Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment

Abstract

Study Objectives: Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that: sleep hygiene and pharmacotherapy are the primary treatments offered; PCPs tend to focus on perceived causes of insomnia rather than the insomnia itself; and neither patients nor providers are satisfied with insomnia treatment options. Although insomnia complaints are typically first reported to primary care providers, little research has focused on perspectives regarding insomnia treatment among PCPs working in the largest integrated health care system in the United States-the Veterans Affairs (VA) health care system. This study was conducted to examine VA PCP perceptions of the availability of insomnia treatments, identify specific strategies offered by PCPs, and examine perceptions regarding the importance of treating insomnia and the role of comorbid conditions. Methods: A survey was conducted within the VA health care system. Primary care providers completed surveys electronically. Results: A high percentage of veterans (modal response = 20% to 39%) seen in VA primary care settings report an insomnia complaint to their provider. Almost half of respondents do not consistently document insomnia in the medical record (46% endorsed "sometimes," "rarely," or "never"). PCPs routinely advise sleep hygiene recommendations for insomnia (ie, avoid stimulants before bedtime [84.3%], and keep the bedroom environment quiet and dark and comfortable [68.6%]) and many are uncertain if cognitive behavioral therapy for insomnia is available at their facility (43.1%). Conclusions: Findings point to the need for systems-level changes within health care systems, including the adoption of evidence-based clinical practice standards for insomnia and PCP education about the processes that maintain insomnia. Commentary: A commentary on this article appears in this issue on page 937.

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review

“…24 In a survey with VA primary care providers who worked in medical centers with access to CBT-I, only 29% reported utilizing CBT-I to treat insomnia. 25 In contrast, over 70% of these providers depended on medications and sleep hygiene.…”

“…A common theme in studies with clinicians is that they lack familiarity with CBT-I treatment components and are unsure of the effectiveness. 4,6,[25][26][27][28][29][30] In a survey study with Belgian family physicians, only 35% indicated that their knowledge of nonpharmacologic approaches to insomnia was sufficient. 30 This finding was replicated in a VA survey study in which 82% of primary care providers had some familiarity with CBT-I, but only 10% had a good understanding and use it in their practice.…”

Insomnia in Primary Care: Misreported, Mishandled, and Just Plain Missed

“…11 It is with this information in mind that the paper by Ulmer and colleagues in this issue of Journal of Clinical Sleep Medicine explores the beliefs, attitudes, and behaviors of VA primary care clinicians regarding insomnia. 12 Overall, the results of this study show that insomnia is frequently misreported or not reported in the medical record, on many occasions mishandled through provision of suboptimal care, and often just plain missed-not discussed or brought up at all. Ulmer and colleagues report that the plurality of clinicians surveyed believed that insomnia symptoms were experienced by 20% to 39% of their patients.…”

“…What is also disturbing is that Ulmer and colleagues report that even within the VA system, recommended first-line treatments are not used. 12 When clinicians were asked how they responded to insomnia, the most common response was counseling on healthy sleep hygiene, which is known to be ineffective for treating insomnia.…”

Issues and challenges in implementing clinical practice guideline for the management of chronic insomnia

“…depression, hypertension, work absenteeism). Not surprisingly, insomnia complaints often remain undiagnosed and untreated (Cheung et al ., ; Ulmer et al ., ). When treatment is initiated, treatment trajectories vary widely depending on individual and contextual factors, such as knowledge about treatment options, availability of treatment and the type of professional from whom someone seeks help (physician, psychologist, pharmacist, nurse).…”