Received: 5 June 2019 | Revised: 13 November 2019 | Accepted: 21 November 2019

DOI: 10.1111/jsr.12967

REG UL AR RE SE ARCH PAPER

The European Academy for Cognitive Behavioural Therapy for

Insomnia: An initiative of the European Insomnia Network to
promote implementation and dissemination of treatment

Chiara Baglioni1,2 | Ellemarije Altena3 | Bjørn Bjorvatn4 | Kerstin Blom5 |

Kristoffer Bothelius6 | Alessandra Devoto7 | Colin A. Espie8 | Lukas Frase1 |
Dimitri Gavriloff8 | Hion Tuuliki9,10 | Andrea Hoflehner11 | Birgit Högl11 |
Brigitte Holzinger12 | Heli Järnefelt13,14 | Susanna Jernelöv5,15 | Anna F. Johann1,16 |
Caterina Lombardo17 | Christoph Nissen18 | Laura Palagini19 | Geert Peeters20 |
Michael L. Perlis21 | Donn Posner22 | Angelika Schlarb23 | Kai Spiegelhalder1 |
Adam Wichniak24 | Dieter Riemann1
1
Department of Psychiatry and Psychotherapy, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
2
Department of Human Sciences, University of Rome ‘G. Marconi’ – Telematic, Rome, Italy
3
UMR 5287, Institut de Neurosciences Intégratives et Cognitives d'Aquitaine, Neuroimagerie et Cognition Humaine, CNRS, Université de Bordeaux, Bordeaux,
France
4
Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
5
Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, and Stockholm Health Care Services, Stockholm County Council,
Huddinge Hospital, Stockholm, Sweden
6
Department of Psychology, Uppsala University, Uppsala, Sweden
7
Centre for Sleep Medicine, Rome, Italy
8
Nuffield Department of Clinical Neuroscience, Sleep and Circadian Neuroscience Institute, University of Oxford, Oxford, UK
9
Nordic Sleep Centre, Tallinn, Estonia
10
Tartu University Hospital, Tartu, Estonia
11
Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
12
Institut für Bewusstseins- und Traumforschung, Wien, Austria
13
Finnish Institute of Occupational Health, Helsinki, Finland
14
Department of Psychology and Logopedics, University of Helsinki, Finland
15
Division of Psychology, Department of Clinical Neuroscience, Karolinska Institutet, Sweden
16
Medical Psychology and Medical Sociology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
17
Department of Psychology, “Sapienza” University of Rome, Rome, Italy
18
University Hospital of Psychiatry and Psychotherapy, Bern, Switzerland
19
Department of Neuroscience, University of Pisa, Pisa, Italy
20
Sleep Medicine Centre Kempenhaeghe, Heeze, The Netherlands
21
Department of Psychiatry, Upenn Behavioral Sleep Medicine Program, University of Pennsylvania, Philadelphia, PA, USA
22
Stanford University School of Medicine, Stanford, CA, USA
23
Department of Psychology, University of Bielefeld, Bielefeld, Germany
24
Sleep Medicine Centre and Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in
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© 2019 The Authors. Journal of Sleep Research published by John Wiley & Sons Ltd on behalf of European Sleep Research Society

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Correspondence
Chiara Baglioni, Department of Psychiatry Abstract
and Psychotherapy, Faculty of Medicine, Insomnia, the most prevalent sleep disorder worldwide, confers marked risks for both
Medical Center - University of Freiburg,
University of Freiburg, Freiburg, Germany. physical and mental health. Furthermore, insomnia is associated with considerable
Emails: [email protected] direct and indirect healthcare costs. Recent guidelines in the US and Europe une-
quivocally conclude that cognitive behavioural therapy for insomnia (CBT-I) should
be the first-line treatment for the disorder. Current treatment approaches are in
stark contrast to these clear recommendations, not least across Europe, where, if any
treatment at all is delivered, hypnotic medication still is the dominant therapeutic mo-
dality. To address this situation, a Task Force of the European Sleep Research Society
and the European Insomnia Network met in May 2018. The Task Force proposed
establishing a European CBT-I Academy that would enable a Europe-wide system of
standardized CBT-I training and training centre accreditation. This article summarizes
the deliberations of the Task Force concerning definition and ingredients of CBT-I,
preconditions for health professionals to teach CBT-I, the way in which CBT-I should
be taught, who should be taught CBT-I and to whom CBT-I should be administered.
Furthermore, diverse aspects of CBT-I care and delivery were discussed and incorpo-
rated into a stepped-care model for insomnia.

KEYWORDS

CBT-I, cognitive behavioural therapy for insomnia, European CBT-I Academy, insomnia,
stepped-care

1 | A S U M M A RY O F PR E S E NT G U I D E LI N E S the pharmacological treatment of insomnia and concluded that even

for short-term pharmacological treatment the evidence for all inves-
In the last 2 years, four national/international guidelines have been tigated substances (including benzodiazepines, Z-drugs, melatonin-
published concerning the diagnosis and treatment of insomnia. The ergic agonists, suvorexant and others) is at best “weak”.
focus of the present article will be on treatment. For Europe in general and Germany specifically, independently
The American College of Physicians, in a series of three articles published guidelines (Riemann, Baglioni, et al., 2017; Riemann,
(Brasure et al., 2016; Qaseem, Kansagara, Forciea, Cooke, & Denberg, Baum, et al., 2017) for the diagnosis and treatment of insomnia
2016; Wilt et al., 2016) and an editorial (Kathol & Arnedt, 2016), came mirror the conclusions of the American College of Physicians.
to the conclusion that cognitive behavioural therapy for insomnia (CBT- Based on a thorough analysis of all meta-analyses published in the
I) should be considered the first-line treatment for all adult patients field, these guidelines stated that CBT-I should be the first-line
presenting with insomnia: “ACP recommends that all adult patients treatment for insomnia and that pharmacological treatment should
receive cognitive behavioral therapy for insomnia (CBT-I) as the initial only be considered when CBT-I was unsuccessful or not available.
treatment for chronic insomnia disorder (Grade: strong recommenda- In the UK, the British Association for Psychopharmacology (BAP)
tion, moderate quality evidence)”. Furthermore, for adults with chronic consensus statement has (since 2010) recommended that “CBT-
insomnia, for whom CBT-I was either unsuccessful or unavailable, a based treatment packages for chronic insomnia, including sleep
shared decision approach, which includes a discussion of benefits and restriction and stimulus control, are effective; and should be of-
costs for the short-term use of medication, was suggested. fered to patients as a first-line treatment” (strength of evidence A:
Wilt et al. (2016), from the same series of articles, focused on directly based on category I evidence) (Wilson et al., 2010, 2019).
pharmacological treatment and concluded that zopiclone, zolpidem The BAP also stated that increased availability of this therapy is
and suvorexant may have a short-term positive effect on sleep required.
outcomes in adults with insomnia, but the comparative effective- Comparing these statements to earlier published guidelines (for
ness and long-term efficacy of pharmacotherapies are unknown. example Schutte-Rodin, Broch, Buysse, Dorsey, & Sateia, 2008),
Furthermore, undesirable side-effects of hypnotic medications were the present guidelines reflect a complete shift in recommendations
stressed. towards CBT-I as the first-line treatment, and away from the use of
The American Academy of Sleep Medicine (AASM; Sateia, sleeping pills. However, as Morin (2017) in his editorial about the
Buysse, Krystal, Neubauer, & Heald, 2017) focused exclusively on European guideline (Riemann, Baglioni, et al., 2017) noted, the central
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 3 of 29

challenge is the implementation of these clinical practice guidelines from more than 5,000 representative participants, indicate an increase
for the management of chronic insomnia within the various health- in the prevalence of insomnia from 2009 to 2016, and a marked in-
care systems of Europe. Data from different sources indicate that at crease in hypnotic prescriptions. Comparing 2009–2016, the preva-
present, CBT-I is offered only to a very small proportion of patients lence of adults who had taken hypnotic medication at least once a year
suffering from chronic insomnia (e.g., Koffel, Bramoweth, & Ulmer, increased from 13.5% to 17.3%. The intake of hypnotic medication in
2018). Furthermore, pharmacotherapy is still by far the most prevalent the last 3 months prior to investigation increased from 4.7% to 9.2% for
intervention for insomnia in routine healthcare worldwide. Given the the whole sample. Data from this detailed report indicate that 38% of
unequivocal guideline recommendation of CBT-I as the first-line treat- adults suffering from insomnia received a recommendation for psycho-
ment for insomnia, and the fact that it is seldom available in practice, therapy. However, it remains unclear what type of psychotherapy was
it felt timely to appoint a Task Force of the European Sleep Research recommended and whether it was actually received. Similar data have
Society and the European Insomnia Network with the aim of establish- been published for Norway (Pallesen et al., 2001; Pallesen, Sivertsen,
ing a European CBT-I Academy. The Academy's aims will be to (a) de- Nordhus, & Bjorvatn, 2014). In a Norwegian study, 80% of patients
fine key aspects of CBT-I and (b) enable a Europe-wide system of CBT-I who used sleeping medications in the past reported a preference
training and training centre accreditation. This should in turn promote for a non-pharmacological treatment alternative (Omvik et al., 2010).
the availability of CBT-I, to similar standards and with comparable However, less than 10% of these patients had actually been offered
levels of dissemination, across Europe. This paper summarizes the anything other than sleeping medications.
deliberations of the Task Force, including an overview of current data In Austria there was a report of a slight decrease in diagno-
on the prevalence of insomnia in Europe and experts' estimation of ses of some sleep disorders from 1997 to 2007 (Zeitlhofer et
CBT-I availability in the 12 European countries of the founding mem- al., 2010). However, there are no data on how many patients re-
bers of the Academy (Austria, Estonia, Finland, France, Germany, Italy, ceive a recommendation for psychotherapy, how many actually
Norway, Poland, Sweden, Switzerland, the Netherlands and the UK). receive psychotherapy and what kinds of psychotherapy are ei-
ther recommended or provided. In this survey, only 7% of people
suffering from sleep problems took medication and 6% sought
2 | A N I NTRO D U C TI O N TO I N S O M N I A psychotherapy. Furthermore, a recent study provided evidence
D I S O R D E R I N EU RO PE : E PI D E M I O LO G Y that in Austria, awareness of certain sleep disorders in women
A N D COS T S seems to be lower than in men (Auer, Frauscher, Hochleitner, &
Hoegl, 2018).
Table 1 provides an overview of epidemiological studies conducted In an internet study conducted by The Dutch Brain Foundation,
in adult populations (age ≥ 18 years) that were identified through 14% of people with sleep complaints were reported to seek help from
PubMed and PsycInfo searches, using “insomnia” AND “prevalence” their general practitioner (GP), 5% sought the help of a psychologist
OR “epidemiol*” as keywords and focusing on prevalence of insom- or other therapist and about 4% contacted a sleep centre (van der
nia in European countries. Velden & Wester, 2015). In line with these data, it has also been re-
Epidemiological data for 25 European countries were identi- ported that about 60% of the patients who received a preliminary
fied. These studies were grouped according to whether they con- sleep disorder diagnosis from their GP went on to receive a benzodiaz-
sidered night-time insomnia symptoms exclusively, night-time plus epine prescription (Hoebert, Souverein, Mantel-Teeuwisse, Leufkens,
daytime insomnia symptoms, or more conservatively, insomnia & Dijk, 2012). These data suggest that only a small proportion of peo-
diagnoses as defined using diagnostic manuals (e.g., International ple with insomnia receive CBT-I in the Netherlands. Nevertheless, in
Classification of Diseases (ICD)-10, Diagnostic and Statistical the Netherlands a decrease in the use of hypnotics and tranquiliz-
Manual of Mental Disorders (DSM)-IV, DSM-5, International ers has also been documented (Van Laar, 2017). A similar decreasing
Classification of Sleep Disorders (ICSD)-2 or ICSD-3). As can be trend emerged in Finland (Kronholm, Markkula, & Virta, 2012; The
seen, by any metric, insomnia is very common. Although estimates Social Insurance Institution of Finland, 2016). In Sweden, around 7%
vary, the median European prevalence for insomnia with night- of adults use sleep medication, a figure that has slowly decreased in
time symptoms alone is 24.8%, 12.5% for night-time together with the past 10 years (The Swedish National Board of Health & Welfare,
daytime symptoms and 10.1% for full insomnia diagnosis.1 When 2018). A survey among 600 GPs (response rate, 58.7%) showed that
looking at the percentage of insomnia diagnoses across different 95% prescribed sleeping medication to their insomnia patients, even
countries, Germany with 5.7% and the UK with 5.8% seem to have though 31% believed that sleeping medication was more harmful
the lowest percentage, whereas Norway, France and Russia, with than the sleep problem itself. Moreover, 80% claimed that they often
percentages, respectively, of 20%, 19% and 23.1%, show the high- referred insomnia patients for CBT and 24% reported sometimes re-
est values. ferring patients for CBT. However, details on the execution, content
Recent data from Germany (Marschall, Nolting, Hildebrandt- and quality of these CBT interventions remain unknown (Swedish
Heene, & Sydow, 2017), based on longitudinal epidemiological data Agency for Health Technology Assessment & Assessment of Social
1
For those studies reporting different prevalence values, e.g. for women and for men Services, 2010). In France, 53% of patients with severe insomnia who
separately, the mean was calculated. were surveyed sought help for their insomnia (Léger, Guilleminault,
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 of 29 | BAGLIONI et al.

