A simplified version of insomnia-related cognitive behavioral therapy (CBT-I) for use in primary care improved sleep, a randomized trial showed.
The "single shot" CBT-I intervention reduced total wake time by 58.3 minutes and improved sleep efficiency by 10.4% compared with controls at 1 month after the session, both significant comparisons, Jamie Walker, MA, LPC, a PhD student at the University of Arkansas in Fayetteville, reported at the SLEEP meeting hosted jointly by the American Academy of Sleep Medicine (AASM) and the Sleep Research Society.
The CBT-I integrated with a primary care visit also increased total sleep time by 44.7 minutes, which although not statistically significant, Walker said still "may reflect a clinically meaningful change, especially in conjunction with reduced wake time."
"These findings highlight one-session CBT-I as an effective, brief, and scalable treatment for insomnia in primary care," Walker concluded, which offers an accessible means to address underutilization of insomnia treatment. "The traditional CBT-I format of 6 to 12 weekly sessions is pretty incompatible with primary care settings, and this limited access often results in a default to pharmaceuticals by primary care providers."
A second trial at the session randomized patients in rural locations to digitally delivered CBT-I, medication (largely off-label trazodone), or the combination in primary care, with the combination showing an advantage. The study was underpowered due to only enrolling 155 of the planned 1,200 participants across seven non-urban centers because of the COVID-19 pandemic starting just after the kickoff in January 2020.
"All three groups experienced significant and large reductions in insomnia symptoms," without a difference between them in Insomnia Severity Index (ISI) scores at the 9-week, 6-month, or 12-month follow-up points, reported Katie Stone, PhD, of the University of California San Francisco.
However, treatment response (a 6+ point reduction in ISI) was consistently higher with combination therapy than medication alone (P<0.05 at all timepoints).
"The truth is there just aren't enough sleep space specialists in the world to see every person with insomnia and not every patient wants to come and see someone like me who's a clinical psychologist," commented Jennifer Martin, PhD, of the University of California Los Angeles and a spokesperson for the AASM. "Some people want to manage this with their primary care provider as a partner, and we should try to make those options available."
Walker suggested that integration into primary care could work as an initial step in a stepped-care approach.
"I guess I approach that topic differently," Martin noted. "I always think that if I were a patient, I wouldn't want something unlikely to work first before I got the thing that is likely to work. I would rather have a healthcare provider who showed me all of the options and then allowed me to pick. Do I want the more intense intervention right now or do I want to try something simple and easy first? So I think rather than the provider or the healthcare system making that decision about what the steps are, I think patients should get to do that."
Walker's trial randomized 37 patients to the intervention or to an attentional control. The intervention consisted of a single 50- to 55-minute session with psychoeducation focusing on stimulus control and sleep restriction conducted by Walker -- "and a lot of me just kind of teaching them why this is important, why it will work, and why it's worth it," she said. Full CBT-I adds lessons about cognitive restructuring and mindfulness over the course of multiple sessions.
The attentional control maintained the same duration, with Walker asking Socratic questions about sleep without telling patients what to do. "It was a lot of reflection and summarizing and validation," she said.
The ISI score (range 0-28) was 4.5 points less with the intervention versus control at 1 month, although the difference narrowed at 3-month follow-up, which "may reflect regression to the mean or the potential need for booster sessions to sustain benefits," Walker said. The Patient Health Questionnaire-9 (range 0-27 points) measuring depression symptoms was about 3 points lower in the intervention group at months 1 and 3.
Limitations included the small sample size, recruitment through a patient portal system that patients didn't always check or bother to log into, and enrollment at a health center on campus such that all participants were students or staff.
Disclosures
Walker disclosed no relevant relationships with industry.
Stone provided no information on conflicts of interest but noted her research was funded through a Patient-Centered Outcomes Research Institute award.
Primary Source
SLEEP
Source Reference: Walker J "'Single-shot' cognitive behavioral therapy for insomnia (CBT-I) is related to improvements in sleep onset and maintenance problems" SLEEP 2025; Abstract 0537.
Secondary Source
SLEEP
Source Reference: Stone K "Comparative effectiveness of medication, digital CBT-I (dCBT-I), and combined therapy for insomnia in rural adults" SLEEP 2025; Abstract 0540.
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