTH technology review: no.7). (View)
2. Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Med Rev. 2015;22:23-36. doi:10.1016/j.smrv.2014.10.001 (View)
3. National Institutes of Health. National Institutes of Health state of the science conference statement: manifestation and management of chronic insomnia in adults June 13-15, 2005. Sleep. 2005;28(9):1049-1057. doi:10.1093/sleep/28.9.1049 (View)
4. Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012;10(4):266-279. doi:10.1080/15402002.2011.607200 (View)
5. Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults [published correction appears in JAMA Intern Med. 2019 Aug 1;179(8):1152]. Arch Intern Med. 2011;171(10):887-895. doi:10.1001/archinternmed.2010.535 (View)
6. Vedaa Ø, Hagatun S, Kallestad H, et al. Long-term effects of an unguided online cognitive behavioral therapy for chronic insomnia. J Clin Sleep Med. 2019;15(1):101-110. doi:10.5664/jcsm.7580 (View)

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