CBT-I

Making Space for the Quality Care: Opportunities for Technology in Cognitive Behavioral Therapy for Insomnia

Authors: Haining Zhu, Yuhan Luo, Eun Kyoung ChoeAffiliation: Penn State UniversityYear: 2017

Role: Project lead

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A Brief Introduction

Background: Insomnia can drastically affect individuals’ overall well-being and work performance, with substantial costs to society and industry. Cognitive behavioral therapy for insomnia (CBT-I) is a psychotherapeutic treatment, which requires patients to track sleep and share the data with CBT-I clinicians. However, the number of specialists who can provide CBT-I limits the number of patients who can receive it.

Goal: In this study, we aim to identify opportunities to leverage technology to assist clinicians in delivering quality and effective CBT-I services to broader populations.

Method: Toward this goal, we conducted formative studies, including 11 CBT-I clinic observations and 17 semi-structured interviews, to understand the current workflow of CBT-I and associated challenges.

Result: We discuss how technology can assist clinicians and patients throughout the various steps of CBT-I workflow while addressing some of the identified challenges, and how technology can facilitate clinicians and patients to build quality therapeutic relationships.

Sleep is Important

Sleep is important, everybody sleeps, and most of us spend approximately a third of our lifetimes sleeping. However, more than 30% of people in the states have insomnia, which is approximately 50 to 70 million Americans. For people older than 65, this number increases to 50%. 10% of the general population has a chronic insomnia disorder which means insomnia occurs three times per week, for at least three months. Approximately 95% of Americans experience insomnia during their lives. Sleep problems hinder overall well-being and work performance. Every year, hundreds of billions of dollars are lost because of direct and indirect medical expenses, such as accidents, or productivity losses.

Cognitive Behavior Therapy for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a great way to treat insomnia. It treats the factors responsible for individuals sleep problems through behavioral modifications, rather than prescription medications; it has fewer known side effects and longer-lasting effects than drugs alone. Currently, we have 2 ways to provide CBTI: in-person CBT-I, and computerized CBT-I (cCBT-I).

The advantages for in-person CBT-I are that patients often have higher motivation, thus higher adherence rates to the CBT-I program. The disadvantages is that there are only 300 certificated CBT-I providers worldwide, which limits treatment accessibility. Moreover, in-person CBT-I is expensive and time consuming.

There is no human involvement in cCBT-I. Patients who opt into cCBTI need to be accountable to themselves, this option requires high self-control to stick to the cCBTI instructions and to make the therapy work. The advantages for cCBTI are more people can get CBTI treatment in more locations, and it is much cheaper than in-person CBTI. The major disadvantages are high dropout rates, and low adherence rates.

Both of the ways to provide CBTI has pros and cons, a better way to provide CBTI might be to combine in-person CBTI and computerized-CBTI.

Method & Research Questions

Finding a right balance between clinician involvement and broader delivery of efficient care by leveraging technology is an important HCI research problem. The CBT-I context offers unique opportunities for us to reflect on the existing care practice, from which we can understand the value of in-person patient-clinician communication as well as existing pitfalls and design opportunities.

Towards this end, we conducted clinical observations (n=11), interview with both clinician (n=10), and patients (n=7) to understand what aspects of in-person CBT-I can be successfully assisted by technology as opposed to remain to be accomplished by clinicians based on a proper understanding of CBT-I workflow.

Results

Although the workflow varied depending on whether the patient was a new patient or a return patient, we find most CBT-I workflows involve 5 high-level activities, and each high-level activities have associated with few sub-activities. The 5 high-level activities are shown as follow:

Clinical Workflow of CBT-I for New Patient

The table on the left is the sub-activities list. The figure below shows a breakdown of the time and location individuals spend during different stages of workflow when clinicians see new patients. Initial visits last 2 hours. There are 2 rooms: above the dotted line is the exam room and below indicate clinician’s office. 3 people involved: red for clinicians, yellow for assistants, and blue for patients. Note that new patients will spend significant amounts of time during their visits in the exam room waiting for clinicians to calculate patient survey/questionnaire scores. The labels correspond to the stages of workflow in the table.

Clinical Workflow of CBT-I for Return Patients

The duration of return patient (the workflow shown as follow) visits varied from 35 minutes to 1 hour. Treatment is terminated for a given patient depending upon his or her progress; a patient who closely follows his or her prescriptions will likely end treatment in fewer sessions than a patient who does not.

Conclusion

Based on the in-depth analysis of the CBT-I workflow, and the interviews, we found that both clinicians and patients value the most of the face-to-face interaction with the each other. However, there are many "spaces" where clinicians left patients on hold to process mundane tasks, such as score the survey or the sleep diary. Utilizing technology in these circumstances could allow clinicians and patients to focus on important tasks such as building a trustful relationship and sharing and reflecting upon experiences.

One of the contributions we made in this study is the inclusion of the patient’s role into the clinical workflow, this trend in which patients seek more active roles in their healthcare will likely become more prevalent in the future, especially where patients are more empowered by technology.

In our paper, we describe several challenges associated with specific activities of the clinical workflow that both clinicians and patients faced in the CBT-I practices which might discourage engagement or negatively affect treatment results, what strategies clinicians employed to promote patient engagement, as well as discuss how to design technology that can assist clinicians and patients throughout the various steps of CBT-I workflow.

Our work offers the following 3 contributions:

A detailed account of in-person CBT-I work-flow, as well as the associated challenges from the perspectives of both clinicians and patients.
Identification of the aspects of CBT-I which can specifically be leveraged by technology versus in-person interaction
Design implications for CBT-I technologies based upon and sensitive to individuals’ differing needs and preferences.

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