Novel Hybrid Model of CBT Delivery for Insomnia Offers Best of All Worlds

Pilot program reveals shortened wait times, increased access

A hybrid model of delivering cognitive behavioral therapy for insomnia (CBT-i) that combines features of individual, group and virtual CBT-i can substantially improve patient access to timely treatment. That’s the conclusion of a Cleveland Clinic pilot program of the novel care delivery model, known as CBT-Initiate.

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The new initiative was among the achievements led by Michelle Drerup, PsyD, DBSM, Director of Behavioral Sleep Medicine at Cleveland Clinic, that were cited by the Society of Behavioral Sleep Medicine (SBSM) when it named Dr. Drerup the recipient of its 2021 Outstanding Innovation in Behavioral Sleep Medicine Service Delivery Award at the SBSM’s annual scientific conference on Sept. 17.

“I am honored to receive this award,” says Dr. Drerup, a staff psychologist with appointments in Cleveland Clinic’s Sleep Disorders Center and Department of Psychiatry and Psychology. “Making effective behavioral sleep medicine (BSM) treatments more widely available and accessible has been a driving force in my career. That has continued through the introduction of CBT-Initiate, which has led to greater access to effective insomnia treatment with shorter wait times for patients.”

The challenge: Keeping up with demand for care

While the development of CBT-Initiate was directly prompted by the COVID-19 pandemic, its roots reach back to a challenge facing Dr. Drerup and others across the country for years: keeping up with the demand for BSM services. “With the abundance of referrals from physicians in our Sleep Disorders Center, not to mention from Cleveland Clinic primary care providers and outside providers, ensuring timely treatment for all patients was difficult,” Dr. Drerup explains.

In response, nearly a decade ago, she served as lead consultant for Go! to Sleep℠, a six-week online program developed by Cleveland Clinic for the treatment of insomnia and promotion of sleep health based on principles and strategies of CBT-i. As detailed previously on Consult QD, Go! to Sleep has been shown in clinical studies to be associated with clinically meaningful improvements in insomnia severity in patients with primary insomnia and in a variety of complex medical populations with sleep complaints, including patients with Parkinson’s disease, multiple sclerosis, cancer and coronary artery disease.

“Online care delivery through a tool like Go! to Sleep has expanded access to CBT-i and shown real potential to improve health outcomes among people with insomnia in a cost-effective way,” Dr. Drerup notes.

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Her experience with Go! to Sleep and years of observing the pros and cons of various CBT-i delivery methods — individual, group, telehealth and web-based programs — positioned Dr. Drerup and her Cleveland Clinic colleagues to quickly develop the hybrid CBT-Initiate program soon after the start of the COVID-19 pandemic in 2020.

How it works

CBT-Initiate was designed to combine the strengths of individual and group CBT-i delivery methods with the convenience of telehealth.

At a patient’s initial evaluation for insomnia, if he or she is determined to be an an appropriate candidate for CBT-i, the patient’s first follow-up visit is a telehealth group session. Up to 10 patients can be scheduled in each virtual group, which is led by an expert in BSM and CBT-i. The 90-minute group session begins with a presentation on the science of sleep, psychoeducation about insomnia disorder, and an overview of stimulus control guidelines and their rationale. Also included is a review of participants’ sleep diaries and tailored stimulus control/sleep compression instructions based on each patient’s sleep data, as well as time for questions from group members. Following this group session, patients return for additional individual treatment/follow-up with their BSM provider for more tailored interventions via telehealth or in-person sessions, depending on patient preference.

In addition to Dr. Drerup, the BSM specialists who see patients in the individual and group components of CBT-Initiate include psychologists Alicia Roth, PhD, DBSM, and Alexa Kane, PsyD, both of whom contributed to the program’s development and implementation.

Pilot program shows promising impact on access

Over the first six months of implementing CBT-Initiate, Dr. Drerup and team completed 17 group sessions, which served as the initial post-evaluation follow-up for CBT-i for 132 patients. The no-show rate for group sessions was 8%. “We have been pleased with this low rate,” Dr. Drerup says.

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The CBT-Initiate model has led to reduced wait times to begin CBT-i in Cleveland Clinic’s BSM clinic, with the average wait from initial evaluation to first follow-up visit declining from a baseline of four to six weeks down to two weeks under the new model. The hybrid model also has expanded access to BSM care, as up to 10 patients can be seen in the CBT-Initiate virtual group, freeing up nine follow-up appointments on the BSM provider’s schedule per week.

Additionally, the one-time group session enables the peer-to-peer support and consultation commonplace in group therapy that helps normalize sleep concerns and gives participants a chance to learn from and motivate each other. At the same time, the model provides treatment tailored to patients’ symptoms and comorbid conditions, both when patients receive individualized feedback on their sleep diaries in the group session and during the one-on-one treatment that follows.

Expect dissemination and data to follow

“I have shared this hybrid concept and model with several other BSM expert clinicians,” Dr. Drerup says, “and they have been exploring ways to implement a similar model in their own institutions. At Cleveland Clinic, we will be exploring process and outcome data from CBT-Initiate and look forward to presenting and publishing these data in the future.”