Insomnia is among the most common complaints that veterans voice to their providers, and the most common sleep disorder. While common in the general population, a high proportion of veterans suffer from insomnia, and it is known to have multiple medical and psychiatric comorbidities. Insomnia is also associated with decreased quality of life. Among other things, it can lead to a lot of unpredictability in daily routines and anticipatory anxiety about the loss of sleep and its effects.
For all of these reasons, treatment of insomnia is very important for veterans, and health care providers are right to take steps to address this concern. However, the ways in which treatment is delivered are not always the most effective and may be harmful in some cases. In part, this is because the aggravating nature of insomnia can cause both veterans and providers to look for a quick fix, usually pharmacotherapy, as the first and often only treatment discussed and offered. Additionally, there is often a lack of information available to veterans and their providers about evidence-based, nonpharmacological treatments that are most effective in restoring sleep, although this is beginning to change.
For most adults with chronic insomnia, including veterans, the American Academy of Sleep Medicine (AASM), National Institutes of Health (NIH), and American College of Physicians (ACP) all recommend cognitive behavioral therapy for insomnia (CBTI). Sedative hypnotics like benzodiazepines (e.g., Temazepam) and non-benzodiazepine-related medications (e.g., Zolpidem) may be considered after a trial of CBTI or similar treatments and only as short-term adjuncts per clinical guidelines. Such sleep medications may not be appropriate at all in some populations, like in older adults and people with history of substance use disorders (SUDs).
Sleep can be described as an interaction between two independent processes. The first is the homeostatic drive for sleep called “Process S” that builds throughout the day, so that people acquire an increased sleep drive by nighttime. The second is the circadian rhythm, or “Process C,” which is the body’s internal pacemaker or clock. This controls many physiological drives. The circadian rhythm responds in part to external factors such as light and darkness, so that people are more wakeful during the day and sleepy at night. These processes need to synchronize to achieve good quality sleep. Situations where they may be out of sync include bedridden patients, shift work, and drastically different sleep schedules on weekdays versus weekends (Borbely, Daan, Wirz-Justice, & Deboer, 2016; Farajnia, Deboer, Rohling, Meijer, & Michel, 2014).
Typical sleep amount varies among individuals and across the lifespan. The National Sleep Foundation recommends that young adults aged eighteen to twenty-five get seven to nine hours of sleep (no less than six or more than eleven hours); adults aged twenty-six to sixty-four should get seven to nine hours (no less than six or more than ten hours); and older adults over the age of sixty-five should get seven to eight hours (no less than five or more than nine; Hirshkowitz et al., 2015).
Sleep can be divided into nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. NREM can be further subdivided into stages N1, the lightest sleep and easiest to wake from; N2; and N3, which is deep sleep, also called “slow-wave sleep.” Normally people enter sleep through N1 and deepen through each stage, finally reaching REM and completing a cycle. REM is associated with vivid dreaming. People will complete multiple cycles in one night. Among adults, REM sleep should comprise 21 to 30 percent of total sleep, as this indicates good sleep quality (Ohayon et al., 2017; Shrivastava, Jung, Saadat, Sirohi, & Crewson, 2014).
Key elements of sleep architecture can further be described by sleep onset latency (SOL), nighttime awakenings, and wake after sleep onset (WASO), and sleep efficiency. SOL is the time from “lights out,” or when patients attempt to sleep, to time of sleep onset. SOL greater than thirty minutes is the typical cut-off for determining difficulty initiating sleep (Shrivastava et al., 2014) and greater than sixty minutes is indicative of poor sleep quality (Ohayon et al., 2017).
Difficulty maintaining sleep, comprised of several nighttime awakenings with trouble returning to sleep, often results in fragmented and nonrestorative sleep. Relatedly, wake after sleep onset, or WASO, refers to amount of time spent awake after sleep has been initiated and before final awakening. WASO less than twenty minutes indicates good sleep quality, while greater than thirty minutes may indicate unrestful sleep. In some situations, individuals may experience multiple brief periods of wakefulness, or changes from deep to lighter sleep, throughout the night that they may not remember and have a general complaint of nonrestorative sleep (APA, 2013; Ohayon et al., 2017; Shrivastava et al., 2014).
