Insomnia is one of the top sleep related diagnoses for military personnel and veterans (Kelly et al., 2019). Additionally, insomnia is associated with a myriad of psychological and medical problems, increases in utilization of healthcare services and costs (Bramoweth et al., 2022; Klingaman et al., 2018). It is a serious problem. The Center for Deployment Psychology, the Department of Veteran Affairs, and others have worked hard to increase the number of trained providers to deliver evidenced based treatments for insomnia such as Cognitive-Behavioral Therapy for Insomnia (CBT-I) or Brief Behavioral Treatment for Insomnia (BBT-I). The goal of these dissemination efforts is to increase access to high quality care for those struggling with the effects of insomnia. As these efforts are ongoing, it can be also important to get data on patient experiences related to treatment of insomnia. This information can help inform training and clinical practice by better understanding the experience of patients such as treatment barriers, treatment experiences, and treatment preferences.
A recent study conducted by Bramoweth et al. (2002) focused on qualitative interviews from a small sample of veterans (n=20) who had an insomnia diagnosis, current self-report of chronic insomnia compliant, and or reported having treatment for insomnia within the past 12 months within a large urban mid-Atlantic VA treatment setting. The authors summarized findings according to the following themes: insomnia symptoms, seeking treatment, intervention experiences, patient preferences and expectations. Key findings from each theme will be highlighted below.
Insomnia Symptom Findings:
- Cognitive hyperarousal (i.e., racing thoughts) was a commonly identified as an internal factor causing or contributing to insomnia.
- External factors cited for causing or contributing to their insomnia included: events from military service, transitioning from active duty to being a civilian, medical and or psychiatric issues (e.g., chronic pain, prostate problems, PTSD), home stress, and job schedule (i.e., shift work).
- Some participants did not know that insomnia was a disorder and a problem that needed to be discussed with a provider.
Seeking Treatment Findings:
- Most participants had initial discussions with their Primary Care Provider (PCP) versus behavioral health providers.
- Reasons for seeking care for their sleep problems included leaving the military, negative impact of sleep on work, and sleep not improving despite other physical health conditions improving with medical care.
- Reasons for not seeking care included trying to solve things by themselves, having normalized their sleep difficulties as just part of their lifestyle versus a medical problem.
- Factors facilitating care included open communication between provider and veteran, communication between providers in different clinics, and treatment options discussed and offered more than once.
- Barriers included location of services, distance to travel, travel costs, travel specific difficulties such as bad weather and difficulties with bus transfers. Participants also noted problems with locating available services (e.g., long wait times), and perceived messaging from DoD and VA to just deal with it and feeling discouraged from seeking help.
Intervention Experience Findings:
- Most participants indicated that their initial or previous insomnia treatment involved prescription medication and reported dissatisfaction with such treatment (e.g., side effects of medication, negative impact on dreams, afraid of pills or becoming dependent on them, frustrated that this seemed to be the only treatment option offered).
- Some participants reported trying behavioral interventions such as staying awake for multiple days, wearing themselves out, reading about insomnia or participating in evidence-based treatments such as CBT-I and BBT-I.
- Most participants believed that their providers (i.e., PCPs and behavioral health) had a good understanding of their sleep needs and took appropriate action (e.g., made a referral to a provider with clinical expertise to address sleep complaints).
- However, 30% of the sample reported providers did not view their sleep as a priority and focused on underlying medical issues.
Intervention Preferences and Expectations Findings:
- Most participants were open to behavioral approaches like BBT-I and CBT-I.
- Most participants also perceived that behavioral health providers were more qualified to manage their insomnia compared to their PCP.
- A slight majority of participants (i.e., 55%) reported preferring behavioral treatments like BBT-I and CBT-I offered in a primary care clinic setting due to ease of access (e.g., routinely receiving services at this clinic).
- However, the most important factor cited by patients was being able to see a provider who had the appropriate training and expertise to effectively address their insomnia.
- Patients with past mental health treatment history, showed a preference for CBT-I because of prior experiences with CBT treatments. Additionally, patients reported that CBT-I appeared to be more thorough than BBT-I.
- One participant noted that they would try BBT-I first and then transition to CBT-I if necessary.
- No participants reported BBT-I or CBT-I as too complex or challenging.
- Most participants reported a positive response to video telehealth, compared to treatment by phone or online. Some participants also noted that they would be more honest and engaged in treatment when seeing a provider in person versus other telehealth options.
Summary and Clinical Implications:
Insomnia is a serious problem that adversely affects an individual’s psychological, medical, interpersonal, and occupational functioning (Klingaman et al. 2018; Kelly et al., 2019). Significant ongoing efforts are being made to train more providers in evidence-based treatments for insomnia such as BBT-I and CBT-I. Results from Bramoweth et al. (2022) study on veterans’ experiences and perspectives provide some insights that can help inform training and clinical practice.
- Several patients cited cognitive hyperarousal as an important factor for their insomnia. It is important that training and clinical practice focus on being able to assess and utilize appropriate interventions to minimize the impact of this arousal on a person’s ability to fall and stay asleep.
- Patients may not know that they suffer from insomnia and that it is a treatable condition. They may normalize their insomnia symptoms. Training and clinical practice should focus on how to screen for insomnia and provide patients with information about this condition and available behavioral treatment options.
- Despite patients being more open to behavioral treatments for insomnia (i.e., BBT-I, CBT-I), many of them were prescribed a sleep aid, or had their medications adjusted in effort to improve their sleep functioning. Training and clinical practice should focus on how to network with PCPs to make sure that they are aware of first line interventions for insomnia (i.e., CBT-I, BBT-I) and how to refer patients to those resources.
- Patients mostly care about whether their provider had the training and expertise to treat their insomnia. They seemed to prefer either in person or video telehealth treatment modalities. Patients tended to have a more positive view of CBT-I compared to BBT-I, seeing it as a more comprehensive treatment. However, some patients expressed interest in BBT-I because it is a shorter treatment protocol. As a result, training and clinical practice should focus on being able to deliver both evidence-based treatments like BBT-I and CBT-I in person and via video telehealth. This allows the patient to have input on the type of behavioral intervention and treatment platform that works best for them.
For information on the next available training for CBT-I from the Center for Deployment Psychology, please go to https://deploymentpsych.org/training.
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.
Tim Rogers, Ph.D., is a Senior Military Internship Behavioral Health Psychologist and serves as the Associate Program Director for the Air Force Clinical Psychology Internship Program at Joint Base San Antonio-Lackland Texas.
Bramoweth, A. D., Rodriguez, K. L., Klima, G. J., Appelt, C. J., & Chinnman, M. J.
(2022). Veterans’ experiences with and perspectives on insomnia treatment: A qualitative study. Psychological Services, 19(1), 134-145. http://dx.doi.org/10.1037/ser0000494
Kelly, M. R., Robbins, R., & Martin, J. L. (2019). Delivering cognitive behavioral therapy for insomnia in military personnel and veterans. Sleep Medicine Clinics, 14(2), 199-208. https://doi.org/10.1016/j.jsmc.2019.01.003
Klingaman, E. A., Brownlow, J. A., Boland, E. M., Mosti, C., & Gehrman, P. R. (2018). Prevalence, predictors and correlates of insomnia in US Army soldiers. Journal of Sleep Research, 27(3), 1-13. https://doi.org/10.1111/jsr.12612