TA B L E 1 Prevalence of insomnia disorder in European countries

% Insomnia % Insomnia diagnosis

syndrome (insomnia diagnoses
(the presence as outlined for
% Insomnia symptoms of night-time example by ICD-10,
(the presence of night- and daytime DSM-IV, DSM-5,
Country Author (year) Sample size time symptoms) symptoms) ICSD-2 or ICSD-3)
Austria Soldatos, Allaert, Ohta, and 490 19.0% 9.8%
Dikeos (2005) #,*
van de Straat and Bracke 54,722 (total sample 20.5%
(2015) # size)
Zeitlhofer et al. (2010) 1,000 (women, 18% 17%
n = 522; men,
n = 478)
Belgium Soldatos et al. (2005) #,* 6,832 36.0% 16.0%
van de Straat and Bracke 54,722 (total sample 27.0%
(2015) # size)
Czech van de Straat and Bracke 54,722 (total sample 25.0%
Republic (2015) # size)
Denmark van de Straat and Bracke 54,722 (total sample 16.6%
(2015) # size)
Estonia van de Straat and Bracke 54,722 (total sample 30.5%
(2015) # size)
Finland Ohayon and Partinen (2002)* 982 37.6% 15.0% 11.7%
Hublin, Partinen, Koskenvuo, 12,126 12% (daily or almost daily)
and Kaprio (2011) 40% (weekly)
Kronholm et al. (2016) 4,852–6,031 (differ- 9.0%–9.6% (often)
ent samples over 40.3–45.3 (sometimes)
6 years)
Lallukka et al. (2016) # 1,885 (men) 8.1% (frequent)
1,875 (women) 24.0% (occasional)
9.2% (frequent)
23,5% (occasional)
France Léger, Guilleminault, Dreyfus, 12,778 29.0% 19.0%
Delahaye, and Paillard
(2000)*
Léger et al. (2011) 1,004 12.0%
Chan-Chee et al. (2011) 15.0%–20.0%
Beck, Richard, and Leger (2013) 27,653 15.8%
van de Straat and Bracke 54,722 (total sample 28.0%
(2015) # size)
Germany Schlack, Hapke, Maske, Busch, 7,988 5.7%
and Cohrs (2013)
Soldatos et al. (2005) #,* 2,016 17.4% 5.2%
van de Straat and Bracke 54,722 (total sample 26.7%
(2015) # size)
Schlarb, Kulessa, & 2,196 16% 7.7%
Gulewitsch, 2012
Greece Paparrigopoulos et al. (2010) 254 25.3%
Hungary Novak, Mucsi, Shapiro, 12,643 47.0% 9.2%
Rethelyi, and Kopp (2004)
van de Straat and Bracke 54,722 (total sample 28.1%
(2015) # size)
Italy Ohayon and Smirne (2002)* 3,970 27.6% 7.0%
van de Straat and Bracke 54,722 (total sample 16.6%
(2015) # size)

(Continues)
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BAGLIONI et al. | 5 of 29

TA B L E 1 (Continued)
% Insomnia % Insomnia diagnosis
syndrome (insomnia diagnoses
(the presence as outlined for
% Insomnia symptoms of night-time example by ICD-10,
(the presence of night- and daytime DSM-IV, DSM-5,
Country Author (year) Sample size time symptoms) symptoms) ICSD-2 or ICSD-3)
Lithuania Lallukka et al. (2016) #,* 600 (men) 24.0%
1,002 (women) 30.0%
Netherlands Kerkhof (2017) 2,089 8.2% (men, 6.8%;
women, 9.5%)
van de Straat and Bracke 54,722 (total sample 16.8%
(2015) # size)
Norway Bjorvatn, Waage, and Pallesen 1,001 20.0%
(2018)
Pallesen et al. (2001), Pallesen 2,001 11.7%
et al. (2014) 2,000 15.5%
Sivertsen et al. (2009)* 47,000 13.5%
Uhlig, Sand, Ødegård, and 40,535 7.9%
Hagen (2014)
Lallukka et al. (2016) #,* 2,378(men) 4.0%
3,858 (women) 7.0%
Poland Nowicki et al. (2016) 2,413 50.5%
van de Straat and Bracke 54,722 (total sample 31.2%
(2015) # size)
Kiejna, Wojtyniak, 47,924 (non-insti- 23.7%
Rymaszewska, and tutionalized, adult
Stokwiszewski (2003) respondents)
Portugal Ohayon and Paiva (2005)* 1,858 28.1% 10.1%
Soldatos et al. (2005) #,* 784 21.2% 6.2%
van de Straat and Bracke 54,722 (total sample 29.8%
(2015) # size)
Romania Voinescu and Szentágotai 588 27.6% 15.8%
(2013)
Russia Averina et al. (2005)* 1,968 (men) 11.3%
1,737 (women) 34.8%
Slovakia Soldatos et al. (2005) #,* 502 32.0% 11.1%
Slovenia van de Straat and Bracke 54,722 (total sample 22.7%
(2015) # size)
Spain Ohayon and Sagales (2010) 4,065 20.8% 6.4%
Soldatos et al. (2005) #,* 1,999 22.4% 8.2%
van de Straat and Bracke 54,722 (total sample 24.3%
(2015) # size)
Sweden Mallon, Broman, Akerstedt, 1,128 24.6% 10.5%
and Hetta (2014)
Ohayon and Bader (2010) 1,209 32.1% (women, 38.3%;
men, 26.1%)
van de Straat and Bracke 54,722 (total sample 19.0%
(2015) # size)
Switzerland Stringhini et al. (2015) 3,391 Women, 34.5%; men,
26.6%
van de Straat and Bracke 54,722 (total sample 17.4%
(2015) # size)
Turkey Benbir et al., (2015) 4,758 51.0% 12.2%

(Continues)
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6 of 29 | BAGLIONI et al.

TA B L E 1 (Continued)
% Insomnia % Insomnia diagnosis
syndrome (insomnia diagnoses
(the presence as outlined for
% Insomnia symptoms of night-time example by ICD-10,
(the presence of night- and daytime DSM-IV, DSM-5,
Country Author (year) Sample size time symptoms) symptoms) ICSD-2 or ICSD-3)
United Calem et al., (2012) 5,425 38.6% 13.9% 5.8%
Kingdom Ellis, Perlis, Neale, Espie, and 1,095 7.9%
Bastien (2012) #
Morphy, Dunn, Lewis, 2,363 37.0%
Boardman, and Croft (2007)*

ICD, International Classification of Diseases; DSM, Diagnostic and Statistical Manual of Mental Disorders; ICSD, International Classification of Sleep
Disorders.
*Data from prior to 2010.
#
Multinational study that included other countries as well as the country of relevance.

Bader, Lévy, & Paillard, 2002) and 10.8% of adults reported regularly a difference in calculation of indirect costs. Similar data are also
taking medication to sleep (Léger, Poursain, Neubauer, & Uchiyama, available for the USA and Canada. Annual direct and indirect costs
2008). In an observational epidemiological survey, it was reported for insomnia have been estimated to be around $150 billion in the
that, in Italy, insomnia symptoms are undertreated and GPs prefer USA (Reynolds & Ebben, 2017), being mainly related to indirect
the pharmacological approach, which is four times more frequent costs such as increased healthcare utilization, poorer performance
than any non-pharmacological therapy (78.6% vs. 18.2%, Terzano, at work and enhanced risk of accidents (Wickwire, Shaya, & Scharf,
Cirignotta, Mondini, Ferini-Strambi, & Parrino, 2006). 2016). A Canadian study (Daley, Morin, LeBlanc, Grégoire, & Savard,
Insomnia is a costly condition. At present, it has been shown, on 2009) reported total annual costs for insomnia disorder alone to be
a meta-analytic level, to convey increased risks of cardiovascular dis- around $6.5 billion and underlined that the highest costs were for
eases (Li, Zhang, Hou, & Tang, 2014; Sofi et al., 2014; Spiegelhalder, alcohol consumed as a sleep aid (58%) and consultations for insom-
Scholtes, & Riemann, 2010), obesity and development of diabetes nia (33%). The study also indicated that, similar to the data from the
(Anothaisintawee, Reutrakul, Van Cauter, & Thakkinstian, 2016; USA, insomnia is associated with significant morbidity in terms of
Chan, Levsen, & McCrae, 2018), depression (Baglioni et al., 2011; health problems, health care utilization, work absenteeism, reduced
Hertenstein et al., 2019), anxiety (Hertenstein et al., 2019) and suicide productivity and risk of non-motor-vehicle accidents. Despite indi-
(Norra & Richter, 2013; Pigeon, Pinquart, & Conner, 2012). Wickwire vidual differences between countries, in all regions direct and indi-
(2019) reported that untreated insomnia is associated with increased rect costs are a heavy burden on society and general health budgets.
all-causes healthcare utilization based on a randomly selected and Data from the Sleep Health Foundation in Australia in 2017 (Adams
nationally representative sample from the USA. Norwegian studies et al., 2017; Sleep Health Foundation Report by Deloitte Access
clearly indicate that insomnia significantly predicts sick leave and dis- Economics, 2017) estimated that 7.4 million Australian adults expe-
ability pension (Overland et al., 2008; Sivertsen, Krokstad, Øverland, rienced poor sleep, resulting in both insufficient sleep and excessive
& Mykletun, 2009). In fact, insomnia has been shown to be a stron- daytime sleepiness. This was associated with a cost of AUS$26.2
ger predictor of disability pension than depression (Overland et al., billion in 2016–2017: AUS$1.8 billion associated with health sys-
2008). In a Finnish nationally representative study it was concluded tem costs, AUS$17.9 billion associated with productivity losses,
that direct costs due to sickness absence could decrease by up to 20% AUS$0.6 billion with informal care costs and AUS$5.9 billion with
if sleep disturbances could be fully addressed (Lallukka et al., 2014). other financial costs. In addition to these costs, a further AUS$40.1
In Europe, data for Germany (Thiart et al., 2016) have shown billion was associated with decreases in well-being. Improving ac-
that direct and indirect costs for insomnia are around €40–50 billion cessibility to an effective, brief and relatively low-cost treatment
annually. In France, direct costs were estimated at $2 billion USD in such as CBT-I is thus strongly warranted.
1995 (Léger, Levy, & Paillard, 1999). Indirect costs are estimated at
€77 per employee per year for costs of absenteeism and €1,062 for
productivity loss (Léger & Bayon, 2010; Leger, Massuel, Metlaine, 3 | A N I NTRO D U C TI O N TO CO G N ITI V E
& SYSYPHE Study Group, 2006). Data from Sweden indicate lower B E H AV I O U R A L TH E R A PY FO R I N S O M N I A
direct and indirect costs of insomnia compared to Germany and (C B T- I)
France, around €325 million annually (Swedish Agency for Health
Technology Assessment and Assessment of Social Services, 2010). Cognitive behavioural therapy for insomnia (CBT-I) largely targets
This discrepancy between countries shows the heterogeneity of those factors that may maintain insomnia over time, such as dysregu-
European health systems concerning insomnia care and probably lation of the sleep drive, sleep-interfering behaviours and cognitions,
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 7 of 29

