Sir Jules Thorn Sleep and Circadian Neuroscience Institute, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
Big Health Ltd., London, UK.
J Sleep Res. 2023 Dec;32(6):e14025. doi: 10.1111/jsr.14025. Epub 2023 Aug 29.
Cognitive behavioural therapy (CBT) is the recommended first-line treatment for insomnia. However, guideline care is very seldom available and most patients receive no treatment, or less effective second-line pharmacotherapy or sleep hygiene, neither of which are evidence-based for chronic insomnia. The primary challenge for CBT has been supply. There are not enough therapists to meet the enormous demand. We must accelerate clinician training, but this approach can never be sufficient, even with abbreviated, efficient therapies. Fortunately, however, the treatment landscape has also changed dramatically. Fully-automated digital CBT (dCBT) has emerged as a safe, effective, and scalable treatment delivery format. dCBT is software only, so it can be disseminated as readily and widely as sleep medication. Moreover, dCBT can be integrated into services. Just as medications can be delivered through health professionals and health systems, approved dCBT programmes can be the same. However, an ecosystem of psychologically-based care should not necessitate a medical prescription model. Our proposed stepped care framework, comprises both population health and clinical health service initiatives, enabling universal access to guideline care for insomnia. The diverse ways in which CBT may be delivered (in-person, face-to-face, using telehealth, group therapy, digitally) can operate congruently and efficiently to optimise treatment for people at all levels of complexity and need. With safe and clinically effective dCBT products now set to become established as treatments, clearly differentiated from wellness apps, there is potential to rapidly transform insomnia services and, for the first time, to deliver clinical guideline care at international scale.
认知行为疗法（CBT）是失眠的推荐一线治疗方法。然而，指导方针护理很少可用，大多数患者没有接受治疗，或者接受效果较差的二线药物治疗或睡眠卫生治疗，这两种治疗方法都不是慢性失眠的循证治疗方法。CBT 的主要挑战是供应。没有足够的治疗师来满足巨大的需求。我们必须加快临床医生的培训，但即使采用简短、有效的治疗方法，这种方法也永远不够。然而，幸运的是，治疗领域也发生了巨大变化。全自动数字化认知行为疗法（dCBT）已成为一种安全、有效和可扩展的治疗方式。dCBT 仅为软件，因此可以像睡眠药物一样易于广泛传播。此外，dCBT 可以整合到服务中。就像药物可以通过医疗保健专业人员和医疗系统来提供一样，经过批准的 dCBT 计划也可以如此。然而，以心理为基础的护理生态系统不应该需要医疗处方模式。我们提出的分级护理框架包括人群健康和临床卫生服务倡议，使所有人都能普遍获得失眠的指南护理。CBT 可能以不同的方式（面对面、使用远程医疗、小组治疗、数字化）进行交付，可以协调有效地运作，以优化各级复杂程度和需求人群的治疗效果。现在，安全且具有临床疗效的 dCBT 产品有望成为治疗方法，与健康应用程序明显区分开来，有可能迅速改变失眠服务，并首次在国际范围内提供临床指南护理。
