How can we make CBT-I and other BSM services widely available?

Abstract

Following several presentations and discussion panels regarding cognitive-behavior therapy for insomnia (CBT-I) during the 2007 annual meeting of the Associated Professional Sleep Societies in Minneapolis, it seems to many of us that the budding field of behavioral sleep medicine (BSM) is at a critical juncture. Six events have occurred that bring us to the present crossroads. First, as result of the vision and generosity of the American Academy of Sleep Medicine (AASM), there is (as of 2004), a credentialing board for BSM that is underwritten and administered by the academy.1 Second, the research literature regarding CBT-I has matured to a point where the 2005 NIH State of the Science panel acknowledged that this form of BSM is to be considered a first-line therapy for chronic insomnia.2 Third, sleep medicine (with the change in the board-certification process from the American Board of Sleep Medicine to the American Board of Medical Specialties) has recently been redefined as a medical subspecialty and, as a result, BSM is not formally a part of sleep medicine. Fourth, with the revamping of AASM sections to be aligned with disease states (vs areas of specialty), BSM is no longer identified as a section within the Academy. Fifth, the recent AASM Comprehensive Academic Sleep Programs of Distinction initiative does not reference BSM nor require that centers within this program have BSM services.3 Sixth, and finally, it now appears that there is a substantial push to alter who should provide CBT-I (non-BSM “physician extenders” vs BSM specialists) and how treatment should be conducted (fewer and shorter sessions). Although each of the last 4 events is relevant for the continued growth of BSM as an allied field and an interdisciplinary component of sleep medicine, the last and most recent event urgently needs to be addressed. The push to make CBT-I more available by diversifying who can provide it and how it is provided is largely based on the following beliefs: (1) There are not enough credentialed BSM specialists to provide treatment for the millions of patients with insomnia, (2) reimbursement for BSM services is complicated and garners too low a level of reimbursement, (3) CBT-I can be conducted by anyone with a minimal amount of training, and (4) BSM specialists have little to offer sleep disorders centers beyond the treatment of insomnia (which can hardly keep one busy enough to justify a part-time equivalent or full-time equivalent salary). Before addressing these issues specifically (and providing a series of recommendations), it is worth addressing the global perspective. Twenty to 30 years ago, sleep medicine itself was faced with many of the same daunting issues (e.g., too few specialists, problems with reimbursement, and a lack of evidence that sleep medicine alone could sustain a dedicated clinical enterprise). Yet, at that time, there was no call to populate the field with non-MDs to conduct polysomnography studies and evaluations (although this was allowed via the American Board of Sleep Medicine) nor was there a call to make polysomnography assessment studies half or one-third night studies to reduce the burden of the assessment process. Instead it was recognized that these issues required time and work to resolve and that only in this way could a clinical specialty be established. What has changed? Why is there such a sense of urgency and a rush toward solutions that can only diminish the effort to establish BSM as a subspecialty of sleep medicine (and behavioral medicine). Whatever the answer, it cannot be one that accepts that sleep medicine is, and should continue to be, a multidisciplinary field.