Cover Story

A week doesn't go by for Ed Stepanski, PhD, without a call from a physician who's looking for a qualified sleep psychologist. As the director of the Sleep Disorders Service and Research Center at Rush-Presbyterian-St. Luke's Medical Center in Chicago, Stepanski is one of about 1,700 board-certified sleep medicine specialists trained to treat insomnia, narcolepsy, circadian rhythm disorders and other sleep problems.

"Sleep disorders are very prevalent," explains Daniel Buysse, MD, former president of the American Academy of Sleep Medicine (AASM) and associate psychiatry professor at the University of Pittsburgh School of Medicine. "They cause significant morbidity and impairment of function. Despite that, there is just a dire shortage of people who have the expertise in treating these individuals."

Sleep medicine is a unique specialty, combining the work of many health professionals, from pulmonologists with expertise in sleep apnea to neurologists, psychiatrists and psychologists. And it's not uncommon for these specialists to work together in the same clinic. Over the last 20 years, the field has grown so fast that the demand for trained sleep psychologists far exceeds the supply.

Indeed, Stepanski is only one out of about 150 board-certified sleep medicine specialists with a PhD in a behavioral field--a background that prepares them to provide behavioral therapies tailored to sleeping disorders, help patients comply with sleep apnea treatment plans, evaluate patients' sleep studies and treat the depression and anxiety that often co-occur with sleep disorders.

Behavioral sleep medicine is such a booming field that the AASM has created a special committee to develop curricula for behavioral sleep medicine training programs and a specialized board exam for sleep psychologists--a move psychologists say should be acknowledged and applauded.

"How often is it that a medical society embraces what psychology has to offer?" asks Michael Perlis, PhD, director of the University of Rochester Sleep Research Laboratory.

The committee, founded under Buysse's presidency, is also lobbying for more consistent reimbursement for sleep psychologists' services. Right now, most sleep apnea treatments are regularly reimbursed by insurers, but other kinds of treatment, including cognitive-behavior therapy (CBT) and evaluating patients' sleep studies, are less frequently covered.

The demand for sleep psychologists will only grow, says Buysse, as evidence attesting to the success of behavioral interventions such as CBT piles up.

For example, a well-publicized double-blind study in the Journal of the American Medical Association (Vol. 285, No. 14) by psychologist Jack D. Edinger, PhD, and colleagues found that CBT produced larger improvements than either progressive muscle relaxation or a placebo treatment.

Sleep-treatment pioneer Charles Morin, PhD, and colleagues found in a 1999 study (see "Further Reading" box) that while a combined behavioral-pharmacological approach produced the best short-term results, those who received cognitive behavior therapy sustained better long-term clinical gains, and the participants rated the behavioral therapy as more effective and satisfying.

And a new study, published in the European Archives of Psychiatry and Clinical Neuroscience (Vol. 251, No. 1) reports that CBT produced enduring treatment effects over a three-year follow-up period. Other studies have found that CBT is effective for insomnia patients who have co-occurring medical and psychological problems.

The evidence is clear, say sleep specialists: CBT is just as effective as pharmacological treatments in the short term and even more effective in the long term for sleep disorders such as insomnia.

"At this point, there's no question about the potency and the power of CBT for insomnia," says Perlis. "This is one of the places where psychology really shines. Now, what we need more than anything is to attract new health-care providers who want to learn CBT and become certified in behavioral sleep medicine."

However, experts caution that appropriate training is a must. For students interested in behavioral sleep medicine, Edinger suggests applying to graduate schools with an AASM-accredited sleep program or with a faculty member with expertise in sleep and finding a sleep-related internship site. Practicing psychologists can get up to speed through training at national sleep meetings or by putting in some learning time at a local sleep clinic.

"While it's relatively easy to learn how to do CBT for sleep disorders, there are a number of things about it that make the practice hard," explains Perlis. "Mentored or formal training is a must. While we want to grow the field, we need to make sure the people who are practicing in the area of behavioral sleep medicine are experts."