Sleep Disorders in Veterans: Effective Non-Pharmacologic Treatments

By Allison Siebern, PhD, CBSM | October 1, 2015
Sleep Health Integrative Program, Veterans Affairs Medical Center in Fayetteville, NC

When I tell people that I’m a sleep psychologist, their first response is usually to tell me how they sleep. Sleeping is a universal process that everyone can relate to in one way or another. Because it is something we all do, there is little stigma or hesitation in discussing it openly. 

Despite the commonalities, personal experience of the sleep process can vary greatly. Some people are hardwired as great sleepers. Others may struggle to get what feels like a good night’s rest.

And even though sleep occurs during a finite period of time, it has an impact across the entire 24 hours of a person’s day. When people are not sleeping well, they can be more irritable. They may not be as engaged in enjoyable activities. They may experience drowsiness while operating a car.

Poor sleep affects a person’s quality of life as well. People may find their abilities impaired in the workplace, at school and at home. There is a public safety impact as well, with drowsy driving or difficulty operating equipment. There is also an impact on physical health. Poor sleep has been associated with chronic conditions such as diabetes, heart disease and high blood pressure, as well as depression and weight gain.

Sleep health is emerging as an important public health concern. The good news is we have effective non-pharmacological ways to address sleep disruption.

Why Can’t I Sleep?

Events in peoples’ lives can predispose them to disrupted sleep, and often people know exactly what the problem is. New parents finally start to drift off to sleep and the baby starts to cry. Women in the hormonal shift of menopause may wake frequently. People can experience troubled sleep at times of difficult life transitions such as losing a spouse or losing a job. The list can go on and on.

And about one in four people with insomnia has no idea what triggered the disruption.

Aging can put people at increased risk for the development of insomnia. As people age, their patterns of sleep change. Older adults spend more time in lighter stages and less time in deep sleep. They tend to have more medical issues and are more likely to experience chronic pain. Medication use is more common, and some medications can disrupt sleep.

Another population that is greatly affected by sleep disruption is veterans. It is estimated that veterans are four times more likely to be affected by sleep issues than the general population. This is why I joined the Veterans Administration (VA) as a frontline provider. I love the field of sleep medicine and want to help veterans improve their sleep.

Non-Medication Treatment for Insomnia—CBT-i

The American Board of Sleep Medicine has certified 213 providers nationally in behavioral sleep medicine (BSM). BSM is a specialty field that utilizes non-medication treatments for sleep disorders. The field applies psychological theory, behavioral change strategies and the science of sleep medicine to improve people’s ability to sleep well.

One of these non-medication treatments for insomnia is called cognitive behavioral therapy for insomnia (CBT-i). This is not a well-known treatment at present, primarily because there are a limited number of individuals trained to provide it.

CBT-i has been shown to be very effective. In fact, when compared to sleep medications, effectiveness of both interventions is quite similar in the short term. More important, as a person continues to practice and improve the cognitive behavioral skills that improve sleep, CBT-i actually has more durable long-term effectiveness. This is the exact opposite of drug interventions for sleep, which typically can become less effective over time.

CBT-i has been tested in many studies and found to improve sleep across a range of populations. It’s been shown to be a good treatment fit even if a person is experiencing comorbidities such as medical or psychiatric disorders. It may even improve some of those comorbidities. Erin Cassidy-Eagle, PhD, Director of Research at ETR, conducted a study using CBT-i and found improved cognitive functioning in a geriatric population by improving sleep.

Taking It to the VA: What We Did

In 2010, the Veterans Health Administration put together a national initiative to train mental health providers to use CBT-i to treat the huge number of veterans with insomnia. Nearly 500 providers have now been trained in VA’s across the country.

Veterans have responded positively to being able to access this treatment. They appreciate that it is short-term (on average between 4-6 sessions) and offers specific goals for improvement of insomnia.