attempts to control the sleep process and sleep-related anxiety. It Most clinical research on CBT-I focuses on the general adult pop-
typically consists of stimulus control therapy, sleep restriction therapy ulation, including older adults. Traditionally, research has focused on
and a range of cognitive therapeutics, supplemented by psychoedu- recruited participants meeting criteria for insomnia but not necessarily
cation/sleep hygiene and relaxation training (Riemann & Perlis, 2009). representative of more complex or typical clinical cases. These cases
Table 2 summarizes the main interventional strategies included in a might include young, working and older adults with insomnia that is
CBT-I protocol. comorbid with different mental and somatic disorders, paediatric pop-
The efficacy of CBT-I for ameliorating night-time symptoms of ulations presenting with developmental disabilities, pregnant women,
insomnia alone or when it presents as comorbid with other mental women at postpartum, women going through the menopause, shift
and somatic disorders has been shown in 14 meta-analyses (Geiger- workers and those entering retirement. Recently, research has also
Brown et al., 2015; Ho et al., 2015; Irwin, Cole, & Nicassio, 2006; focused on the efficacy and clinical effectiveness of CBT-I in adults
Johnson et al., 2016; Koffel, Koffel, & Gehrman, 2015; Miller et al., whose insomnia is comorbid with a wide range of mental and somatic
2014; Montgomery & Dennis, 2004; Morin, Culbert, & Schwartz, disorders. Findings from such studies have afforded greater confi-
1994; Murtagh & Greenwood, 1995; Okajima, Komada, & Inoue, dence in the applicability of CBT-I to insomnia disorder, wherever and
2011; Pallesen, Nordhus, & Kvale, 1998; Tang et al., 2015; Trauer, however it presents. Likewise, CBT-I appears to be applicable to pae-
Qian, Doyle, Rajaratnam, & Cunnington, 2015; Wu, Appleman, diatric populations, including infants, toddlers, preschoolers, school-
Salazar, & Ong, 2015). In seven meta-analyses the efficacy of CBT-I age children, adolescents and young adults. Less evidence is available
was demonstrated for daytime or comorbid symptoms (Ballesio et on CBT-I's applicability to some specific populations, such as pregnant
al., 2018; Belleville, Cousineau, Levrier, & St. Pierre-Delorme, 2011; women, women going through the menopause, older adults with cog-
Ho et al., 2015; Johnson et al., 2016; Koffel et al., 2015; Tang et al., nitive impairment, children with developmental disabilities and shift
2015; Wu et al., 2015). CBT-I is as effective as sedative hypnotics workers.
during acute treatment (4–8 weeks; Smith et al., 2002) and is more
effective in the long term (Morin, Colecchi, Stone, Sood, & Brink,
1999). CBT-I is associated with an average treatment effect of about 4 | I N S O M N I A : S CO PE O F TH E PRO B LE M
50% improvement, with large effect sizes that are reliably around A N D CU R R E NT C LI N I C A L PR AC TI C E I N
1.0 (Perlis, Jungquist, Smith, & Posner, 2005). Follow-up studies EU RO PE
showed that CBT-I promotes stable changes for sleep onset latency
and wake after sleep onset and slower but substantial improvements Although insomnia is prevalent and costly, there is a lack of invest-
for total sleep time (Perlis et al., 2005). ment in evidence-based first-line treatment (CBT-I). This may, in part,

TA B L E 2 CBT-I ingredients

CBT-I strategy Description

Sleep restriction Behavioural strategy: A method which aims to strengthen homeostatic sleep pressure and stabilize circadian control of
sleep and wakefulness, by decreasing the opportunity to sleep over successive nights. Patients are instructed to restrict
their time in bed to match their average (self-report in sleep diaries) total sleep duration. The time in bed is then gradually
increased until it reaches patients’ optimal sleep need. An alternative method, called sleep compression, involves gradual
constriction of time in bed, which is then similarly increased until reaching the optimal sleep need
Stimulus control Behavioural strategy: A set of instructions that aim to strengthen the bed as a cue for sleep, weakening it as a cue for activi-
ties that might interfere with sleep, and helping the insomniac acquire a consistent sleep rhythm, based on operant con-
ditioning model: (1) Lie down to go to sleep only when you are sleepy. (2) Do not use your bed for anything except sleep
and sexual activity. (3) If you find yourself unable to fall asleep, get up and go to another room. Stay up as long as you wish,
and come back to bed when you feel sleepy. (4) If you still cannot fall asleep, repeat step 3. Do this as often as is necessary
throughout the night. (5) Set your alarm and get up at the same time every morning irrespective of how much sleep you
got during the night. (6) Do not nap during the daytime
Sleep hygiene Behavioural and educational strategy: General health instructions about internal and external factors that might influence
education sleep (e.g., sport, light, temperature, etc.)
Relaxation Behavioural and cognitive strategy: A set of methods that aim to reduce somatic or cognitive hyperarousal (e.g., progressive
muscle relaxation, autogenic training, imagery training, meditation)
Cognitive Cognitive strategy: Strategies designed to reduce dysfunctional beliefs, attitudes, concerns, and false beliefs about the cause
reappraisal of insomnia and about the inability to sleep
Cognitive control/ Cognitive strategy: The patient is instructed to sit comfortably in an armchair and write down a list of worries alongside
Worry time plans for the next day. The rationale of this strategy is to prevent emotionally loaded intrusive thoughts during the sleep-
onset period, as all worries have been “already” processed before going to bed
Paradoxical Cognitive strategy: Strategy aimed at reducing the anticipatory anxiety at the time of falling asleep. Patients are instructed
intention to remain still in bed with their eyes closed and to try to stay awake as long as they can. This reduces sleep effort, which in
turn often leads to falling asleep quicker
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 of 29 | BAGLIONI et al.

be linked to a current lack of standardization of CBT-I, such that the usually not specifically trained in sleep medicine), who will handle
treatment, although generally effective, can vary considerably in sleep problems (e.g., insomnia symptoms, as these are often related
content and duration from clinician to clinician. Moreover, primary to work stress and might affect work performance). Some facilities
care practitioners are often poorly informed on sleep disorders, offer e-versions of “CBT-I” provided by private companies, although
which remain underdiagnosed and sub-optimally managed (Grandner these are rarely evaluated or quality controlled.
& Chakravorty, 2017; Grandner & Malhotra, 2015). This is despite it Exact data for the number of patients treated with CBT-I per
being well documented that the prevalence of insomnia in primary year were not available publicly for any of the 12 countries. In many
care patients is higher than that in the general population (Bjorvatn, European countries this is mainly dependent on individual psycho-
Meland, Flo, & Mildestvedt, 2017; Grandner & Chakravorty, 2017). therapists who may offer CBT-I and for whom data are hard to es-
In an Italian observational epidemiological survey, insomnia was re- timate. Where possible, experts' estimations suggest that CBT-I is
ported by 64% of 3,284 interviewed patients under 738 GPs, with very seldom available for insomnia patients in Europe. In each coun-
20% reporting both night-time and daytime symptoms and 44% try, only data from specialized clinical centres, either in hospitals
complaining of night-time symptoms only (Terzano et al., 2004). or in universities, could be tracked. Via these institutions, sleep or
There is a high degree of variability in both CBT-I availability and CBT-I experts offer or could offer training for health profession-
clinical administration across Europe. Alongside a severe shortage of als. Another complication is that countries within Europe adhere to
European CBT-I experts, this variability calls for greater efficiency differing professional and legal systems regulating the delivery of
and standardized certification of CBT-I clinicians through examina- clinical care, including treatment of insomnia. First of all, psycho-
tion and supervised practice of CBT-I's core evidence-based com- therapists, clinical psychologists, other applied psychologists with
ponents. To address this situation, the Task Force group collected a licence to practice recognized by the national healthcare system
information on current availability of CBT-I education and practice in and physicians (mainly from neurology and psychiatry) are involved
the 12 countries of the founding members of the Academy (Austria, in insomnia treatment. Sleep specialists in sleep centres may also be
Estonia, Finland, France, Germany, Italy, Norway, Poland, Sweden, involved.
Switzerland, the Netherlands and the UK; see Table 3). It needs to be emphasized that in many European countries GPs
It should be stressed that each European country has its own have a central role in health care organization and are seen as the key
specific national healthcare system and there is no overarching navigators of most healthcare systems. Thus, GPs have a pivotal role
European healthcare system at an EU level. For example, in the UK, in treating patients with insomnia. Despite this, available data indi-
the National Health Service (NHS) covers all medical and health-re- cate that GPs rarely prescribe or are able to offer CBT-I to patients
lated issues. The NHS is a central health service organized by the with insomnia (e.g., Everitt et al., 2014; Koffel et al., 2018). In the
government through the Department of Health and Social Care; Netherlands, according to national GP standards, GPs should offer
everyone who lives in the UK has equal access to the NHS and its certain aspects of CBT-I. This is often delivered by a ‘practice assis-
benefits and the NHS is financed by the taxpayer. In France, the tant’ for mental healthcare at the GP's office through internet-based
healthcare system also provides universal cover for all citizens irre- therapy modules. In Sweden, Norway, Finland and the UK, insomnia
spective of age or socioeconomic status. The costs are covered by is mainly a primary care and/or occupational health issue and man-
a combination of central government funding, employment fees and aged principally by medication. In the UK, however, digital CBT-I
healthcare users, who generally pay a low percentage of the cost of (dCBT-I)2 is currently being piloted (2018/2019) in the southeast of
the healthcare (e.g. medication and visits to physician) they receive. England, with access made available to patients, free at the point of
The Italian health system works in a similar manner to its French delivery, through NHS primary care services. In Finland, a public
equivalent. In contrast, the German healthcare system consists of a sleep disorder outpatient clinic that also focuses on complex insom-
mixture of highly regulated institutions/processes organized through nia cases and the delivery of CBT-I was established in 2016.
the government and a semi-private system linked to hospitals and However, it is clear that most patients with insomnia in Europe
private practices. There are several hundred health insurance com- are never referred to sleep centres. In any case, these centres do
panies, including so-called “private” health insurance, and premiums not typically treat insomnia, and if they do treat it, do not typically
to health insurance are paid by employers and employees on an provide CBT-I. Although insomnia is supposed to be handled in pri-
equal basis. In Sweden, public health care, which includes CBT-I, is mary care, in Sweden it is rarely formally diagnosed and patients
financed through taxes and available to all. The maximum fee paid by who complain of sleep problems are generally prescribed sleeping
the individual per year for healthcare is approximately €100/person. medication. A few primary care centres have clinicians who can
There is a similar system for medication, which includes approved provide CBT-I, but this varies between regions, with greater ac-
sleeping medications. In addition to the public healthcare system, cess in larger city regions (similarly to the IAPT [Improving Access
a separate private system exists. Here companies often provide a to Psychological Therapies] services in the UK). Some regions may
“healthcare” service to their employees for problems that might offer dCBT-I. For instance, Stockholm County Public Health has
be related to or might affect work performance. These “corporate an internet treatment clinic (the Internet Psychiatry Clinic), which
healthcare facilities” quite often have “CBT therapists” (sometimes 2
Many authors use the term Internet CBT (ICBT). In this paper, we will use dCBT-I to
psychologists or psychotherapists, not necessarily licensed, and refer to all digital internet-delivered CBT for insomnia.
 TA B L E 3 Current availability of CBT-I education and practice in the 12 countries of the founding members of the CBT-I Academy
BAGLIONI et al.