Sleep efficiency measures how much time in bed is actually spent sleeping and is useful in assessing sleep quality. It can be measured by the following equation: total sleep time/time in bed x 100. Sleep efficiency greater than 85 percent is typically considered an indicator of good sleep quality (Shrivastava et al., 2014; Siebern, Suh, & Nowakowski, 2012).
The fifth edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines insomnia disorder, which is distinct from insomnia symptoms as criteria for other psychiatric disorders (e.g., major depressive disorder), as a complaint of dissatisfaction with sleep quantity and quality, with one or more: trouble initiating sleep; maintaining sleep with frequent awakenings; and/or early morning awakenings (APA, 2013). Precipitating factors vary widely, from stress to health to psychosocial issues. Some unique precipitating factors of insomnia for veterans may include past deployment overseas, exposure to combat, shift work, irregular schedules both while deployed and stateside, hypervigilance secondary to deployment and/or combat, and readjustment to civilian life after discharge from the military (Bramoweth & Germain, 2013). A key factor for the diagnosis of insomnia is there must also be clinically significant distress in important areas of functioning such as work, school or relationships. The sleep difficulty must occur at least three nights per week for at least three months and must occur despite adequate opportunity for sleep. Symptoms must not occur exclusively during the course of another sleep wake disorder, must not be attributed to the physiological use of a substance, and must not be adequately explained by coexisting conditions. However, the DSM-5 does allow for specifiers for psychiatric comorbidities (e.g., depression, posttraumatic stress disorder, substance use), medical comorbidities (e.g., chronic pain, obstructive sleep apnea) or another sleep disorder (e.g., restless leg syndrome). Time course can be specified as episodic (between one and three months), persistent (three months or greater), and recurrent (at least two episodes within a year). Criteria met for less than three months are diagnosed as other specified insomnia disorder (APA, 2013).
Clinicians must remember that dissatisfaction is an important component of insomnia. Patients may complain about poor sleep quality or nonrestorative sleep, which is not as easily evaluated as sleep quantity. They may say they do not feel rested despite sleeping an “adequate” number of hours. If nonrestorative sleep without difficulty initiating or maintaining sleep is present, and frequency, duration, and daytime distress and impairment criteria are met, patients are diagnosed with “other specified insomnia disorder” or “unspecified insomnia disorder” (APA, 2013).
Tools for Insomnia
Many brief subjective tools are available to assist in measuring severity of insomnia. One of the most common is the insomnia severity index (ISI). This seven-item questionnaire assesses sleep latency, sleep maintenance, and early morning awakenings. It also considers patients’ satisfaction with their sleep patterns, noticeability of sleep problems, and anxiety surrounding lack of good quality sleep. The ISI has been shown to be a reliable instrument in detecting and following treatment of insomnia, particularly the items about satisfaction and worry about sleep difficulties (Bastien, Vallières, & Morin, 2001; Morin, Belleville, Bélanger, & Ivers, 2011).
Another useful tool that provides a broader assessment is the Pittsburgh sleep quality index (PSQI). This nineteen-item questionnaire assesses subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime functioning. It has good reliability and validity in detecting insomnia (Buysse, Reynolds III, Monk, Berman, & Kupfer, 1989).
Sleep diaries or logs are also helpful for estimating sleep patterns and behaviors and measuring aspects of insomnia like SOL, WASO, and sleep efficiency. One- to two-week sleep logs or even retrospective reports of nightly sleep are helpful in defining severity and frequency of insomnia symptoms (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003).
Incorrect beliefs about sleep may exacerbate or perpetuate insomnia. For example, people very anxious about the amount of sleep they are getting may keep checking the bedside clock during the night rather than relaxing enough to sleep. They may believe there is no way to function without at least eight hours of sleep. A way to assess these maladaptive beliefs and the need for reeducation is the dysfunctional beliefs and attitudes about sleep (DBAS) questionnaire. This questionnaire may also point towards the need to further assess for anxiety or depression (Morin, Vallières, & Ivers, 2007).
When looking for the presence of insomnia, the importance of a thorough clinical interview cannot be overstated. Medical and psychiatric comorbidities as well as sleep behaviors are all important components of sleep health. Whatever measures are used, whether one of the tools mentioned here or an open-ended question at each visit such as, “How has your sleep been?” the important thing is to use it consistently. This helps both providers and patients track improvements or worsening of insomnia, and may signal to continue a present strategy or try something else (Edinger et al., 2015).
