By Allison T. Siebern, Ph.D., CBSM
I was a Clinical Assistant Professor at Stanford University's Sleep Medicine Center, the first sleep center in the world. For many years I helped patients improve their sleep using non-pharmacological treatments. In 2010, I was asked to join a team of eight sleep experts from around the nation to help the Department of Veterans Affairs (VA) develop training to make insomnia treatment more accessible to Veterans. That experience changed everything for me.
There is a great need for insomnia treatment within the VA to treat Veterans' disrupted sleep. One of the most common sleep disorders, insomnia, has an estimated prevalence rate of 40% in the Veteran population (1) as compared to 10-15 percent in the general population (2). Insomnia disorder is defined as difficulty getting to sleep, or difficulty staying asleep, with daytime impairment or distress as a result. The preferred treatment for insomnia is called cognitive behavioral therapy for insomnia (CBT-I) and is considered a first-line treatment by the American Academy of Sleep Medicine (3) and by the 2005 State of the Science Consensus meeting (4).
CBT-I is a multicomponent approach that addresses patients' sleep-interfering behaviors and cognitions and is deemed very effective even in studies comparing it to sleep medications (5, 6). Outcomes from Veterans that received the CBT-I treatment included improvement in sleep and quality of life and a decrease in suicidal thoughts and depressive symptoms (7, 8). During my work on this training - which was a national dissemination initiative to train mental health providers in using CBT-I to treat their Veteran patients - I not only was proud to be a part of the initiative but also the seed was planted in my mind to one day join the VA as a frontline provider and start a sleep health program.
A noteworthy item which is not well-known to the general public is that there is a field of behavioral sleep medicine (BSM) specialists that provides non-pharmacological treatments for many sleep disorders (9, 10). There are only 213 providers certified in behavioral sleep medicine by the American Board of Sleep Medicine nationally, and only 10 work for the VA system.
CBT-I is one sleep treatment among many that a behavioral sleep medicine specialist can offer. A provider with behavioral sleep medicine experience can treat more sleep disorders than just insomnia. Other treatable conditions include nightmares and circadian rhythm disorders (such as shift work, being a "night owl" or "morning lark"), as well as helping patients maintain or improve sleep while the patient works with their prescribing provider to gradually discontinue use of sleep medications, and assisting patients to acclimate to using continuous positive airway pressure (CPAP) to treat sleep apnea.
I was part of the VA CBT-I national dissemination initiative for nearly 5 years and the experience led to my departure from Stanford, at which time I was Director of the Behavioral Sleep Medicine Program. A unique opportunity presented itself to join one of the fastest growing VAs in the country and to start a sleep program. Thanks to the forward-thinking leadership at the Fayetteville, NC Veterans Affairs Medical Center (FNCVAMC), a Sleep Health Integrative Program (SHIP) is being created to help Veterans with disrupted sleep. It is an honor to bring my experience to the VA to establish this program.
I am very fortunate to have the FNCVAMC leadership's support in creating this model of care and making Veterans' sleep health a priority. Since my transition, I am often asked why I would leave a career at Stanford University's School of Medicine, and to that I reply: "To help the Veterans, of course!" Helping Veterans improve their sleep health is a passion for me and I am very grateful that I have the opportunity to do the work that I love.
Sources:
1. Mustafa, M., Erokwu, N., & Strohl, K. Sleep problems and the risk for the sleep disorders in an outpatient veteran population. Sleep Breath 2005;9(2):57-63.
2. Ohayon, M. Epidemiology of insomnia; what we know and what we still need to learn. Sleep Med Rev 2002; 6: 97-111.
3. Morgenthaler, T., et al. Practice Parameters for the Psychological and Behavioral Treatment of Insomnia: An Update. An American Academy of Sleep Medicine Report. Sleep 2006; 29(11): 1415-1419.
4. NIH State-of-the-Science Conference Statement on manifestations of management of chronic insomnia in adults. NIH Consens State Sci Statements 2005; 22(2): 1-30.
5. Siversten, B., et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA 2006; 295(24):2851-8.
6. Morin, C., etc. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA 2009; 301(19):2005-15.
7. Karlin, B., et al. National dissemination of cognitive behavioral therapy for insomnia in veterans: therapist- and patient- level outcomes. J Consult Clin Psychol 2013; 81(5): 912-7.
8. Trockel, M., et al. Effects of cognitive behavioral therapy for insomnia on suicidal ideation in veterans. Sleep 2015; 38(2):259-265.
9. American Board of Sleep Medicine certified behavioral sleep medicine specialist: http://www.absm.org/BSMSpecialists.aspx
10. Society of Behavioral Sleep Medicine. Find a BSM provider http://www.behavioralsleep.org/FindSpecialist.aspx
Dr. Allison Siebern is a sleep psychologist at the Fayetteville, NC Veterans Affairs Medical Center. She is a consulting assistant professor at Stanford Center for Sleep Sciences and Medicine where she remains involved in the training of sleep medicine postdoctoral fellows and research. This Center is the birthplace of sleep medicine and includes research, clinical, and educational programs that have advanced the field and improved patient care for decades. To learn more, visit us at: sleep.stanford.edu.