Many of the veterans participating in the treatment reported significant satisfaction in the outcome. It was common for individuals who hadn’t slept well in years to describe improvement in the quality of their sleep in a short period of time. Veterans noted a decrease in fear about going to sleep and satisfaction with the tools they learned to help quiet the mind when they wanted to be sleeping.

Our data reinforced these anecdotal accounts. Veterans using CBT-i revealed significant improvement in sleep, improved quality of life and decrease in symptoms of depression and suicidal thoughts.

Treatment providers also reported high satisfaction with learning and implementing the treatment for their patients. They appreciated its short duration and the effective results.

I had the great privilege of working on this VA initiative from the beginning, as one of the original eight sleep experts assigned to the project. Being part of the initiative for this duration allowed me to watch it develop from seedling concepts to a full-grown and tested program. This heightened my own passion to continue to help increase access to sleep services within the VA system.

The VA’s national level training is an exceptional model. I encourage other healthcare systems to take note—and then take steps to increase patient access to evidence-based treatments. I’m particularly committed to improving access to CBT-i, given that insomnia is the most prevalent sleep disorder in the nation. The use of non-pharmacologic interventions has considerable promise for meaningful improvements in the nation’s health.

Translating This Work to a Program in the VA

Working with the VA at a national level on this training initiative enhanced my interest in working with the VA as a frontline provider to help veterans with sleep issues. I recently left a fulltime career at Stanford Sleep Center, the birthplace of sleep medicine, to join one of the fastest-growing VA’s in the country, the Veterans Affairs Medical Center in Fayetteville, North Carolina.

We will be starting a comprehensive behavioral sleep medicine program that provides CBT-i for disrupted sleep. We’ll also be offering non-pharmacological treatments for nightmares, assistance with acclimating to the use of sleep apnea treatments and help addressing circadian rhythm disorders (such as shift work, being a “night owl” or “morning lark”). Additionally, we’ll support veterans as they work with their prescribing providers to gradually discontinue use of sleep medications.

This program is uniquely integrated with other facets of our sleep assessment and treatment planning efforts. These include our sleep laboratory, the Sleep Medicine Clinic, and Continuous Positive Airway Pressure treatment, where respiratory therapists work with patients diagnosed with sleep apnea. The team approach allows us to look at the bigger picture of influences on a person’s sleep. This is essential to developing an integrated and effective care model.

The field of sleep medicine is moving in a direction of overall sleep health. This means addressing not only sleep time, but waking hours which can be impaired or distressing as a result of not sleeping well. There is increasing recognition of the bidirectional relationship between waking and sleep.

How to Access CBT-i and Behavioral Sleep Medicine Providers

Positive results from our own and other studies indicate that CBT-i is a very effective treatment for insomnia across numerous populations with a range of complicating comorbidities. It is important that more people experiencing troubled sleep have an opportunity to consider this very effective treatment. If you’d like to find out more about CBT-i for your own clients/patients (or for yourself or your own family), BSM providers can be found though the American Board of Sleep Medicine and the Society of Behavioral Sleep Medicine.

Time to Build the Network

It is imperative we continue to build the number of providers adequately trained to provide CBT-i. We also need to grow comprehensive behavioral sleep medicine and sleep health programs that address additional sleep issues in a non-pharmacological way, both for veterans and for the general public. Sleep is such an essential component for health, and such a vital indicator of quality of life, it should be one of our nation’s highest healthcare priorities.

 

Allison Siebern, PhD, CBSM, is a licensed clinical psychologist who is board-certified in behavioral sleep medicine. Dr. Siebern’s current research focuses on special considerations for sleep treatment implementation in various population. She is also widely cited in the media on sleep topics. She just joined the Veterans Affairs Medical Center in Fayetteville, NC, to build the Sleep Health Integrative Program. She is also a consulting assistant professor at Stanford Center for Sleep Sciences and Medicine where she remains involved in training sleep medicine postdoctoral fellows and research. She can be reached at asiebern@stanford.edu or found on LinkedIn.