According to the NIH, chronic insomnia affects approximately 20 percent of adults (NCSDR, 2011). Veterans and active military members have higher rates of insomnia compared to the general population. For example, veterans serving in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) have twice the rate of insomnia as the general population (24 to 54 percent versus 10 to 22 percent of civilians; Bramoweth & Germain, 2013). Insomnia is commonly comorbid with both psychiatric (e.g., depression, PTSD) and medical disorders (e.g., hypertension, diabetes, and obstructive airway disease). Chronic pain, cardiopulmonary disorders, and depression may be exacerbated by insomnia and may subsequently exacerbate the insomnia, leading to a vicious cycle of poor sleep and daytime functioning. Furthermore, chronic insomnia can increase risk of developing other serious disorders such as depression, substance abuse, suicidal behaviors, and cardiopulmonary disease (Ancoli-Israel, 2006; Katz & McHorney, 1998). Insomnia increases risk of chronic psychological and physical war-related injuries. Active duty service members in particular utilize high levels of caffeine, which perpetuates difficulty initiating sleep and subsequent daytime cognitive deficits. Alternatively, both active duty personnel and veterans report using alcohol to facilitate sleep onset, and/or reduce hyperarousal during the day (Bramoweth & Germain, 2013).
While female veterans are a minority, they are a growing population in the Department of Veterans Affairs. Women are more likely to suffer from insomnia in part due to a variety of neurohormonal and environmental fluctuations throughout their lives, such as menarche, peripartum period, and menopause (APA, 2013; Roth, 2007). Also, as veterans age, insomnia incidence rises. This may be due to age-related degeneration in the suprachiasmatic nucleus of the hypothalamus, which is responsible for circadian rhythm. These changes lead to increase in awakenings and sleep fragmentation. Additionally the elderly have less N3 deep sleep (Farajnia et al., 2014). There is also decreased ability to synchronize and reset phases influenced by the environment. Circadian rhythm may also be disrupted by medications, recreational substances, and medical and psychiatric conditions (Conroy & Arnedt, 2014; Farajnia et al., 2014; Shrivastava et al., 2014). Veterans with substance use disorders and chronic pain may be at particular risk for insomnia. Substance use and insomnia share a mutually perpetuating, sometimes synergistic relationship. Among patients with history of SUDs, insomnia can occur throughout withdrawal and years after abstinence. In one study, 60 percent of patients with alcohol use disorder had insomnia, 45 percent reported using alcohol to help them sleep, and 60 percent of those with insomnia compared to 30 percent without insomnia relapsed after SUD treatment (Brower, Aldrich, Robinson, Zucker, & Greden, 2001). Among those with chronic pain, 50 to 80 percent also have sleep problems. Prolonged SOL and poor sleep quality are associated with poor physical functioning and longer pain duration. Also, self-reported insomnia severity is associated with pain intensity and vice versa (Bramoweth et al., 2016).
Medication Use in Insomnia
Prescription medications commonly used in the treatment of insomnia include the following (Qaseem et al., 2016):
- Benzodiazepines and nonbenzodiazepine receptor agonists (BZRA; e.g., Temazepam, Zolpidem)
- Antidepressants (e.g., trazodone)
- Melatonin and melatonin receptor agonists (e.g., ramelteon)
- Antipsychotics (e.g., quetiapine)
- Orexin receptor antagonists (e.g., suvorexant)
Many other medications and recreational substances can affect sleep architecture depending on their ability to cross the blood-brain barrier and their central nervous system interactions.
The benefit of sleep medications is they often quickly result in reduction of symptoms. While they are typically recommended for short-term, many individuals end up taking these medications long-term (i.e., over ninety days), which might result in physiological tolerance, often requiring higher doses that may increase chances of side effects (Qaseem et al., 2016).
Among older adults who are treated with benzodiazepines, nearly one-third use them on a long-term basis. Furthermore, many older adults receive their prescriptions from nonpsychiatrists in part due to reluctance to see a mental health provider (Cook, Biyanova, Masci, & Coyne, 2007; Olfson, King, & Schoenbaum, 2015). Unfortunately, older adults are generally more likely to experience adverse effects of medications than younger adults (AGS, 2015). In part, this is because they are more likely to be on multiple long-term medications. Among patients who have conditions that disrupt sleep, like depression or chronic pain, this can lead to potentially serious interactions with antidepressants and opiates. Furthermore, metabolism and clearance of substances may be altered due to changes in liver and kidney function. Kidney function, for example, decreases naturally with age, and may drop even more precipitously in cases of long-standing diabetes or hypertension. Liver function has an important role, along with modification and metabolism of medication, in drug binding. The latter depends on the nutritional status of patients, which may decline with age due to physiological and behavioral factors.
