Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Despite the significant impacts of insomnia, it remains under-treated. When identified, insomnia is most often treated in the primary care setting with pharmacotherapy, rather than evidence-based psychotherapy-Cognitive Behavioral Treatment for Insomnia (CBTI)-which is effective and recommended over prescription sleep medications. However, a number of system-, provider-, and patient-level barriers, as well as treatment-related barriers, contribute to the gap between the high prevalence of insomnia and access to CBTI. To increase the viability of behavioral treatments for insomnia in the VA, it is critical to determine which behavioral treatments are most effective, and which implementation factors (e.g., barriers and facilitators to care) most impact uptake of treatments by patients and providers into routine clinical practice. Compared to CBTI, a treatment that is shorter (?4 sessions), allows for phone delivered treatment, and can also be delivered by non-doctoral level clinicians (e.g., nurses) may help to overcome barriers that limit access to insomnia care. Brief Behavioral Treatment of Insomnia (BBTI) offers the treatment flexibility that can increase access and is efficacious among Veterans and military personnel. Furthermore, BBTI's aforementioned characteristics make it an ideal intervention for delivery in the context of collaborative, integrated primary care within VA's Primary Care Patient-Aligned Care Teams (PACTs) and Primary Care-Mental Health Integration (PC-MHI) initiatives. Uptake of BBTI into PACTs could effectively and efficiently increase access to insomnia treatment and thus decrease the risks and burdens associated with chronic insomnia. Although efficacious, it is not known if BBTI achieves the same clinical outcomes as CBTI, a VA supported evidence-based psychotherapy. Additionally, the implementation factors associated with the delivery of BBTI in PACTs from the perspective of providers and patients remains unknown. Broad implementation of BBTI in Primary Care PACTs could have a significant impact on Veteran health and healthcare, but it is necessary to determine which treatment-CBTI or BBTI- yields the best outcomes with the least patient, provider, and system barriers. My long-term career goal is to be a VA HSR&D Investigator with a program of research on the dissemination and implementation of behavioral treatments for insomnia, and methods to decrease the impact of insomnia on Veteran health. My proposed CDA will support training in new research methods and analytic strategies, and the conduct of research activities necessary for transition to independence. My proposed Research Aims are: (1) to conduct a pilot comparative effectiveness trial of BBTI vs. CBTI; and (2) to conduct a qualitative needs assessment to identify factors associated with the implementation of behavioral treatments for insomnia in Primary Care PACTs. My proposed Training Aims are: (1) to gain proficiency in quantitative methods and analytic strategies for comparative effectiveness research, including: recruitment, measurement of outcomes, and equivalency analysis; (2) to develop expertise in health services research and implementation science, including the application of theoretical frameworks, and the design, conduct, and evaluation of implementation trials; and (3) to learn advanced skills in qualitative methods and analyses for use in health services research, including: data collection methods (e.g., interviews, focus groups), data analytic methods, and the use of software for data analysis.
Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Evidence-based psychotherapies, such as brief behavioral treatment for insomnia (BBTI) and cognitive behavioral treatment for insomnia (CBTI), are effective treatments and are recommended over prescription sleep medications. However, a gap exists between the high prevalence of insomnia in Veterans and access to treatments like BBTI and CBTI. Uptake of BBTI into routine clinical care in VA primary care settings, where insomnia is typically first recognized, may effectively and efficiently increase access to these needed interventions and help decrease the risks and burdens related to chronic insomnia.
| Bramoweth, Adam D; Germain, Anne; Youk, Ada O et al. (2018) A hybrid type I trial to increase Veterans' access to insomnia care: study protocol for a randomized controlled trial. Trials 19:73 |
| Koffel, Erin; Bramoweth, Adam D; Ulmer, Christi S (2018) Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. J Gen Intern Med 33:955-962 |
| Bramoweth, Adam D (2017) A Step in the Right Direction: Moving Toward Increased Access to Insomnia Care. J Clin Sleep Med 13:161-162 |
