Journal of General Internal Medicine

, Volume 33, Issue 6, pp 955–962 | Cite as

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

  • Erin Koffel
  • Adam D. Bramoweth
  • Christi S. Ulmer
Review Article


The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.


insomnia implementation guidelines cognitive behavioral therapy for insomnia 



We would like to thank Jonathan Koffel, MSI, for his assistance constructing the search strategy. This material was the result of work supported with resources and the use of facilities at the Minneapolis VA Health Care System, Minneapolis, MN, VA, Pittsburgh Healthcare System, Pittsburgh, PA, and Durham VA Medical Center, Durham, NC. The views expressed in this article are those of the authors and do not reflect the official policy or position of the US Department of Veterans Affairs or the US Government.

Funding Information

Drs. Koffel, Ulmer, and Bramoweth were supported by the Department of Veterans Affairs Health Services Research and Development Service Career Development Awards (CDA 15-063, 09-218, and 13-260, respectively) while working on this manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Supplementary material

11606_2018_4390_MOESM1_ESM.docx (39 kb)
ESM 1 (DOCX 38 kb)


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Copyright information

© This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2018

Authors and Affiliations

  • Erin Koffel
    • 1
    • 2
  • Adam D. Bramoweth
    • 3
  • Christi S. Ulmer
    • 4
    • 5
  1. 1.Center for Chronic Disease Outcomes ResearchMinneapolis VA Health Care SystemMinneapolisUSA
  2. 2.University of Minnesota Medical SchoolMinneapolisUSA
  3. 3.Center for Health Equity Research and Promotion, Mental Illness Research, Education and Clinical CenterVA Pittsburgh Healthcare SystemPittsburghUSA
  4. 4.Durham VA Health Services Research and DevelopmentDurhamUSA
  5. 5.Department of Psychiatry and Behavioral SciencesDuke UniversityDurhamUSA

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