The Beers Criteria is a list of potentially inappropriate medications (PIM) for adults over age sixty-five. As of 2015, providers are encouraged to avoid prescribing benzodiazepines as well as BZRA altogether. Previously, recommendations were to limit use of these drugs to less than ninety days; however this caveat has been removed due to deeper understanding of the harm these medications can cause. For example, a study conducted between 2009 and 2011 implicated sedatives and anxiolytics as a major cause of adverse drug events resulting in emergency department visits in patients aged forty-five and older (AGS, 2015; Hampton, Daubresse, Chang, Alexander, & Budnitz, 2014).
Older adults have increased sensitivity to these medications, including increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle crashes. Long acting benzodiazepines are metabolized more slowly in adults over age sixty-five, leading to unpredictable half-life and length of action (AGS, 2015; Hampton et al., 2014; Qaseem et al., 2016).
In a 2014 brief, the Substance Abuse and Mental Health Services Administration (SAMHSA) recommended avoiding benzodiazepines and BZRA among patients with history of substance use disorders due to increased risk of inappropriate usage. Some patients may become dependent on their anxiolytic action, as well as the euphoric effect as in the case of Zolpidem (Liappas et al., 2003). At high doses BZRA may lose their selectivity and act like benzodiazepines, including their side effects (Liappas et al., 2003; SAMHSA, 2014).
Nonpharmacological Treatment Methods for Insomnia
As mentioned in the introduction, the evidence-based recommended treatment for insomnia is CBTI (Qaseem et al., 2016). CBTI is an intervention usually lasting four to eight sessions, consisting of stimulus control, sleep restriction, cognitive therapy regarding sleep, relaxation training, and sleep hygiene (Siebern et al., 2012). The VA has greatly supported the dissemination of CBTI, and has trained approximately eight hundred mental health providers across the country to deliver CBTI (Manber et al., 2012).
Stimulus control involves limiting the bedroom to sleep and sex behaviors and eliminating wakefulness in bed (e.g., in bed watching TV, reading or simply waiting to fall asleep). Another key aspect is waking at the same time every day, no matter when sleep occurs. Sleep restriction is indicated when sleep efficiency is less than 85 percent. By reducing time in bed to less than what patients are accustomed to and matched to the amount of sleep actually obtained, homeostatic sleep drive increases and sleep becomes more consolidated (Siebern et al., 2012; Spielman, 2010).
Cognitive therapy involves confronting maladaptive thought processes about sleep, which perpetuate insomnia by increasing emotional distress such as worrying or unrealistic expectations of sleep. Relaxation therapy involves progressive muscle relaxation, deep breathing techniques, and autogenic training, which involves visualizing a peaceful scene and repeating autogenic phrases to deepen relaxation. These two component scans help reduce both cognitive and physiologic hyper-arousal, which is important since people with insomnia tend to perceive their lives as more stressful and have difficulty feeling calm before sleep (Morin, Rodrigue, & Ivers, 2003; Siebern et al., 2012).
Sleep hygiene involves advice to help improve sleep, such as avoiding heavy meals close to bedtime, limiting caffeine products throughout the day, avoiding alcohol to aid sleeping, avoiding smoking close to bedtime, avoiding naps during the day time, and avoiding vigorous exercise close to bed time (Siebern et al., 2012). However, sleep hygiene is rarely sufficient on its own to treat insomnia and lacks any research support, but it can be an appropriate adjunct to stimulus control, sleep restriction, cognitive therapy, and relaxation.