Who treats insomnia with CBT-I?

How many patients have been How many centres/therapists offer Who is entitled to practice
Countries treated with CBT-I in the last years? CBT-I specifically? Who can teach CBT-I? CBT-I? Reimbursement for CBT-I?

Austria No exact data are available. Approx. three to five Centres Experts in insomnia and CBT-I; Clinical and health psychologists, No reimbursement for CBT-I in
However, CBT-I is certainly not for Sleep Medicine and Sleep sleep experts, sleep coaches, sleep psychotherapists, psychiatrists, the basic healthcare system. If
sufficiently offered to insomnia Research, one Medical University coaches certified by the Medical neurologists, paediatricians, psychotherapists offer CBT-I,
patients. Estimates of 10–20 and a few private psychotherapists University of Vienna geriatricians, sleep coaches cer- it is partially reimbursed (de-
patients per year at Innsbruck tified by the Medical University pending on insurance)
Medical University; around 20 pa- of Vienna
tients at the Institution for Dream
and Consciousness Research,
around 10–20 in private practices
and some sleep laboratories
Estonia Approx. 1,000 patients per year Approx. three well-established CBT therapists (MDs and clinical Clinical psychologists, MDs who Reimbursed as psychotherapy if
teams offer CBT-I as a component psychologists) who have also had have received training in CBT delivered by clinical psycholo-
of multidisciplinary sleep disorders CBT-I training, about five CBT-I and in CBT-I, mental health gists or psychiatrists, or as
management. experts who could teach clinicians, nurses with training in CBT-I a nurseʼs outpatient visit in
30 CBT therapists – clinical psy- experienced mental health nurses (under supervision) public medical system; limited
chologists, psychiatrists – use at with CBT-I training, (four such reimbursement in private med-
least some techniques nurses currently in practice) ical system if referred by GP
and psychotherapy delivered
by a clinical psychologist
Finland Approx. >1,000 patients per year Approx. 100 occupational and About 5–10 experts could teach Psychologists, psychotherapists, Totally or almost totally reim-
public health centres (delivery by CBT-I to clinicians psychiatrists, medical doctors bursed in public and occupa-
trained nurses), the Finnish Sleep and nurses who have received tional health systems and in
Association (FSA), one to two pri- training in CBT-I the FSA. Partly reimbursed as
vate sleep centers and 20 private part of private psychotherapy,
therapists offer CBT-I no reimbursement in other
private sector systems
France No exact data are available. Estimated at about 15–30 centres Psychologists, psychotherapists, Psychologists, psychotherapists, In principal, only psychiatrist
However, CBT-I is certainly not in France, mostly academic hospi- psychiatrists and medical doctors psychiatrists and medical doc- treatment is reimbursed in
sufficiently available to insomnia tals with a sleep clinic who have received training in tors who have received training France. However, antici-
patients CBT-I in CBT-I pated changes may allow for
psychologist treatment to be
(partially) reimbursed
Germany Approx. >1,000 patients per year Approx. 10 sleep centres. Not pos- Experts in insomnia and CBT-I in Psychologists, psychotherapists Reimbursed as psychotherapy
sible to estimate the number of about 10 sleep centres around and psychiatrists
private psychotherapists offering Germany
CBT-I
|

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 10 of 29

TA B L E 3 (Continued)
|

Who treats insomnia with CBT-I?

How many patients have been How many centres/therapists offer Who is entitled to practice
Countries treated with CBT-I in the last years? CBT-I specifically? Who can teach CBT-I? CBT-I? Reimbursement for CBT-I?

Italy Approx. 300 patients in 2017. Of Five hospital centres for sleep About 15 experts could teach CBT-I Psychologists, psychotherapists Reimbursed by private health
those treated in medical centres, medicine, one university clinical to clinicians and psychiatrists insurances as psychotherapy
the vast majority also received centre and a few private therapists
pharmacological intervention
Norway Approx. 600 patients per year: 100 Three to four specialized centres About 10 experts could teach CBT-I Medical doctors (not only psy- Not for private clinics, but if
at Bergen Sleep Disorders Centre, to clinicians chiatrists), psychologists, nurses GPs offer CBT-I, treatment is
500 in clinical studies, mostly via subsidized by the government
guided Internet treatments
Poland Approx. 400 patients per year Three specialized sleep medicine Experts in insomnia and CBT, about CBT-I trained psychologists, Reimbursed as psychotherapy in
centres and 10–15 CBT psycho- 10 experts from three specialized physicians and nurses. In prac- public mental health services;
therapists in private practices sleep medicine centres tice, CBT-I is delivered mostly not reimbursed in other public
around Poland by CBT psychotherapists and healthcare settings and for
psychiatrists private practices
Sweden Approx. 2,000–3,000 in total. Internet treatment providers, a few About 10–15 experts could The practice of CBT is not Within the public healthcare
Approx. 1,000 of these in clinical primary care facilities, a few psy- teach CBT-I to clinicians, mostly regulated other than within the system, CBT-I is reimbursed in
studies, mostly via guided Internet chologists and psychotherapists psychologists public healthcare system where the same way as other forms
treatments in private practice and nurses. No CBT for any condition could be of treatment. Within private
specialized sleep centres offer carried out by licensed person- practice it is reimbursed if
CBT-I nel with adequate training. This the practitioner is linked to
means CBT-I can be provided the public healthcare system,
by licensed CBT-I-trained otherwise not
psychologists, psychotherapists,
physicians, psychiatrists or
nurses
Switzerland No exact data are available, esti- Approx. seven centres About 15 experts could teach CBT-I Psychiatrists and psychologists Reimbursement as
mate of approx. 150 patients to clinicians psychotherapy
The No exact data are available. Two tertiary care sleep centres, Psychologists, nurse practitioners. Healthcare psychologists, clinical Besides CBT-I delivered by a
Netherlands Estimated that approx. 2,000– several secondary care sleep Healthcare psychologists, clinical psychologists, psychotherapists, mental healthcare assistant at
3,000 patients receive face-to- centres, one specific sleep centre psychologists, clinical neuropsy- psychiatrists, nurse practitioner, the GP there is no reimburse-
face CBT-I for psychiatric patients, health- chologists, psychotherapists and psychologists ment for CBT-I in the basic
care psychologists in basic mental psychiatrists mental healthcare system
health care, practice assistants for (primary care). In secondary
mental healthcare in the general and tertiary care sleep centres
practitioners office, a few internet there is no reimbursement for
treatment providers CBT-I (there are no diagnosis-
related groups for insomnia)

(Continues)
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 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 11 of 29

provides CBT-I with psychologist support via the Internet and has

by the UK government. Private

Any NHS treatment is provided
done so since September 2017. The service includes a full psychiatric

by private health insurance

treatment may be covered
Reimbursement for CBT-I?
assessment and diagnosis performed by physicians or psychologists.

providers although this is

The internet treatment is available to all Swedes over the age of 16,
through the citizens' right to choose their health centre or clinic
for outpatient care. Generally speaking, however, it is a challenge

uncommon
to provide CBT-I in primary care. In the UK, there has been some
recent project-based implementation funding to offer digital (web/
mobile) dCBT-I (Sleepio™) to large populations (e.g., 8 million people
in London for a time-limited period). The intention behind this is to
find a pathway to deliver dCBT-I to mainstream services. In France,
chiatrists, and CBT therapists

the majority of patients with insomnia are prescribed sleeping med-

Who is entitled to practice

Clinical psychologists, psy-

ication by their GP, whereas a minority of patients are referred to

a sleep clinic for their insomnia complaints. However, the National
(psychotherapists)

Sleep Foundation (SFRMS), the foundation Sommeil et Santé and

the Morphée Network (Reseau Morphée) make efforts to address the
needs of those with insomnia by providing treatment and special-
CBT-I?

ist information online. Reseau Morphée even offers free treatment

to severe insomnia patients in the Paris region (Londe et al., 2011;
psychiatrists and other physicians),

Storch, Denesle, Liyan, & Lainey, 2007). In France, group therapy is

CBT therapists (psychotherapists)
CBT-I (including clinical psycholo-
gists, practitioner psychologists,
Appropriately trained experts in

also often provided and online treatment is available (Hartley et al.,

2016; Lopez et al., 2017).
Whether healthcare professionals such as nurses or social work-
Who can teach CBT-I?

ers might play a role in providing CBT-I, as suggested in previous

publications (e.g., Espie et al., 2008; Espie, Inglis, Tessier, & Harvey,
and nurses

2001), remains to be investigated. In Finland, for example, CBT-I is

effectively delivered by trained nurses in occupational health, show-
ing long-term improvements in insomnia symptoms (Järnefelt et al.,
2014).
clinical psychologists, psychiatrists

provided by the NHS, a small num-

How many centres/therapists offer

Although it is clear that differences in the way that healthcare

Access to Psychological Therapies

uniformly across all regions of the

Thomas’ Sleep Disorders Centre).
and private). Although not widely
Who treats insomnia with CBT-I?

some patients (e.g., Guy's and St

(IAPT) centres but not provided

ber of specialist sleep disorders

group CBT-I through Improving

Some patients may also access

is organized across Europe are not a barrier to the ubiquitous avail-

and CBT therapists (both NHS

centres may provide CBT-I for

Typically provided by specialist

ability of pill-based solutions, the structure of health services and

associated reimbursement mechanisms may play a part in ‘rationing’
access to CBT-I. Likewise, because CBT-I is traditionally delivered
CBT-I specifically?

face-to-face, the shortage of training in CBT-I represents an intrinsic

limitation to the scalability of CBT-I to meet population need and
country

demand. As shown in Table 3, dCBT-I is being used to remedy this

problem in some countries (e.g., Sweden) and there are large pilot
schemes investigating feasibility of widespread dCBT-I provision un-
treated with CBT-I in the last years?

derway (e.g., the UK and France).

How many patients have been

No exact data are available

5 | PR E S E NT S IT UATI O N O F C B T- I
TR A I N I N G A N D IT S D I S S E M I N ATI O N I N
EU RO PE
(Continued)

Table 4 summarizes current availability of CBT-I education/training in

the 12 founder countries (Austria, Estonia, Finland, France, Germany,
Italy, Norway, Poland, Sweden, Switzerland, the Netherlands and the
UK). For some countries, such as the UK and the Netherlands, for
Kingdom
Countries
TA B L E 3

reasons of space, no comprehensive course list is provided. Here,

United

general information on the types of courses that are available in

these countries is reported instead.
 TA B L E 4 Current courses offered in the 12 countries represented in the CBT-I Academy
12 of 29

Does the course

|

include teaching Do the course/s

on clinical include
adaptation of interactive
CBT-I for the teaching
To whom is the By whom is the Duration of the lifespan or special and/or case What is the participation's
Country Course/s course/s offered? course/s given? course/s What is taught? populations? supervision? fee? Who pays?

