Health Services Research & Development

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2017 HSR&D/QUERI National Conference Abstract

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1075 — A Mixed Method Assessment of Sleep Needs and Barriers of Veterans with SMI

Lead/Presenter: Elizabeth Klingaman
All Authors: Klingaman EA (VISN 5 Mental Illness Research, Education, and Clinical Center; University of Maryland School of Medicine Department of Psychiatry) Lucksted AA (VISN 5 Mental Illness Research, Education, and Clincal Center; University of Maryland School of Medicine Department of Psychiatry) Crosby E (VISN 5 Mental Illness Research, Education, and Clinical Center) Bennett ME (VISN 5 Mental Illness Research, Education, and Clinical Center; University of Maryland School of Medicine Department of Psychiatry)

Objectives:
Sleep problems are prominent in people with serious mental illness (SMI; up to 80%) and worsen mental illness, health, quality of life, and suicide risk. The VHA is disseminating the gold standard of insomnia care, Cognitive-Behavioral Therapy for Insomnia (CBT-I), as a national evidence-based psychotherapy for VA clinicians. However there is a dearth of research on the applicability and accessibility of CBT-I for Veterans with SMI. The current study utilizes a mixed-methods design to characterize the sleep treatment needs of Veterans with SMI and provider perspectives on implementation within the VHA.

Methods:
Veterans with SMI and sleep dissatisfaction were recruited for quantitative (n = 60) and qualitative (n = 25) interviews; VA SMI health providers were recruited for qualitative interviews (n = 8). Medical record review determined insomnia diagnosis and insomnia treatment history. Participants completed assessments of insomnia severity and sleep-related behaviors and cognitions; multivariate analyses predicted insomnia severity from these factors. Phenomenological qualitative analyses explored Veteran and provider experiences receiving and delivering sleep treatment, respectively.

Results:
Most participants (81.66%) reported moderate to severe insomnia, yet less than 1% were formally diagnosed. A significant proportion of variance was explained in insomnia severity by cognitive and behavioral factors in the multivariate analysis, R2 = .31, F(6,53) = 4.00. No Veteran had been offered CBT-I, despite many wanting non-pharmacological sleep treatment. The central barrier to offering CBT-I to this population was a lack of VHA-disseminated guidance for how to apply it in the context of clinical challenges; providers who found innovative and effective solutions to these obstacles did so largely through trial-and-error.

Implications:
Veterans with SMI presented with symptoms that may be well-addressed by gold-standard evidence-based interventions, yet none were receiving and most were unaware of these treatments. Results suggest the need for nationally-disseminated guidance on innovative and effective applications of evidenced-based treatments to the needs of this underserved population in order to accelerate implementation.

Impacts:
Addressing insomnia among Veterans with SMI is an essential, but largely overlooked component of both prevention and wellness enhancement. The VHA Uniform Mental Health Services Handbook clearly states that Veterans with SMI must be offered quality interventions comparable to the care received by other Veterans. This inequity should be addressed through large-scale dissemination of clinical practice guidelines for this population.