Boosting access to evidence-based insomnia care: our experience with a stepped care approach in Canada

Insomnia is a major issue due to its prevalence, health effects, and economic burden. In Canada, 45% of the population report trouble initiating or maintaining sleep and 16% meet criteria for insomnia disorder. Despite evidence that sedative-hypnotic medications have limited long-term effectiveness and pose risks to patient and public health, pharmacotherapy remains commonplace. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line intervention for insomnia; however, access to CBT-I is uneven and inequitable. We developed a stepped care model aimed at boosting Canadians' access to CBT-I. The model promotes a flexible, equitable approach to the effective management of insomnia by optimizing the efficient use of CBT-I resources and reducing chronic sedative-hypnotic medication use. Self-guided approaches are the foundation. Subsequent steps include interventions by primary care providers and community pharmacists, trained CBT-I providers, and behavioral sleep experts. In this commentary, we illustrate how this model can optimize intervention access and how it provides a framework for the training of various healthcare providers in evidence-based insomnia care. We include research evidence from each step and discuss the place of this model within Canadian healthcare systems. We hope the concepts from this broad, applied approach will be valuable for other countries.