Austria Medical University of Vienna MDs, medical Sleep and dream Three-semester Sleep education, sleep Sleep Coaching The Sleep The costs of the Sleep
Sleep Coaching Course; students, researchers Sleep Coaching training, Course includes Coaching Coaching Course are
CBT-I courses at the Institute clinical and health and experts, Course (Medical sleep hygiene, relaxation tech- sleep in the el- Course €1,500, per semester;
for Dream and psychologists, psychologists, University of niques including self-hypno- derly, menopause includes inter- 2–3 day CBT-I courses cost
Consciousness Research, the psychotherapists, psychotherapists Vienna); sis and dreamwork including and children and active teaching around €400;
CBT Society and the Austrian nurses, 2–3-day CBT-I nightmare treatment, basics adolescents and case Costs are borne by
Sleep Research Association physicians, courses of gestalt therapy including supervision participants themselves,
HR personnel awareness training; pharma- sometimes supported by
cological treatments their employer

Estonia (a) Tartu University CBT-I (a), (b) & (d): MDs, (a) & (d): sleep (a), (b) & (c): 0.1 day; (a) & (d): sleep physiology; (a)– (a) & (c) include (a)–(d): no About €100 for 1-day, €200
course (Tartu University psychologists, experts, MDs, (d): 2 days (d) sleep education; specific modules (e): role play, for 2-day course and
together with Nordic Sleep psychotherapists; psychologists; (a), (c), (d) & (e): sleep on adolescent supervision €60 for 1-day nurses
Centre); (c): nurses; (b): psychologists; restriction; and elderly course.
(b) CBT-I course Tallinn (e): CBT therapists (c): mental health (a), (c) & (e): stimulus control; insomnia and Employers or participants
Regional Hospital; in training nurses, sleep- (a) & (c): relaxation; related adapta- pay
(c) CBT-I course for nurses in- (MDs, clinical expert MDs; (e): cognitive techniques in tion of the CBT-I
cluding other sleep disorders psychologists) (e): CBT therapists CBTI; protocol for these
(Tartu University); (sleep-expert (a)–(d): tapering hypnotics; populations
(d) Tartu University courses MDs, clinical (a), (c) & (d): sleep disorders;
on sleep disorders, includ- psychologist) d): pharmacotherapy of sleep
ing CBT-I; (e) Estonian CBT disorders
school. CBT-I session

Finland Different courses and web- Nurses, psycholo- Psychotherapists, 2–3 days (16–24 hr) Basics of sleep and sleep Adaptation in co- Interactive Depends on the courses,
based programme to deliver gists, physicians sleep medicine (some courses disorders; screening and di- morbid insomnia teaching, case e.g. costs of the 3-day
CBT-based treatment in pri- specialists, include clinical agnosing insomnia; pharma- and the meno- examples, course without supervi-
mary, secondary, and tertiary (NOSMAC, supervision) cological treatments; sleep pause included. communication sion are about €1,000/
levels of healthcare Nordic Sleep education; CBT-I methods, Lifespan (espe- skills and role student
Medicine relaxation and mindful- cially elderly) playing, self
Accreditation/ ness techniques, hypnotic and working life governed stud-
ESRS ac- technique perspectives ying (textbook),
creditations), (e.g., shift work) internet-based
psychiatrists, included in material, clini-
sleep research- some courses. cal supervision
ers, nurses Special additional and guidance
courses (infants,
children and
adolescents)

(Continues)
BAGLIONI et al.

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 BAGLIONI et al.

TA B L E 4 (Continued)

Does the course

include teaching Do the course/s
on clinical include
adaptation of interactive
CBT-I for the teaching
To whom is the By whom is the Duration of the lifespan or special and/or case What is the participation's
Country Course/s course/s offered? course/s given? course/s What is taught? populations? supervision? fee? Who pays?

France (a) Course on managing Psychologists, psy- Psychologists, 1–3 days depending Screening and diagnosing Yes, for instance Yes, case studies Depending on participant
insomnia, including CBT-I, at chiatrists, medical psychiatrists, on the course insomnia; pharmacological insomnia in neu- and evaluation status and course, be-
Université Paris Descartes. doctors sleep medicine treatments; sleep education; rodegenerative methods are tween €100–1,400
(b) Training for a national di- specialists and CBT-I disorders discussed in
ploma in behavioural therapy sleep researchers small work-
in which CBT-I is part of the shops on the
curriculum, by AFTCC (French course
Association for Cognitive
Behaviour Therapy).
(c) Two-day course on CBT for
insomnia, with an optional
1-day course for insomnia
with psychiatric comorbidities
(Montrouge, S. Dagneaux)

Germany (a) Course on CBT-I, including (a) Clinical psy- (a) Sleep, insomnia (a) 2 days. (a) Basics of sleep–wake- (a) Comorbid (a) Yes, com- (a) 400 Euro.
information on interventions chologists, medi- and CBT-I experts (b) Part of the regulation; screening and insomnia. munication and (b) part of the curriculum
for other sleep disorders cal doctors, and (psychologists curriculum diagnosing insomnia; comor- (b) no role playing.
at the Sleep Laboratory of social workers. and medical doc- bidities; epidemiology and (b) no
the University of Freiburg (b) Psychologists tors) of the Sleep aetiology of insomnia; sleep
Medical Centre. and psychiatrists Laboratory of education, CBT-I methods,
(b) Four or five institutes for the University of relaxation, pharmaco-
behavioural therapy in which Freiburg Medical therapie; acceptance and
CBT-I is part of the curriculum Centre. commitment to therapy for
(b) Psychologists insomnia.
(b) Basics of sleep–wake-
regulation; screening and
diagnosing insomnia;, CBT-I
methods

(Continues)
| 13 of 29

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 TA B L E 4 (Continued)
14 of 29

Does the course

|

include teaching Do the course/s

on clinical include
adaptation of interactive
CBT-I for the teaching
To whom is the By whom is the Duration of the lifespan or special and/or case What is the participation's
Country Course/s course/s offered? course/s given? course/s What is taught? populations? supervision? fee? Who pays?

Italy (a) Intensive 1-year CBT-I (a) Psychologists, (a) (a) 12 modules of (a) Basics of sleep and sleep (a) The course (a) Yes, the (a) €1,500. (The fee is payed
course at “Sapienza” univer- psychotherapists, Psychotherapists, 8 hr each distrib- disorders; psychophysiol- teaches CBT-I course is highly by the participant or sup-
sity of Rome since 2018. medical doctors psychologists, uted in 1 year. ogy of insomnia; screening for the lifespan interactive ported by any public or
(b) Annual CBT-I courses of- during training medical doctors (b) 2 days. and diagnosing insomnia; (infants, children, including inter- private institution; credits
fered during the Italian Sleep to become who are experts (c) 1 and a half days. pharmacological treatments; adolescents, the active teaching, may be recognized for
Medicine Congress since a specialist/ in sleep, insomnia sleep education; CBT-I meth- elderly); specific role playing, other courses (e.g. mas-
2015. psychotherapist. and CBT. ods, relaxation, mindfulness women’s lifespan and case super- ters degree, specialization
(c) Annual courses hosted (b) Neurologists, (b) techniques, techniques from (pregnancy, men- vision. school, etc.)
by the University of psychiatrists, Psychotherapists, acceptance and commitment opausal); mental (b) and (c) Yes, (b) €100/day with a dis-
Pisa Psychiatric Clinic, pneumologists, psychologists, therapy; insomnia across the and somatic the courses count for AIMS meeting
Department of Neuroscience: child and adoles- medical doctors, lifespan: basic and clinical comorbidities. include interac- participants
each year (September/ cent psychiatrists, psychiatrists, aspects; efficacy and limita- (b) All the courses tive teaching (c) €100/day
October) since 2015 physicians, child and adoles- tions of CBT-I. have been on and activities
psychologists. cent psychiatrists (b) Basics of sleep and sleep a theme and
(c) neurologists, who are experts disorders; psychophysiology addressed
psychiatrists, in sleep and in- of insomnia; screening and CBT-I across
pneumologists, somnia research diagnosing insomnia; sleep the lifespan (i.e.,
child and adoles- and are part of education; CBT-I method. infants, children,
cent psychiatrists, the association of (c) Basics of sleep and sleep adolescents,
physicians, the Italian sleep disorders; psychophysiology the elderly), and
psychologists medicine society. of insomnia; screening and in those with
(c) diagnosing insomnia; sleep mental health
Psychotherapists, education; CBT-I methods and somatic
psychologists, practice sessions, how to comorbidities.
medical doctors, apply CBT-I (c) All the courses
psychiatrists, have been on
child and adoles- a theme and
cent psychiatrists addressed
who are experts CBT-I across
in sleep and in- the lifespan (i.e.,
somnia research infants, children,
and are part of adolescents, the
the association of elderly); also
the Italian sleep womens’ specific
medicine society complexities
(pregnancy, the
menopause);
mental health and
somatic comor-
bidities, and other
sleep disorders as
comorbidities
BAGLIONI et al.

(Continues)

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 BAGLIONI et al.

TA B L E 4 (Continued)

Does the course

include teaching Do the course/s
on clinical include
adaptation of interactive
CBT-I for the teaching
To whom is the By whom is the Duration of the lifespan or special and/or case What is the participation's
Country Course/s course/s offered? course/s given? course/s What is taught? populations? supervision? fee? Who pays?

Norway One annual course in sleep Health profes- Most courses 2-days Sleep medicine, Yes Yes About €300 for a 2-day
medicine, in which the focus sionals: GPs, are given by CBT-I methods course
is on CBT-I. psychiatrists, Norwegian
In addition, several other psychologists and Competence
courses (three to five at other medical Center for Sleep
least) given annually provide specialists (neu- Disorders and/
information about CBT-I to rology, clinical or the
clinicians neurophysiology, universities
thoracic medicine, by a medical
ENT), medical doctor and a
and psychology psychologist
students at the
University of
Bergen

Poland CBT-I training during compre- Psychologists, Teaching centres Obligatory 10 hr CBT-I methods Only basic CBT-I Only for The fee is paid by the par-
hensive CBT course physicians accredited of theoretical protocol is participants ticipant for the whole CBT
by Polish education in CBT-I taught, literature interested in course (approx. €9,000
Association for for all participants. for CBT-I pro- sleep medicine including supervision), it is
Cognitive and Additionally, tocols in special not possible to take part in
Behavioural possibility of populations CBT-I training only
Therapy supervision, clinical (comorbid insom-
training and guided nia, childhood,
self-education for elderly patients)
those interested is provided

(Continues)
| 15 of 29

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 TA B L E 4 (Continued)

Does the course

16 of 29

include teaching Do the course/s

|

on clinical include
adaptation of interactive
CBT-I for the teaching
To whom is the By whom is the Duration of the lifespan or special and/or case What is the participation's
Country Course/s course/s offered? course/s given? course/s What is taught? populations? supervision? fee? Who pays?

Sweden At least some CBT-I training Psychologist Psychologists/ On the psycholo- Example from Karolinska Focus on basic All psychologist No fee, part of the curricu-
is normally included in the students sleep researchers, gist programmes, Institutet psychologist CBT-I. students have lum for the psychologist
university-level psychologist experts in CBT-I between 0.5 and programme: Basics of sleep– Within the supervised programme. Private 2-day
programmes for students 3 days specifi- wake regulation, function Karolinska clinical work courses €300–600
on the CBT-track. Two-day cally for sleep and of sleep, psychoneuroim- Institutet with a small
courses in CBT-I are offered CBT-I, in addition munology of sleep, screening psychologist number of
on an irregular basis by pri- to the general and diagnosing insomnia; programmes, lec- patients. Many
vate and public institutes and specific CBT specific CBT-I methods (sleep tures/discussions see at least one
training within the diary use, sleep restriction, on adaptations patient with
programme stimulus control); how to of CBT, but not sleep problems
use general CBT techniques specifically on (insomnia) as
in the context of insomnia CBT-I part of their
(relaxation, cognitive tech- problem
niques, mindfulness, etc.);
the evidence base for CBT-I;
limitations of CBT-I; informa-
tion on pharmacological
treatments and medication
tapering within CBT-I

Switzerland Currently no official CBT-I course is offered in Switzerland

The Several courses are delivered Psychology Sleep specialists Mostly 1–2 days CBT-I rationale and methods Briefly Interactive Ranging from €245 to 600
Netherlands at tertiary care sleep centres students, (GZ-psychologist Insomnia diagnostics as well as teaching, role The participant, or the
In-company training delivered psychologists, or somnologists) screening/characteristics of playing, employer
by sleep specialists for third- GZ-psychologist, other sleep disorders supervision on may pay part of the total
party education institutes clinical (neuro) own cases cost of the education
Courses within the curriculum psychologists, possibilty for program
of a psychology Master’s de- psychiatrists, intervision
gree or post-Master’s training nurse practitioners, after course,
Sleep street training for GPs: GP's Videos
a programme which aims to
instruct GP's and practice as-
sistants for mental healthcare
to evaluate and treat insom-
nia (complaints) in primary
care. The programme has
been developed by several
(healthcare) organizations

(Continues)
BAGLIONI et al.

