Take a moment and reflect on the training you received to become a licensed healthcare professional. What continues to affect the way you provide healthcare services? Throughout the course of our professional lives we come across a lot of information. Despite this massive exposure, some trainings or information tends to exert a greater influence on our professional practice than others.
When reflecting on important learning experiences, the training I received pertaining to the assessment and treatment of sleep disorders is at the top of my list. Why? My academic training program did not have a strong emphasis on health psychology issues. When I was ready to start my internship, what I knew about sleep came from a class I took that covered all of the mental health diagnoses in the Diagnostic Statistical Manual. So, I had a lot to learn about sleep and moving forward I have been amazed how often I utilize this knowledge.
The lack of training pertaining to the assessment and treatment of sleep disorders is not uncommon amongst behavioral healthcare providers. When I am conducting trainings for CDP, few attendees endorse receiving any formal training pertaining to the assessment and treatment of sleep disorders. However, when asked about the patients that they work with, most attendees indicate the vast majority of their patients have sleep problems. This critical knowledge gap between training and clinical needs of patients underscores the importance of training in the assessment and treatment of sleep disorders. In particular, I want to highlight some key points I have taken from my training in this area and have found to be very helpful in my clinical practice, supervision and training.
(1) Problematic Sleep Can Be More Than Symptom
It is common for behavioral healthcare providers to view problematic sleep as a symptom of a psychiatric disorder like depression or anxiety. Sleep literature estimates that approximately 80-90% of patients with sleep problems such as sleep apnea may not get diagnosed (Chen et al, 2015). Why? There are several reasons to include: (a) the bi-directional nature of sleep and mental health problems makes diagnostic decision making confusing, (b) assessment tools (e.g., intake questionnaires and brief mental health screening tools) ask few questions about sleep functioning making it difficult to know whether a patient meets criteria for a sleep disorder, and (c) the lack of training in the assessment and treatment of sleep disorders.
Lesson from Training: It is important to assess sleep functioning more carefully to rule out potential sleep disorders
(2) Assessment Goals and Tools
Accurate assessment is an important part of the treatment process. There are effective and evidence-based treatments for many sleep disorders (see https://aasm.org/clinical-resources/practice-standards/practice-guidelines/). However, treatments that work for one disorder may not work for others. For example, effective treatment for insomnia will not work for obstructive sleep apnea, and could be harmful due to misdiagnosis and delay of effective treatment. In many cases, providers need to identify whether they need to refer the patient to a sleep specialist or PCM as some conditions need additional testing to confirm diagnosis. Behavioral healthcare providers can treat some sleep conditions with proper training, such as Insomnia Disorder (i.e., Cognitive Behavioral Therapy for Insomnia, Brief Behavioral Therapy for Insomnia), Nightmare (i.e., Image Rehearsal Therapy) and Circadian Rhythm disorders (i.e., melatonin therapy, light therapy, environmental entrainment, and consistent bed and wake times). Other sleep disorders such as Obstructive Sleep Apnea, Narcolepsy, Rapid Eye Movement Sleep Disorder, and Restless Leg Syndrome are conditions that often require a referral to a sleep specialist or primary care physician due to the necessity of medical interventions. Assessment tools such as the Insomnia Severity Index (7 items), STOP (OSA; 4 items), are relatively brief instruments that can help screen for sleep disorders like Insomnia and OSA that are the most common type of sleep disorder in the military population.
Lesson from Training: It is important to know when to refer, what to treat, and how to treat it
(3) Importance of Diagnosing Sleep Problems
My experience as a clinician, supervisor, and trainer/consultant has taught me that providers treat what they diagnose. If problematic sleep is viewed as merely a minor issue, it is not likely to be closely monitored during the course of treatment, or be the subject of any particular intervention. This can be particularly significant given research findings that problematic sleep is associated with a variety of negative health outcomes and can persist despite successful treatment of mood-, anxiety-, and trauma-related disorders. Good sleep is critical to overall health and functioning.
Lesson from Training: It is important to diagnose and treat patients if they meet criteria
I am very grateful for the training in sleep assessment and treatment that I have received. It was an area that I once knew very little about and now use on a very frequent basis as a clinician, supervisor, and trainer. I encourage all behavioral health providers to take advantage of the different training opportunities that CDP is providing this month (Online Cognitive Behavioral Therapy for Insomnia on 12-13 April, Brief Behavioral Therapy for Insomnia on 26-27 April, Sleep Disorder Care in the Military on 25 April) and in the future. You can tell me in the comments whether your experience in the assessment and treatment of sleep disorders has also had a significant impact in the way you work with patients.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Timothy Rogers, Ph.D., is a Military Behavioral Health Psychologist at Wilford Hall Ambulatory Surgical Center, Lackland AFB, TX.
Chen, X., Wang, R., Zee, P., Lutsey, P.L., Javaheri, S., Alcantara, C., Jackson, C.L., Williams, M.A., & Redline, S. (2015). Racial/ethnic differences in sleep isdturbances: the Multi-Ethnic Study of Atherosclerosis (MESA). Sleep 38(6): 877-888. doi: 10.5665/sleep.4732