Related treatments to CBTI also show good evidence in reducing acute and chronic insomnia symptoms. Brief behavioral treatment for insomnia (BBTI) consists of two in-person treatment sessions and two phone calls in about four weeks. It emphasizes behavioral treatment components, sleep restriction, and stimulus control. Studies in both the general population and in military personnel and veterans have shown BBTI to be effective. Online and mobile-based interventions are also becoming more popular. Programs like SHUTi™ (myshuti.com; Ritterband et al., 2017) and Sleepio™ (sleepio.com; Espie et al., 2012), among others, offer the same components as traditional in-person CBTI, but delivered online at the pace of the user and often in the comfort of their own homes. A recent randomized-control trial of the SHUTi program showed good effectiveness in people with chronic insomnia and most with at least one medical or psychiatric comorbidity (Ritterband et al., 2017). At one year posttreatment about 70 percent were deemed responders (significant reduction in symptoms) based on their ISI scores and about half achieved remission status (meaning minimal to no insomnia).
Evidence suggests CBTI is more effective alone than combined treatments with CBTI and sleep medications. According to a randomized-control trial in patients with persistent insomnia, CBTI alone compared to CBTI plus medication found that the CBTI plus medication group produced some benefits during acute therapy. However, better long-term outcomes resulted when medication was discontinued and participants attended six, monthly, individually tailored, ninety-minute CBTI sessions (Morin et al., 2009).
CBTI is also effective in complex cases, often the case when treating veterans, who may have higher rates of comorbid psychiatric and medical disorders. Stimulus control, sleep hygiene, and relaxation techniques have successfully been used to treat insomnia in deployed soldiers. Sixty percent of veterans who completed CBTI reported significantly reduced insomnia severity, with 30 percent in remission. Many veterans who completed treatment also endorsed improved depression and increased quality of life (Bramoweth & Germain, 2013).
Access to Care
One barrier veterans and community members with insomnia face may be a lack of available providers trained to deliver CBTI or BBTI. Even with the VA’s commitment to training providers, access to care is still often limited. Part of the problem is geographic availability, with many trained providers clustered in the larger VA Medical Centers, typically in urban areas. For veterans in rural and other underserved areas, there is often limited help. One method the VA has utilized to reach these veterans is through tele-insomnia, utilizing two-way video teleconferencing technology. This allows veterans at clinics without access to a trained CBTI provider, often in community clinics in rural settings, to connect with a trained provider at another site. Outside the VA, organizations like the Society for Behavioral Sleep Medicine and University of Pennsylvania have created directories to help identify trained providers across the country. However, for veterans and the general public, there are still not enough trained providers to treat the many individuals with insomnia.
One bridge over this barrier involves disseminating information about treatment of insomnia to veterans and providers in the VA, as well as to the general public and medical community. Another involves better matching treatment options to patient needs. In a 2009 article, Espie describes a stepped-care model that assigns care with increasing expertise and resources depending on symptom severity and comorbidities. Espie recommends initial allocation to a particular level based on need, which requires assessment of patient history and characteristics. For example, veterans who do not respond or only partially respond to a lower level of treatment should be referred to a higher level. Self-administered CBTI, such as through workbooks or online treatments, may be appropriate as initial treatment options for less severe insomnia. Veterans who do not respond, or for those who have comorbid disorders that increase complexity of symptoms, can be treated in groups or individually with BBTI or CBTI delivered in primary care settings. For more severe cases, individual treatment with trained and certified providers, usually licensed psychologists, would be the final step, with the possibility of using medication as needed. Treatment location is another area of discussion. Currently, most insomnia is treated by mental health clinicians in mental health settings, but increased efforts are being made to deliver care in primary care settings, especially for less complex patients. Multidisciplinary sleep centers are another arena where patients may have access to providers trained in CBTI (Espie, 2009).
As discussed above, another resource to consider for increasing access to care is electronic and/or mobile health. Ironically, though mobile devices can themselves disrupt sleep by exposure to light and increased arousal, mobile applications are now being used to deliver CBTI, information about proper sleep hygiene, and even relaxation techniques (Olson, 2016). For highly motivated and self-driven people who are struggling with insomnia, these applications may offer a more accessible gateway to treatment. Some clear drawbacks to using electronic and/or mobile health interventions include having access to these resources, education level, and technology literacy. Patients who may not have regular Internet or mobile access, or struggle with literacy, may be unable to optimally utilize this level of care. These patients may function better in a face-to-face setting.
