New research suggests that cognitive behavioral therapy delivered live over telemedicine works as well as in-person sessions for insomnia patients. What that could mean for your sleep practice.
When sleep psychologist Kristin Daley, PhD, DBSM, logged onto her computer to meet with a patient over video-conference, she was startled to see a bustling café appear on her screen. Her patient, who was receiving cognitive behavioral therapy for insomnia (CBT-I), had decided to take their therapy session into a crowded public space, rendering the encrypted, HIPAA-protected telemedicine software on Daley’s computer ineffective.
After a brief conversation about the importance of confidentiality, the patient relocated to a car for their session. This has been far from the only moment of surprise since Daley began practicing telemedicine to treat insomnia patients. However, one element of the practice that has not been unexpected is the positive patient outcomes. Many of her telemedicine patients live long distances from Daley’s North Carolina private practice and would not otherwise get the therapy they need.
“Cognitive behavioral therapy for insomnia has been shown in multiple clinical trials to be effective across different patient groups, so we know it is a very effective first-line treatment. But one of the limitations is that there are an insufficient number of providers to meet the demands for the number of people who suffer from chronic insomnia,” says J. Todd Arnedt, PhD, co-director of the Sleep and Circadian Research Laboratory and director of the Behavioral Sleep Medicine Program at the University of Michigan.
New preliminary research shows that CBT-I delivered by telemedicine is as effective as in-person therapy. Arnedt coauthored two abstracts, which were published recently in an online supplement of the journal Sleep and presented in San Antonio at SLEEP 2019, that showed the efficacy of CBT-I administered by telemedicine.1,2
Results of a randomized controlled trial demonstrate that CBT-I delivered through telemedicine is just as effective at improving sleep outcomes measured by sleep diaries, sleep latency, and time spent asleep. There also were no differences between the two delivery methods in patient perception of therapeutic relationship, warmth, and confidence in the therapist’s ability.
The study’s therapist, who met with all patients either in person or via the AASM’s telemedicine platform SleepTM, Deirdre Conroy, PhD, says she originally thought the quality of her CBT-I sessions might be compromised if the patients were not physically present in the office with her.
“However, our findings suggest that important elements of a positive therapeutic alliance, like patient’s perception of therapist’s warmth, empathy, and skill level were no different in the telemedicine group compared to the face-to-face group. Patients reported being equally satisfied with the treatment regardless of condition,” says Conroy, who is clinical director of the Behavioral Sleep Medicine Program at the University of Michigan.
Another abstract presented at SLEEP 2019 showed that a telemedicine CBT-I program called HALEO is effective in reducing symptoms of insomnia, as measured by the Insomnia Severity Index and has similar results to traditional in-person CBT-I.3
“Telemedicine may be the best solution to the issue of CBT-I accessibility. Recent studies suggest that effective, therapist-led CBT-I can be made accessible via video-conferencing,” says coauthor Philippe Stenstrom, PhD, scientific director of Montreal-based HALEO Preventive Health Solutions.
“For instance, HALEO’s telehealth CBT-I program was found to significantly reduce insomnia symptoms, with an effect size similar to that found in studies examining traditional face-to-face CBT-I therapy. Research also suggests that CBT-I delivered by telemedicine avoids adherence issues found with digital self-help CBT-I programs,” Stenstrom says.
Despite these positive outcomes, Daley cautions that there are obstacles when pursuing a telemedicine CBT-I practice. For instance, insurance companies don’t typically cover CBT-I telehealth visits, so patients must pay out of pocket.
It can also be more challenging to create meaningful bonds and build trust with patients who she may never meet in person. She has found that she needs to be more proactive in tracking telemedicine patient outcomes. “It can be harder to sustain the therapeutic relationship, so it might require a little bit more attention with follow up,” she says. “We have to make sure that we are keeping up with our patients’ sleep dairies and we have tools to keep track of our patients’ progress.”
Telemedicine can also become more complicated when she wants to accept out-of-state patients, in states where there are different licensure requirements. To treat patients outside of their state, telemedicine psychologists need to contact the psychology board of each state to understand the requirements.
When she first started out in telemedicine, Daley found that there is no reciprocity between different state boards. When working with a patient from Georgia, the state psychology board approved her to practice for just 10 days per month without being licensed in Georgia. On the other hand, board officials in Florida said that as long as she is physically practicing in North Carolina, she doesn’t need to be licensed in Florida to treat patients there via telemedicine.
“I would say the biggest hurdle that we run into has to do with licensure and the perception of where you are practicing,” says Daley. “That’s the biggest thing that can be incredibly complicated.”
Another sleep psychologist who utilizes telemedicine, Ryan Wetzler, PsyD, who runs a practice in Kentucky, says he often sees patients who have first been prescribed potentially harmful medication for their insomnia. “It is still quite rare for me to see somebody who hasn’t already been prescribed a medication or tried a variety of over-the-counter medications,” says Wetzler.
“My advice to other providers is that we have to do a better job at getting the word out about how effective [CBT-I] is and how it doesn’t carry any of the risks of any of these other treatment modalities,” says Wetzler. “My general experience with it has been very positive. I agree with all the research that has come out suggesting that [telemedicine] is just as effective as in-person.”
Lisa Spear is associate editor of Sleep Review.
Arnedt JT, Conroy DA, Mooney AJ, et al. 0363 Efficacy of cognitive behavioral therapy delivered via telemedicine vs. face-to-face: Preliminary results from a randomized controlled non-inferiority trial. Sleep. 12 April 2019;42(suppl_1):A148.
Conroy DA, Mooney A, Pace D, et al. 0364 Comparison of therapeutic alliance for telemedicine vs. face-to-face delivered cognitive behavioral therapy for insomnia: preliminary results. Sleep. 12 April 2019;42(suppl_1):A148-9.
Stenstrom P, Davidson J, Denesle R, et al. 0362 Video-conference delivery of cognitive behavioral therapy for insomnia: Effects on insomnia, depression and anxiety symptoms. Sleep. 12 April 2019;42(suppl_1):A147-8.