More is better right? I have heard this often vis a vis treatment of sleep disorders, i.e. if only we had more providers trained in Cognitive-Behavioral Therapy for Insomnia (CBT-I), then we could reach more patients. Today, I want to impart to you the idea that having greater numbers of trained CBT-I providers is insufficient without addressing attitudes of referring medical providers-particularly those primary care providers (PCPs) who are our patients’ point-of-contact with the medical system.
Let me start with what probably will not surprise you. We know that the rate of insomnia in primary care settings is high among both civilians and military-connected patients, where 44% of civilians and 38% of Veterans in a VA clinic scored at least above the ‘mild’ cutoff on the Insomnia Severity Index (Krakow et al, 2013 and Shepardson et al, 2014, respectively). Indeed, patients with insomnia likely deliberately seek out primary care visits, as 79% of Veterans with sleep complaints reported a preferred treatment approach of talking to their PCP (second to self-management; Shepardson et al).
Moreover, many of these patients prefer non-medication approaches, and this is particularly true for insomnia treatment. A study of 200 active duty soldiers found that 85% expected their PCP to teach them behavioral skills for insomnia treatment; 59% preferred a behavioral approach solely or initially, with another 23% preferring at least a combination approach, leaving only 18% who desired medication solely or initially (Ee et al, 2016). Similarly among Veterans, approximately two-thirds did not endorse a desire for medication (Shepardson et al).
You may already know that CBT-I works very well for insomnia (Trauer et al, 2015), and there are also effective interventions that have been adapted from CBT-I strategies for primary care, such as Brief Behavioral Treatment for Insomnia (BBTI; Germain et al, 2014) (Click here for my thoughts about the importance of offering integrated behavioral healthcare in primary care). These have been studied in civilian and in military-connected populations. CDP offers trainings in both CBT-I and BBTI, and has trained just under 1,000 psychologists, social workers, and other professionals to work with military-connected insomnia patients in the last three years alone.
So where is the gap between all of these patients in need who are open to behavioral treatment and the trained behavioral health providers eagerly awaiting them? It’s where the rubber meets the road, where Service members and Veterans first connect with medical care, in primary care clinics.
Unfortunately, PCPs often view sleep problems as secondary or less important than other concerns and nearly half do not even document sleep problems in the medical record (Ulmer et al, 2017). Indeed, among Veteran patients, only 44% of those with self-reported sleep problems reported their PCP had discussed any type of treatment, behavioral or medication (Shepardson et al). When treatment is discussed, the majority of PCPs provide sleep hygiene or pharmacotherapy as an initial intervention vs offer CBT-I, perhaps in part because as few as 1 in 10 may have a good understanding of hypothesized CBT-I mechanisms (Ulmer et al, 2017).
I should point out that this is despite the fact, as I have mentioned before, that CBT-I is recommended as the front line treatment by the ACP, who represents primary care physicians, and that sleep hygiene is not effective for chronic insomnia.
Perhaps, part of the disconnect is prospective-patients with insomnia focus more on addressing the present problem whereas PCPs may focus more on rooting out presumed underlying causes, believing if they treat those the ‘secondary’ insomnia will just go away (Dyas et al, 2010). I recommend further reading of the article by Dyas and colleagues for patient perspectives on just how important PCP attitudes are. Understandably, PCPs are constrained by a high-demand, time-limited environment and likely drained by pressure to prescribe, a myriad of clinical practice guidelines, few resources, and long days. They do immensely important and often underappreciated work.
I submit that those of us who provide and research behavioral sleep medicine need to revisit our role. When I worked in primary care, I considered my job to be to assist the PCPs first, and helping their patients as an extension. We can train in CBT-I or BBTI, but in order to truly disseminate behavioral treatments for insomnia, we need to reach out to PCPs. Instead of waiting for referrals, let’s go to PCPs, let’s assist them and their patients to manage sleep problems by also training them-about insomnia etiology, the rationale for CBT-I, and the specific mechanisms and strategies-and by interfacing with health care systems to make CBTI referrals a stated part of healthcare protocols.
To hear from medical providers and behavioral sleep medicine subject matter experts on their perspectives, I encourage you to join us for the upcoming CDP Presents webinar: Sleep Disorder Care in the Military on 25 April from noon to 1:30 p.m. Eastern.
For more on sleep, be sure to visit our Sleep Spotlight page here, where we'll be adding sleep-related content and resources all month!
Diana C. Dolan, Ph.D., CBSM, is a clinical psychologist serving as a Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
Dyas, J.V., Apekey, T.A., Tilling, M., Orner, R., Middleton, H., & Siriwardena, A.N. (2010). Patientsʼ and cliniciansʼ experiences of consultations in primary care for sleep problems and insomnia: a focus group study. British Journal of General Practice DOI: 10.3399/bjgp10X484183.
Ee, J.S., Berry-Caban, C.S., Nguyen, D.R., Boyd, M., Bennett, N., Beltran, T., & Williams, M. (2016). Soldiers’ perspectives of insomnia behavioral treatment in a primary care setting. Journal of Sleep Disorders & Management 2(2): 1-5.
Germain, A.G., Richardson, R., Stocker, R., Mammen, O., Hall, M., Bramoweth, A.D., Begley, A., Rode, N., Frank, E., Haas, G., & Buysse, D.J. (2014). Treatment for insomnia in combat-exposed OEF/OIF/OND military veterans: preliminary randomized controlled trial. Behavioral Research & Therapy 61: 78-88.
Krakow, B., Ulibarri, V.A., Romero, E.A., & McIver, Natalia D. (2013). A two-year prospective study on the frequency and co-occurrence of insomnia and sleep-disordered breathing symptoms in a primary care population. Sleep Medicine 14: 814-823.
Shepardson, R.L., Funderburk, J.S., Pigeon, W.R., & Maisto, S.A. (2014). Insomnia treatment experience and preferences among Veterans Affairs primary care patients. Military Medicine 179(10): 1072-1076.
Trauer, J.M., Qian, M.Y., Doyle, J.S., Rajaratnam, S.M.W., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Annals of Internal Medicine 163(3): 191-204.
Ulmer, C.S., Bosworth, H.B., Beckham, J.C., Germain, A., Jeffreys, A.S., Edelman, D., Macy, S., Kirby, A., & Voils, C.I. (2017). Veterans Affairs primary care providers perceptions of insomnia treatment. Journal of Clinical Sleep Medicine 13(8): 991-999.