Why Patients Don't Try CBT-I: Provider Challenges

In a recent poll to this community, only 8 percent of you said you have tried cognitive behavioral therapy for insomnia (CBT-I). This was surprising to us because we frequently write about its effectiveness. It got us wondering, "Why haven't more of our readers tried CBT-I?"

It turns out there are very real barriers that can get in the way of CBT-I. The barriers fall into 2 broad categories:

1. Medical provider challenges that limit who is referred for CBT-I
2. Obstacles that get in patients' way

In this post, I will describe the obstacles that hinder providers from referring patients for CBT-I. More importantly, I will offer suggestions for how you can advocate for yourself at your next appointment.

Feel free to participate in the poll Carin mentioned, here:

Does your provider know how to treat insomnia?

You may talk about your insomnia symptoms to many different types of providers – primary care, urgent care, or a medical or behavioral health specialist. Unfortunately, most providers receive little education on how to assess and treat insomnia disorder. And the education they do receive is often outdated.

Until recently, medical providers were taught that insomnia is just a symptom of other conditions. They may think it is a symptom of a mental health condition like PTSD or major depression. Or they might think it is a symptom of a physical condition like chronic pain or hyperthyroidism.

In the past, providers believed that insomnia would just go away once the "main" condition was treated. We now know that is not true. Once insomnia disorder takes hold, specific perpetuating factors keep it going. Those factors need their own attention.

Of course, the gold standard treatment for insomnia disorder is CBT-I. It is recommended by dozens of medical organizations worldwide, including the American College of Physicians. Unfortunately, in the US, only a small percentage of people with insomnia disorder are referred for CBT-I by their primary care providers. Instead, providers tend to prescribe medications or make sleep hygiene recommendations. And, as many readers know, those tools are usually short-term solutions.^1,2

A shortage of CBT-I providers

If a patient does get referred for CBT-I, they are likely to encounter another obstacle: a shortage of trained providers. Today, the International Directory of CBT-I Providers lists only 680 providers worldwide. Approximately 10 percent of the adult population struggles with insomnia, so the demand for CBT-I wildly exceeds supply. And finding a provider who accepts your specific insurance plan is an additional challenge.^2-4

How to advocate for yourself

These challenges may sound daunting, but they are not impossible to overcome. If you are interested in CBT-I, here are some ways to navigate these challenges.

Request a referral

If your healthcare coverage requires referrals, prepare for your next medical appointment. Clearly state how long you have been experiencing insomnia symptoms and how they are impacting your life. Describe the impact on your mood, physical health, work/school performance, and/or cognitive health. Tell your provider that you want a referral for CBT-I, the treatment recommended by the American College of Physicians.

Search the International Directory of CBT-I Providers

The directory is available to the public, and you can search for providers in your area. Or search for providers who are available via telehealth.

Confirm that your provider will use CBT-I

Providers offer many different techniques for treating insomnia, including relaxation training, sleep hygiene, and meditation. Still, these are not the same as CBT-I. They are just pieces of the treatment package. Ask if your provider will deliver the full treatment.

Try a self-guided CBT-I program

Given the shortage of CBT-I providers, you may struggle to find someone accepting new patients. Fortunately, self-guided CBT-I programs are very effective for many patients.

One free and highly rated option is the Insomnia Coach app, which incorporates all of the components of CBT-I. Many other apps and online programs are available to purchase and boast positive reviews. I recommend that you follow a program that includes an assessment of your insomnia problems, a method for tracking your sleep (aka sleep log), and personalized feedback.

Overcoming the barriers to CBT for insomnia treatment

It is sad to know that there are so many obstacles standing between patients and effective insomnia treatment. But if we understand the obstacles, we can start to generate solutions. Education about sleep disorders is evolving. More providers are getting trained in CBT-I, and more self-guided options are available.

In my next post, I will talk more about the obstacles facing patients. In the meantime, let us know if you have encountered any of these obstacles. If so, how did you deal with them?