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BAGLIONI et al. | 17 of 29

Several CBT-I courses are currently offered in European coun-

and university run courses

What is the participation's

no personal cost through

their NHS trusts. Private
able to access training at
tries. These are generally given in sleep centres or universities and

will vary in their pricing

NHS employees may be
offered to psychologists, specialist physicians and psychotherapists,
although GPs, nurses and/or other health professionals may also

fee? Who pays?

be included. Other than in Norway (one 2-day course), no courses
specifically for GPs are offered. Trainers are sleep experts, both
psychologists and medical doctors, or CBT experts with knowl-
edge of insomnia. Most courses last approximately 2 days and teach

themselves and
case examples.
Do the course/s

core aspects of CBT-I, including CBT-I strategies and the basics of

through these
role plays and

clinical teams

is not by and
Some courses

ised/offered
large organ-
may include

done within
Supervision
supervision?

is generally
and/or case

insomnia and other sleep disorders. The courses often include a

interactive

courses
teaching
include

module on pharmacological treatment. Three courses have a long

duration, one specifically on CBT-I, one including different aspects
of psychological treatment for sleep disorders and one as a mod-
on adult and older
training seems fo-
lifespan or special

cused principally
include teaching
Does the course

ule of a Sleep Medicine graduate programme. In Italy, an intensive

adult patient
adaptation of

populations
CBT-I for the

populations?

1-year CBT-I course has been offered at the “Sapienza” University of

May do but
on clinical

Rome since 2019. The course includes 12 modules (covering basics

of sleep and sleep disorders, screening and diagnosis of insomnia,
pharmacological treatments, sleep education, CBT-I methods, re-
nents (e.g., SRT titration, SCT
models of insomnia and diag-
nostic criteria, CBT-I compo-

and role plays, screening for

laxation, mindfulness techniques, techniques from acceptance and

for treatment, case studies
on sleep–wake regulation,

instruction) and rationale

May include information

commitment therapy, insomnia across the lifespan: basic and clin-

other sleep disorders

ical aspects, insomnia across women's lifespan: basic and clinical

What is taught?

aspects, and efficacy and limitations of CBT-I) of 8 hr each, distrib-

uted over 12 months. In Austria, a three-semester Sleep Coaching
Course is offered at the University of Vienna. The course includes
modules on sleep education, sleep hygiene, relaxation, self-hypno-
sis, dream intervention (including treatment of nightmares), basics of
Mostly 1 or 2-day

Gestalt therapy (including awareness training) and pharmacological

Duration of the

treatment. Finally, at the University of Oxford in the UK, an online

workshops

2-year part-time MSc/PgDip in Sleep Medicine was established in

course/s

2016. One of the eight modules is on insomnia, with an emphasis

on CBT-I as the preferred intervention. As well as the CBT-I module
psychologists and
Typically, clinicians

being available online as “standalone” CPD (continuing professional

with expertise in
course/s given?
By whom is the

CBT-I (princi-

psychiatrists)

development), the University of Oxford also offers a 2-day CBT-I

pally clinical

masterclass course delivered in person. All courses listed in Table 4

include some form of interactive teaching and some of them provide
case supervision. The fee is generally paid by the participants. The
list provided in Table 4 is not, however, comprehensive as it is cur-
medical doctors,
course/s offered?

and other health

CBT therapists,
To whom is the

rently difficult to gain a clear overview of all CBT-I trainings offered

professionals
Clinical psy-
chologists,

across Europe. Furthermore, current provision is not yet sufficient

and varies consistently across countries. Current courses do not yet
address the different levels of competencies between profession-
als in terms of both administering and being able to teach CBT-I. A
therapy training institutes and
associations (e.g., BABCP) and

module on insomnia; teaching

hoc basis through the individ-
ual NHS trusts, psychological

modules on doctoral training

Sleep Medicine contains one
offered throughout the UK.

of Oxford Online Course in

universities (e.g. University
Several workshops and brief

Most are offered on an ad-

main objective of the CBT-I Academy is to promote a coordinated

courses for trainee clinical
training days on CBT-I are

European system of CBT-I training. which will be formed of specialist

CBT-I practitioners and trainers. Furthermore, the Academy aims to
psychologists)

compile information on current CBT-I offered in Europe and to pro-

(Continued)

vide a comprehensive list of accredited courses.

Course/s

6 | TH E C B T- I AC A D E M Y
TA B L E 4

Kingdom
Country

United

The Task Force group of the European Sleep Research Society and the
European Insomnia Network met in May 2018 in Freiburg (Germany)
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18 of 29 | BAGLIONI et al.

and developed this outline proposal to establish the European CBT-I steps are suggested in the model, gradually increasing the expertise
Academy to enable a Europe-wide system of homogeneous CBT-I of the therapist and adaptation of the intervention to the needs of the
training and training centre accreditation. Deliberations concerned: patient. These three steps range from “individual or small group CBT
ingredients of CBT-I, how CBT-I should be administered, how to inte- delivered by a graduate psychologist” to “individually tailored CBT de-
grate CBT-I training into European healthcare systems, preconditions livered by a clinical psychologist” to “expert CBT delivered by behav-
and qualifications for health professionals to teach CBT-I, the way in ioural sleep medicine expert”. The purpose of the stepped-care model
which CBT-I should be taught and to whom it should be taught. is twofold: first, to help individual patients find the best approach for
them, and second, to develop a high-quality service at a population
level that is both effective and economically viable.
6.1 | Ingredients of CBT-I Here we propose a simplification of the model proposed by Espie
(2009) and Espie et al. (2013), which could be adapted for use within
CBT-I should be defined as a family of evidence-based interventions, a given national health system. A first level includes prescriptions
including behavioural, cognitive and educational interventions. Just from GPs for behavioural treatment of insomnia or evidence-based
as pharmacotherapy is a methodology with many drugs, CBT-I is a dCBT-I developed by an expert therapist and promoted by well-
system of therapy, not a single therapy. This suggests that the term known health systems. It could be that the GP or other professional
CBT-I is used as a convenient label but that treatment could include recommends, or in some way ‘prescribes’, this solution; or it could
different evidence-based psychological interventions, such as moti- be that the responsible health authority (such as the NHS in the UK)
vational and emotional strategies, which are currently less well de- promotes ready access even more directly. The clear intention, how-
fined or standardized. Recently, other psychotherapeutic approaches, ever, would be to develop services in such a way that CBT-I becomes
such as mindfulness and hypnotherapy, centring on powering emo- available at a scale equivalent to medication. The important point is
tion-regulation skills, have been empirically investigated (Gong et al., that patients and their GPs would have immediate access to CBT-I.
2016; Kanen, Nazir, Sedky, & Pradhan, 2015; Lam et al., 2015) and Of course, this is an ideal model, would take time to develop and will
acceptance and commitment therapy has been proposed as a pos- initially be based, where a clinician is involved, on appraisal of the pa-
sible intervention for non-responders to CBT-I (Hertenstein et al., tient's needs, preferences about formats of engagement, as well as
2014). Together with the main strategies listed in Table 2, knowledge what is on offer locally. Ideally, such an insomnia care pathway would
on sleeping medication tapering or withdrawal should be considered also involve patients somehow being reviewed after 4–6 weeks to
a component of CBT-I. The insomnia research literature provides a ascertain their degree of treatment response.
strong evidence base, with proof of efficacy and clinical effective- Based on patients' response to this initial step (GPs’ prescriptions
ness, both for multicomponent CBT-I and also for single components, or dCBT-I), complexity or patients' preference and what is available
such as sleep restriction, stimulus control and relaxation therapies, locally, two higher levels of treatment are then suggested: (a) man-
and to a lesser extent cognitive therapies. The decision as to whether ualized CBT-I delivered by a trained therapist, either face to face
to apply CBT-I as a ‘package’ intervention or as individual compo- or via the internet in small groups, or (b) individually tailored ther-
nents should be at the discretion of expert clinicians or defined in a apy delivered by a CBT-I expert face to face individually or through
stepped-care model, as discussed in the next paragraph. group therapy. The use of dCBT-I programmes could also be useful in
these stages because one goal of CBT is to enable patients to imple-
ment effective therapy components at home in between traditional
6.2 | How CBT-I should be administered treatment sessions. The stepped-care model, therefore, reflects a
pyramid of therapeutics gradually increasing the level of therapist/
6.2.1 | A stepped-care approach to insomnia clinician expertise and time commitment. Stepped care therefore
conserves these most expensive of human resources for those situ-
In order to increase the likelihood of sufficient evidence-based thera- ations where they are most required, whilst optimizing the volume
peutic provision for insomnia across Europe, we suggest the adoption of patients who can be successfully and effectively treated. It is not
of a stepped-care approach inspired by the model proposed by Espie necessary that each patient tries all steps, but rather the allocation
(2009) and Espie, Hames, and McKinstry (2013). This model promotes to the best-fitting therapy would depend on insomnia severity or
the idea that the greatest numbers of patients could be managed complexity, therapist/clinician judgement and/or patient preference.
through readily accessible self-help therapies, including dCBT-I via The model is summarized in Figure 1.
the internet and mobile devices, as well as books and audio resources.
There is now a substantial evidence base for dCBT-I and such ap-
proaches have been incorporated into clinical guidelines (e.g., Wilson 6.3 | How to integrate CBT-I training into the
et al., 2019). Dependent upon treatment response, clinical complexity healthcare systems in Europe?
and/or treatment preference, patients may be ‘stepped-up’ to a more
time and resource-intensive level of CBT-I; for example, including It is clear that, given the heterogeneous situation of healthcare
manualized treatment delivered by trained therapists. Three further in Europe, no unified training model can be proposed. We will,
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 19 of 29

F I G U R E 1 An evidence-based
stepped-care model for CBT-I.

Individual tailored CBT-I

administered by
psychotherapists
qualified as CBT-I
experts. At this step,
the therapist should be
highly familiar with all
CBT-I strategies, as
well as other innovative
interventions.

Assessment/ Review/discharge/
Manualized CBT-I: delivered using internet therapy, face-
Allocation to-face group therapy, individual therapy administered by Refer on
health professionals qualified as CBT-I experts. Ideally,
different programmes/protocols should exist in all European
languages for all possible target populations. These should
include different CBT-I components and eventually
motivational/emotional additional strategies.

GPs: basic information on sleep, insomnia and CBT-I core strategies (sleep restriction
and stimulus control) for all possible populations.

Digital CBT (dCBT) or Internet CBT (ICBT) for insomnia: developed by an expert
therapist and supported through an established national health system. This should
include different CBT-I components.

