Journal Article Review - Michael Nadorff, PHD

Identifying the Demographic and Mental Health Factors That Influence Insomnia Treatment Recommendations Within a Veteran Population

Adam D. Bramoweth ORCID Icon, Jenna G. Renqvist, Barbara H. Hanusa, Jon D. Walker, Anne Germain & Charles W. Atwood Jr.

Pages 181-190 | Published online: 02 May 2017

Those of you who frequently read The Sleep Talker likely already know I am a huge fan of implementation science.  One can have the best treatment in the world,but if you cannot implement it in the real world, or it is not used, it is not worth much.  Sadly, our interventions commonly have this issue: they are very good,as many of us have shown time and time in our research, but they are not commonly utilized .  We have gotten the recognition the treatments deserve in the AASM treatment guidelines, but those recommendations are often not followed.

So what gives?  Why is it that despite the strength of evidence for CBT-I, and the recommendations supporting its use, I still see so many clients prescribed trazodone for sleep?  Perhaps the first step is looking at prescriptions/referrals to see when hypnotics are being prescribed vs. CBT-I referrals are being made.

Bramoweth and colleagues (2019) examined this question in more than 5,000 Veterans who were referred for either CBT-I or a hypnotic medication.  The authors found that, unsurprisingly and dishearteningly, that hypnotic prescriptions far outnumbered CBT-I referrals.   Factors that increased CBT-I referrals were military service-related disability, insomnia diagnosis, and having one or more psychiatric diagnoses.  On the other side, having a diagnosis of PTSD decreased the likelihood of a CBT-I referral.   

These findings are very interesting, as it is not that prescribers are not making referrals, but they appear to be to vary referrals based upon other factors. 

Why is it that prescribers are less likely to send patients with PTSD our way?  Certainly there is research that demonstrates CBT-I is still effective with PTSD (e.g. Taylor & Pruiksma, 2014).  Perhaps we need to reach out to our prescriber colleagues and make sure they are aware of this research, or ask them what barriers exist for CBT-I referrals? 

Regardless, Bramoweth and colleagues (2019) show that there is a great need for implementation work in behavioral sleep medicine, and they lay important groundwork for this research.  If you are interested in this topic as well, there is a career to be had in improving the utilization of behavioral sleep medicine interventions.  It is very valuable work!