Using eHealth to Expand Access to Cognitive Behavioral Therapy for Insomnia in Hispanic Primary Care Patients

Adoption of this research will expand access to evidence-based alternatives to medication for the management of chronic insomnia and may narrow existing racial and ethnic disparities in access to high quality behavioral health care for patients.

Project Details -
Completed

Chronic insomnia is a significant public health burden and is associated with increased morbidity, mortality, and high economic costs. Insomnia affects over 30 million US adults, most of whom seek care in the primary care setting. While Hispanics are at greater risk for insomnia than Whites, access to the recommended first-line treatment, cognitive behavioral therapy for insomnia (CBT-I), is limited. Lack of qualified bilingual behavioral providers and high costs are two key factors that limit access. Advances in self-guided electronic health (eHealth) treatments represent an innovative and scalable means to address mental health care disparities; however, its implementation in underserved communities has not been implemented.

This project will evaluate the effectiveness of the Spanish-language version of a self-guided, eHealth CBT-I course versus a culturally adapted version. This is an interactive and tailored web- and mobile-based program modeled on the primary tenets of face-to-face CBT-I, which have demonstrated effectiveness at reducing insomnia symptoms. Participants will be recruited from primary care practices within the diverse New York Presbyterian Hospital System.

The specific aims of the project are as follows:

  • To examine the effectiveness of a culturally adapted online CBT-I program compared to enhanced usual care. 
  • To identify organizational, patient, and provider barriers and facilitators to implementation of the adapted CBT-I eHealth intervention. 
  • To determine the cost-effectiveness of delivering the adapted eHealth CBT-I intervention versus enhanced usual care in the primary care setting. 

By leveraging recent advances in eHealth and capitalizing on the increasing rates of Internet use among Hispanic adults, this study has the potential to expand access to evidence-based alternatives to pharmacotherapy for the management of chronic insomnia, and to narrow existing racial and ethnic disparities in access to high-quality behavioral health care for primary care patients. Researchers hypothesize that the adapted CBT-I eHealth intervention will result in improved Insomnia Severity Index scores, and that it will result in greater improvements in quality of life. Findings will identify viable implementation strategies for the successful integration of an eHealth version of CBT-I into the primary care setting and may have implications for other use cases involving the implementation of such interventions in Spanish-speaking patients.

Using eHealth to Expand Access to Behavioral Healthcare for non–English-Proficient Hispanic Patients

Significance and Potential Impact

Adoption of this research will expand access to evidence-based alternatives to medication for the management of chronic insomnia and may narrow existing racial and ethnic disparities in access to high quality behavioral health care for patients.

Access to behavioral healthcare is often a challenge but is even more difficult for non–English-proficient patients to find bilingual behavioral providers who understand how culture affects patients’ interactions with the healthcare system. While cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based alternative to medication, access is limited because of the lack of qualified bilingual behavioral health providers.

Cultural adaptation is the systematic process of modifying and adapting the intervention by integrating cultural components that align with patients’ worldview. Beyond language adaptations, it includes “deep structure” cultural adaptations such as changing examples to make them culturally relevant and avoiding Spanish-language regionalisms.

Developing a cultural adaptation of an interactive digital program to deliver cognitive behavioral therapy for insomnia.

Dr. Carmela Alcantara, from Columbia University, is conducting research with non–English-proficient Hispanic patients with insomnia and behavioral health providers to develop a cultural adaptation of an existing digital CBT-I program. This intervention is an interactive program that can be delivered via tablet, smartphone, or computer that has been effective at reducing insomnia symptoms and co-occurring psychological symptoms.

Dr. Alcantara and her research team will conduct a randomized controlled trial with non–English-proficient Hispanic patients with chronic insomnia that compares the effectiveness of the culturally adapted digital version of CBT-I with enhanced usual care on reduction of insomnia symptoms.