+ Self-administered CBT-I delivered by booklet, CD/DVD* (made by health

professionals qualified as CBT-I experts) recommended by GPs or dCBT
programmes.

instead, suggest an ‘ideal’ generic model, which has the potential to is, CBT-I clinicians should be also fully licensed and insured for all
be adapted to the healthcare system of each respective European of their working healthcare practice and should practice within the
country. boundaries of their professional training. The important caveat here
Here we provide a brief overview of what has been published is that a CBT-I practitioner must already possess a license to practice
to date about how to integrate CBT-I into general healthcare. In clinically, and that simply undertaking a CBT-I course does not in it-
Appendix 1, a list of relevant publications directed at the general self confer a license to see patients.
population in different European languages is provided. There is a parallel here with medical management in that a li-
Perlis and Smith (2008 speculated upon how to make CBT-I ser- censed physician is intrinsically qualified to prescribe medication, in-
vices more widely available, with a focus on the USA. Their approach cluding that not yet developed or distributed, but is likely to require
led to the establishment of a behavioural sleep medicine specialty further orientation to and training in a particular therapy or thera-
within the broader sleep medicine field. The behavioural sleep medi- peutic approach. In the same way, a licensed clinical or practitioner
cine provider is able to offer CBT-I, alongside other behavioural sleep psychologist, psychotherapist or psychiatrist is already qualified to
treatments and expertise, and is affiliated to AASM-accredited sleep see patients and to take clinical responsibility based on their national
centres (Perlis & Smith, 2008). Curricula for CBT-I are developed and laws and professional regulations, and is best placed to extend his or
endorsed by the AASM and the BSM Committee. The authors rec- her skills into the CBT/insomnia area.
ommended the development of intensive training opportunities for
CBT-I. When one considers the ubiquitous availability of second-line
treatments such as hypnotics (numbering billions of prescriptions 6.4 | Preconditions for health professionals to teach
worldwide), it is clear that CBT-I has a very long way to go to offer CBT-I
patients the choice of an alternative treatment path.
It is our suggestion that, in Europe, the CBT-I Academy should One aim of the CBT-I Academy is to establish a qualification pro-
not be exclusively tied professionally to the field of sleep medicine. cedure; that is, professionals intending to practise CBT-I should be
Rather, and necessarily, there should be strong connections to the adequately trained. This academy approach would be expected to
field of cognitive and behavioural psychotherapy/psychiatry. Thus, facilitate an increase in the number of health experts in CBT-I, to
expert providers of CBT-I would by definition already be health pro- improve focus on effective clinical practice in insomnia care and to
fessionals with a recognized license to provide clinical psychology/ reduce treatment variability across clinicians. In order to inaugurate
psychotherapy/mental healthcare, but who have further to that the academy, at the end of 2017 interested insomnia expert clini-
obtained qualification and the associated supervised education cians and members of the European Insomnia Network (EIN) were
and practice in sleep medicine and sleep clinical psychology. That invited by e-mail to take part in the initiative. Attendees worked
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20 of 29 | BAGLIONI et al.

together to prepare the present manuscript (the authors of this well-established CBT-I professionals in their respective countries.
paper). At the first Academy meeting, which took place in Freiburg, Further first-generation CBT-I expert clinicians and trainers could
Germany, on May 4th, 2018, the authors of the present paper and be added to the Academy if they are established CBT-I clinical pro-
founding members of the Academy were declared first-generation fessionals with widely recognized expertise in CBT-I clinical and re-
trainers (“grandmothers and grandfathers”) qualified as CBT-I train- search aspects and are sponsored by the founding members.
ers and practitioners. Figure 2 provides a list of the founding mem- Second-generation CBT-I expert clinicians and trainers will be
bers of the Academy. A Steering Committee was elected during health professionals who (a) have a licence to practice clinically and
the inaugural Freiburg meeting, comprised of two chairs (D.R. and (b) have attended an accredited CBT-I course. Thus, they will be able
C.A.E.) and five members (E.A., C.B., S.J., A.S. and B.H.). The CBT-I to practise CBT-I as a form of psychological treatment.
Academy Steering Committee will have the task of reviewing and Ideally, three levels of expertise should be considered.
approving course proposals, creating a European register of CBT-I
practitioners (by merging data from national registers; see below) 1. Expert level: This level of expertise would allow licensed health
and coordinating new initiatives to promote CBT-I education across professionals to be expert CBT-I practitioners, who are able
Europe. to conduct individually tailored CBT-I. This level of expertise
We assume that until this point no European country has a gov- is suited to clinical and healthcare psychologists, psychothera-
erning body controlling whether or not somebody is competent to pists, psychiatrists and sleep experts whose CBT-I expertise is
practice CBT-I. On the other hand, most European countries have core to their professional clinician level knowledge. They would
governing bodies controlling who is permitted to practise clinical be expected to have attended a high-quality, certified course,
psychology or psychotherapy, or to call themselves a psychother- endorsed by the Academy, and have followed at least three
apist. In establishing the CBT-I Academy our starting assumption cases over the course of 3–6 months under the guidance of
is that eligible individuals have a legitimate license to practice in a a CBT-I qualified expert. CBT-I practitioners with certificated
clinical context. That is, CBT-I skills can only be an extension of a knowledge in sleep medicine and sleep clinical psychology could
person's practising certificate. It is that certification (e.g., as a phy- operate also as CBT-I trainers and supervisors.
sician, clinical psychologist, health or practitioner psychologist, or 2. Advanced level: This advanced level of expertise would allow
psychotherapist) that provides the governance structure enabling a health professionals to be trained therapists who could conduct
person to see patients, and thus to be regulated as a professional in manualized CBT-I delivered face to face or digitally, under the
their country of practice. The first-generation European trainers all supervision of an expert-level CBT-I supervisor. This level of ex-
meet these criteria, in addition to which they have recognized ex- pertise would be suited to clinical and health psychology master's
pertise in CBT-I, being members of the European Insomnia Network graduates and psychiatrists in training and, in some countries,
(EIN). Moreover, the foundation of the Academy could benefit from nurses or social workers. To be entitled to an advanced level of
the collaboration with world-leading experts in CBT-I from the USA. expertise, practitioners would be expected to have attended a
The founding members have been selected as European repre- certified course, endorsed by the Academy, including interactive
sentatives; they also represent and are in close contact with other and supervising activities.

THE EUROPEAN CBT-I ACADEMY:

AN INITIATIVE OF THE EUROPEAN INSOMNIA NETWORK

STEERING COMMITTEE
Chairs: Dieter Riemann (Germany), Colin A. Espie (UK).
Members: Ellemarije Altena (France), Chiara Baglioni (Italy, Germany), Susanna Jernelöv (Sweden),
Angelika Schlarb (Germany), Brigi„e Holzinger (Austria).

First (founding) members of the CBT-I Academy: Ellemarije Altena (France), Chiara Baglioni (Italy,
Germany), Bjørn Bjorvatn (Norway), Kers‰n Blom (Sweden), Kristoffer Bothelius (Sweden), Alessandra
Devoto (Italy), Colin A. Espie (UK), Lukas Frase (Germany), Dimitri Gavriloff (UK), Tuuliki Hion (Estonia),
Andrea Hoflehner (Austria), Brigi„e Holzinger (Austria), Heli Järnefelt (Finland), Susanna Jernelöv
(Sweden), Anna F. Johann (Germany), Caterina Lombardo (Italy), Christoph Nissen (Switzerland), Laura
Palagini (Italy), Geert Peeters (The Netherlands), Dieter Riemann (Germany), Angelika Schlarb
(Germany), Kai Spiegelhalder (Germany), Adam Wichniak (Poland), Birgit Högl (Austria).
F I G U R E 2 List of founding members
Non-European Members: Michael L. Perlis (USA), Donn Posner (USA). of the European CBT-I Academy.
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 21 of 29

3. Foundation level: This level of expertise is specifically suited to

ties, e.g. role playing, work in small groups,

GPs and should reflect more basic knowledge of CBT-I behav-

Courses should include interactive activi-

Courses should comprise clinical phases

discussion of difficult situations. Case

Courses could be given face-to-face or

ioural strategies and sleep medicine obtained through attendance

including at least three cases with

at a CBT-I Academy certified course.

supervision should be offered.

The Academy will identify these three levels of expertise by
classifying endorsed courses following this three-level categoriza-
tion. As a consequence, trained CBT-I practitioners, depending on

Teaching methods

All expertise levels:

the course(s) attended, will then be recognized by the Academy as

supervision.
Expert level:
CBT-I practitioners at the expert, advanced or foundation level of
expertise. After publication of this paper, the Steering Committee

online
will create a register and an associated website containing all the rel-
evant information on the processes and initiatives of the Academy.

Advanced and Expert levels (advanced knowledge

2. Advanced knowledge on sleep and insomnia.

3. Motivational and emotional CBT-I strategies.
In this way, the registered list of founding, first-generation and sec-

3. Advanced knowledge on CBT principles and

1. Advanced knowledge in sleep medicine and
3. Stepped-care model and allocation issues.

5. Knowledge on sleep medication/tapering.

ond-generation members, their qualifications and their levels of

1. Basic knowledge in sleep medicine and

CBT-I expertise will be in the public domain.

2. Core behavioural CBT-I strategies.

1. Individually tailored treatment.

2. Cognitive CBT-I components.
6.5 | The way in which CBT-I should be taught

intervention strategies.
4. Basic CBT principles.
Table 5 summarizes the CBT-I course criteria identified by the

of CBT is required):
Teaching contents

All expertise levels:

Academy. Courses for aspiring CBT-I practitioners of any level should
be of a minimum of 2 days in duration and may be offered to peo-

Expert level:
insomnia.

insomnia.
ple with pre-existing qualifications in different healthcare areas with
Template for criteria of European courses for CBT-I, which will be supported by the Academy

a recognized licence to see patients in mental healthcare contexts.

Courses should include teaching on sleep itself, on insomnia disorder

Expert level: Psychotherapists, psychiatrists, clinical psycholo-

and its assessment, as well as on core CBT-I components (such as
license to provide clinical psychology/ psychotherapy/ men-
tal health care, who received qualified and essential further

psychologists, sleep experts, clinical or healthcare master's

sleep experts for whom insomnia and its treatments is part
gists, healthcare psychologists, practitioner psychologists,

Foundation level: GPs (similar modules could be conceptual-

care practice and should practice within the boundaries of
behavioural and cognitive intervention) and additional CBT-I com- should be also fully insured for all of their working health-
All expertise levels: Health professionals with a recognized

cal psychologists, healthcare psychologists, practitioner

supervised education in sleep medicine. CBT-I clinicians

ponents (such as emotional and motivational strategies). Courses

Advanced level: Psychotherapists, psychiatrists, clini-

ized for pediatricians, gynaecologists, or geriatrics).

directed at a foundation level of expertise may focus specifically on

psychologist graduates; nurses, social workers.

CBT-I behavioural components. Courses should include conceptual
elements covering sleep mechanisms and pathophysiology; theo-
retical underpinnings of insomnia development and maintenance; of their core professional expertise.
Courses which will provide a European Certification for CBT-I practitioners

formulation of CBT as an intervention. The stepped-care model of

insomnia service delivery may be also taught. Courses should cover
their professional training.

basic principles of CBT therapy. A module on sleep medication and

tapering off/withdrawing medication should be included. Depending
on national laws, some health professionals may be prohibited from
discussing any change in medication status with patients as they do
Participants

not have the necessary professional competences. Nevertheless,

any health professional dealing with patients with insomnia at a
clinical level should be aware of sleep medication mechanisms and
effects during intake and withdrawal. Courses should be organized
practitioners

to be interactive (e.g., role playing, work in small groups and difficult

level CBT-I

situations) and case supervision should be offered. It is possible that

Teachers

Expert-

some elements of the CBT-I programme could involve interactive

training and be offered online.
For the expert level, courses should comprise extensive teach-
term or comprise

refresher course

ing of the individual tailoring of treatment, advanced knowledge on

courses should
be either long-

after circa half

At least 2 days

a follow-up/

sleep medicine, insomnia and CBT principles, and clinical experience

Expert-level
TA B L E 5

Duration

(e.g., at least three case studies), and either have a long-term dura-
a year

tion or include a follow-up/refresher course to discusses cases.

Trainers should all be expert-level CBT-I professionals.
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
22 of 29 | BAGLIONI et al.