A challenge that may present is treating patients that have been maintained on a sedative-hypnotic for greater than ninety days. They may likely benefit from a medication taper; however providers may meet with resistance when initiating the conversation. Cook et al. (2007, 2007) assessed older patients’ and primary care providers’ views on chronic benzodiazepine use. Although physicians understood guidelines and adverse effects of medications, they continued to prescribe benzodiazepines to their elderly patients. Both patients and providers mentioned the complexity of the patients’ other medical conditions. Frequently there was not time during the office visit to discuss tapering the medication. Patients often felt emotionally dependent on the reliability of their medication, and anxiety over stopping. They often minimized side effects they were experiencing. Providers did not feel patients were displaying drug-seeking behavior or acting like addicts were “expected to act.” Many times, providers felt it unkind to take something away that their elderly patients depended on, particularly given their patients’ limited life spans (Cook et al., 2007; Cook, Marshall, Masci, & Coyne, 2007).
That patients may feel anxious stopping a medication they have been maintained on for long periods is understandable. However, given the adverse effects of these medications, initiating a conversation about tapering, reduction, and discontinuation, and providing information about the effectiveness of CBTI, is within a provider’s responsibility and often in the best interest of these patients.
A useful tool for this process is deprescribing.org (Pottie, 2016), which provides a script and algorithm for tapering benzodiazepines and BZRA in collaboration with patients (e.g., 25 percent reduction every two weeks and planned drug-free days near end of the taper). The first step is to determine why patients are taking the medication. If the reason is standalone insomnia or insomnia with managed comorbidities, a taper is encouraged. Engaging patients involves empathizing with their struggle while still conveying potential risks of medications, particularly with increasing age. It also involves discussing the benefits of stopping, a withdrawal plan, and possible symptoms of withdrawal.
Benefits of stopping sedative-hypnotics may include improved alertness, reduced daytime sedation, decreased fall risk, and reduced risk of polypharmacy interactions and adverse effects. There is a risk of withdrawal side effects, including rebound insomnia, anxiety, irritability, sweating, and gastrointestinal symptoms. These symptoms are usually mild and last days to a few weeks. Allowing patients to control the rate of their taper based on what they can handle helps them retain a sense of control. Tapering the medication while beginning a behaviorally based treatment like BBTI or CBTI can be beneficial, as the added structure may counter withdrawal side effects of the taper. This results in quicker symptom improvement than waiting to finish the taper before starting behavioral treatment. The website also provides additional information on CBTI effectiveness to share with patients (Pottie, 2016).
While no standard exists for a stepped-care model, the following offers a general approach to stepped-care treatment for service members and veterans with chronic insomnia:
- Collect patient history to rule out undiagnosed and untreated medical, psychiatric or other sleep disorders as primary cause for current insomnia symptoms. Comorbid conditions may exacerbate insomnia (and vice versa), in which case treatment of both disorders may be indicated.
- If insomnia is mild to moderate, and there are no complex comorbid disorders, offer web and/or mobile-based treatment or a self-help workbook to patients who have not previously engaged in CBTI or related evidence-based insomnia treatments. If patients decline self-help approaches or prefer face-to-face treatment, BBTI or CBTI with trained providers is recommended. Depending on provider availability and training, patients may receive treatment in primary care, mental health or even sleep clinics. Group-based care and tele-health are additional options for treatment delivery depending on resources.
- If patients do not respond to face-to-face treatment, the addition of a BZRA or other sedative-hypnotic may be necessary to help with symptom reduction. However, as previously mentioned, medication should be utilized for short periods and with the lowest effective dose. An algorithm and clinical guideline, developed by Bramoweth and colleagues for an older veteran population, can serve as an example of a stepped-care process for behavioral treatment (Bramoweth et al., 2016). It can be adapted to various settings and populations and it provides recommendations for sedative-hypnotic medications.
Our understanding of insomnia and treatment development has advanced greatly in the past few decades. One of the major limitations we now face is dissemination of knowledge to providers and patients and limitations on access to evidence-based care. However, continued education and information made available to patients, training of providers in different clinical settings, and the growth of electronic and mobile-based intervention are pathways to treatment. The application of a stepped-care approach can best meet the needs of diverse patient populations struggling with insomnia.
Acknowledgements: This material is the result of work supported with resources and the use of facilities at the VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC), VA Pittsburgh Healthcare System. Dr. Adam Bramoweth is also supported by Career Development Award 13-260 from the US Department of Veterans Affairs, Health Services Research and Development Service. The views expressed are those of the authors and do not necessarily represent the views of the US Department of Veterans Affairs or the United States Government.
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