These criteria are not intended to be overly prescriptive, neither summarized the current availability of training in CBT-I. Despite
are they completely comprehensive. However, we have attempted differences between countries, the general conclusion is that ac-
to set expectations and minimum standards for what may be re- cess to CBT-I for patients and training in CBT-I for health profes-
garded as necessary and feasible. sionals are poor and require standardization. Thus, as founders
of the CBT-I Academy, we have proposed minimal criteria that
should be met in each country to provide adequate CBT-I training
6.6 | How courses may become endorsed at differing expertise levels for health professionals, alongside a
stepped-care approach to service delivery. This is also expected
It is proposed that the qualification and training standards set by to impact clinical research standards. It is desirable that clinical
the Academy will first be approved by the ESRS and its special in- trials involving CBT-I will involve CBT-I trained practitioners. This
terest group in insomnia, the European Insomnia Network (EIN). would impact very positively on the quality and comparability of
Once this is the case, the Academy will be in a position to invite CBT-I clinical studies across Europe. A closer relationship between
submissions with a view to reviewing them against training criteria clinical practice and research contexts would also be expected to
and then to provide approval. It is hoped that this process will en- add to the current evidence base of CBT-I, particularly with regard
courage organizations, institutions and local societies to develop to the diverse groups of patients seen clinically, including chil-
high-quality curricula and that the ESRS imprimatur of endorse- dren and young people, pregnant women, women at postpartum,
ment will encourage health professionals to apply for and to com- women going through the menopause, shift workers, those with
plete CBT training. disabilities and retirees.
Appendix 2 comprises a form that could be used for submitting
course proposals. The form will be uploaded and updated on the ESRS AC K N OW L E D G E M E N T S
website. To support the process, it is suggested that each European The authors would like to express their gratitude to the European
country designates a central National CBT-I Training Centre (i.e., Sleep Research Society and its current board members (Walter
centre of excellence for CBT-I). For countries where there are al- McNicholas, Tiina Paunio, Tom de Boer, Lino Nobili, Raffaele Manni,
ready several established centres, a collaborative network could Hans-Peter Landolt and Pierre-Herve Luppi) for their endorsement
be formed to support education and dissemination of CBT-I. These and the financial support provided (travel costs for the Freiburg first
centres should have on board a medical specialist (general medicine, meeting, 4 May, 2018). We would like to further thank the mem-
psychiatry, neurology or sleep medicine) or a clinical psychologist/ bers of the executive committee of the Associated National Sleep
psychotherapist who is accredited to practice medicine/psychiatry/ Societies (Barbara Strazisan, Oana-Claudia Deleanu, Lyudmila
psychotherapy in her/his given country. Furthermore, these persons Korostovtseva, Samson Khachatryan and Ysbrand D. van der Werf).
should have accredited expertise to practise and supervise psycho-
therapy and CBT-I. Each country should also establish a national C O N FL I C T O F I N T E R E S T
register of CBT-I practitioners. This could be achieved in collabora- CAE is co-founder and Chief Medical Officer of Big Health of the
tion with the national sleep society or national clinical psychology company that makes the digital CBT intervention, Sleepio. He has
or cognitive behavioural therapy associations. In Appendix 3 a form shares in the company and receives a salary from the company. DG
for national registers is provided. The national registers also will be is the director of a private CBT-I clinic and sleep medicine consul-
uploaded and updated on the ESRS website. tancy, Sleep Well Oxford Ltd. He is also a salaried employee of and
Clinical Engagement Lead for non-employee sleep medicine con-
sultant for Big Health (Sleepio), with shares in the company. BH re-
7 | CO N C LU S I O N S ports personal fees from Abbvie, Lundbeck, Janssen Cilag, Novartis,
Mundipharma, Otsuka, Illy, Inspire and AoPOrphan, personal fees
The European guidelines for insomnia (Riemann, Baglioni, et al., from Axovant, Benevolent Bio, Roche and AoPOrphan, and other
2017) highlighted that “cognitive behavioural therapy for insom- fees from Habel Medizintechnik Austria, outside the submitted
nia, although being the first-line treatment for insomnia, is not work. DR reports personal fees from Heel Germany, personal fees
easily available. It is assumed that only a minority of patients with from different publishers, personal fees from the Freiburg Training
chronic insomnia will receive this treatment in Europe. Thus, the Institute for Behaviour Therapy, and personal fees from different in-
widespread implementation of CBT-I will be a major challenge for stitutes, hospitals, etc., in Germany, outside the submitted work. All
the future.” In response to this statement, European CBT-I experts other authors have nothing to disclose.
from 12 different countries have instituted the CBT-I Academy,
with the aim of establishing and promoting Europe-wide stand- AU T H O R C O N T R I B U T I O N S
ards for CBT-I training and training centre accreditation. The in- The first and the last authors worked together in every phase of the
tention is to substantially improve the availability of high-quality manuscript preparation. All authors participated in the first meet-
CBT-I in Europe within the next 10 years. In this paper, we have ing of the European Academy for Cognitive Behavioural Therapy for
highlighted the very limited availability of CBT-I across Europe and Insomnia, which took place in Freiburg, Germany, on the 4th May,
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
BAGLIONI et al. | 23 of 29

2018, contributed information on a national level and to the manu- practice guideline by the American College of Physicians. Annals of
Internal Medicine, 165(2), 113–124.
script writing.
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BAGLIONI et al. | 27 of 29

APPENDIX 1

R E L E VA N T B I B L I O G R A P H Y

CBT-I text books or self-help books available in European languages

Backhaus, J., Riemann, D. (2003). Poruchy spanku (Slovakian ed.). Trencin: Hogrefe Verlag.
Bjorvatn, B. (2012). Søvnsykdommer. Bergen: Fagbokforlaget.
Coradeschi, D., & Devoto, A. (2012). Insonnia. Strumenti di valutazione. Trento: Erickson.
Crönlein, T. (2013). Primäre Insomnia. Göttingen: Hogrefe.
Dagnaux, S. (2016). Prendre en charge l’insomnie par les TCC. Paris: Dunod.
Devoto, A., & Violani, V. (2009). Curare l'insonnia senza farmaci. Metodi di valutazione e intervento cognitivo-comportamentale. Roma: Carocci Faber
ediotre.
Devoto, A. (2011). Dormire come un bambino. Come aiutare lo sviluppo naturale del sonno dei vostri figli. Cinisello Balsamo: San Paolo Editore.
Goulet, J., Chaloult, L., & Ngo, T. L. (2013). Guide de pratique pour le traitement de l’insomnie. Retrieved from https​://tccmo​ntreal.files.wordp​ress.
com/2014/01/guide-de-prati​que-insom​nie-final-21sept-2013.pdf
Harvey, A. G., & Buysse, D. J. (2018). Treating sleep problems – A transdiagnostic approach. New York: Guilford Press.
Hauri, P. J. (1991). Case studies in insomnia. New York: Plenum Medical Book Company.
Hertenstein, E., Spiegelhalder, K., Johann, A., & Riemann, D. (2015). Prävention und psychotherapie der insomnie. Stuttgart: Kohlhammer.
Holzinger, B., & Klösch, G. (2013). Schlafcoaching. Wien: Goldegg Verlag.
Holzinger, B., & Klösch, G. (2018). Schlafstörungen – Psychologische behandlung und schlafcoaching. Heidelberg: Springer-Verlag.
Järnefelt, H., & Hublin, C. (2018). Työikäisten unettomuuden hoito. Työterveyslaitos.
Kajaste, S., & Markkula, J. (2011). Hyvää yötä. Apua univaikeuksiin. Helsinki: Kirjapaja.
Lichstein, K., & Morin, C. M. (2000). Treatment of late-life insomnia. London: Sage Publications Inc.
Manber, R., & Carney, C. E. (2015). Treatment plans and interventions for insomnia. A case formulation approach. New York, London: Guilford
publications
Morgan, K., & Closs, J. S. (1999). Sleep management in nursing practice. London: Churchill Livingstone.
Morin, C. M. (1993). Insomnia. New York, London: Guilford Press.
Morin, C. M., & Espie, C. A. (2004). Insomnia - a clinical guide to assessment and treatment. New York: Springer.
Müller, T., & Paterok, B. (1999). Schlaftraining. Göttingen: Hogrefe.
Perlis, M. L., Jungquist, C., Smith, M. T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia. New York: Springer.
Royant-Parola, S., Brion, A., & Poirot, I. (2017). Prise en charge de l’insomnie. Paris: Elsevier Masson.
Spiegelhalder, K., Backhaus, J., & Riemann, D. (2011). Schlafstörungen (Fortschritte der Psychotherapie). Göttingen: Hogrefe.
Verbeek, I., & van de Laar, M. (2014). Protocollen voor de GGZ: Behandeling van langdurige slapeloosheid. Houten: BSL.

CBT-I self help books

Adrien, J. (2014). Mieux dormir et vaincre l’insomnie. Paris: Larousse.
Bjorvatn, B. (2013). En håndbok til deg som sover dårlig. Bergen: Fagbokforlaget (2. utgave).
Ellis, J. (2017). The one-week insomnia cure. London: Penguin Random House.
Espie, C. A. (2010). Overcoming insomnia and sleep problems. A self-help guide using cognitive behavioural techniques. London: Robinson.
Lemoine, P. (2017). Dormir sans médicaments, ou presque. Pocket.
Lemoine, P. (2018). Dormez! Le Programme complet pour en finir avec l'insomnie. Hachette Pratique.
Jacobs, G. D. (1998). Say good night to insomnia. New York: Holt and Company.
Jernelöv, S. (2007). Sov gott! Råd och tekniker från KBT. Stockholm: Wahlström and Widstrand.
Morin, C. (2009). Vaincre les ennemis du sommeil. L’homme.
Paiva, T. (2008). Bom sono, boa vida. Cruz Quebrada: Officina do livro.
Pihl, S., & Aronen, A.-M. (2016). Unen taidot – löydä uni ilman lääkkeitä. Helsinki: Kustannus Oy Duodecim.
Riemann, D. (2016). Ratgeber Schlafstörunge. Göttingen: Hogrefe (2. Auflage).
Royant-Parola, S. (2002). Comment retrouver le sommeil par soi-même. Odile Jacob.
Verbeek, I., & Klip, E. (2015). Hulpboek Slapeloosheid. Amsterdam: Boom.

CBT-I web-based approaches

Shuteye (http://www.myshu​ti.com/)
Sleepio (https​://www.sleep​io.com/)
SleepWell (http://inter​netps​ykiat​ri.se/behan​dling/​somnp​roblem-insomni)
I-Sleep: (https​://www.i-sleep.nl/)
Somnio (https​://www.somnio.nl)
Somnovia (https​://dak.somno​via.de/)
Therasomnia (https​://www.thera​somnia.com/)
Web-based therapy for insomnia (https​://www.miele​nterv​eysta​lo.fi/netti​terap​iat/lahet​eohje​et/Pages/​unett​omuud​en_lahet​teet.aspx)
 13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
28 of 29 | BAGLIONI et al.

APPENDIX 2
C B T- I C O U R S E P R O P O S A L FO R M ( TO B E S U B M I T T E D TO C B T- I AC A D E M Y S T E E R I N G C O M M I T T E E )
INFORMATION ON THE COURSE

Name of the course

Person(s) in charge
Language of the course
Qualification of the
person(s) in charge
Institution in which the
course will be delivered

Brief description of the

course

Full duration of the

course
Modality of the course
(e.g. face-to-face or
online)
Participants (to whom is
the course offered)

CONTENTS OF THE COURSE

Core CBT-I components (bedtime restriction and stimulus control)

Cognitive CBT-I components
Basic element of sleep mechanisms
Insomnia pathophysiology
Additional CBT-I components (motivational and emotional interventions)
Modules for tapering medication
Basic knowledge of CBT-I stepped care model
Individual tailored treatment for patients with insomnia disorder
Other: Specify:

TEACHERS
Provide a full list of the course's teachers, their qualification and what topic they teach.

INTERACTIVE ACTIVITIES AND CASE SUPERVISION

Provide a detailed description of how courses will be made interactive and how case supervision will be included and done.
13652869, 2020, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jsr.12967 by Readcube (Labtiva Inc.), Wiley Online Library on [28/11/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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C B T- I N AT I O N A L R EG I S T E R ( TO B E S U B M I T T E D TO C B T- I AC A D E M Y S T E E R I N G C O M M I T T E E )

City
Institution
Qualification for
CBT-I practice
Academy
member
(yes/no)
CBT-I
Qualification
Country

Name
APPENDIX 3
BAGLIONI et al.