As the number of women Veterans increases due to changes in the composition of the active duty military, understanding the healthcare needs of this growing segment of the patients we serve is of utmost importance. In 2011, we completed the first study of sleep issues among women Veterans who receive VA healthcare (HSRD PPO09-282-1; PI: Martin). Based on that study, 54% of respondents met diagnostic criteria for an insomnia disorder, a rate substantially higher than expected based on research with non-Veteran women. There is a strong evidence base and identified "best practices" for the treatment of insomnia, and VHA is currently training mental health clinicians across the country to provide Cognitive-Behavioral Therapy for Insomnia (CBT-I) within an Evidence Based Psychotherapy (EBP) roll-out. While insomnia is a clinical condition receiving increasing attention from VA, the current plan for dissemination of CBT-I does not emphasize issues specifically relevant to women Veterans (e.g., military sexual trauma, menopause). In addition, the high rates of insomnia in our preliminary study suggested the current plan to train a relatively small number of mental health providers to deliver individual psychotherapy for insomnia may not sufficiently address the issue. As a result, there is a pressing need to determine the nationwide scope of the problem so we may consider whether additional treatment options and/or adaptation of currently-available services are needed. This project therefore falls in line with QUERI Step 1: Identify high risk/high volume diseases/problems.
The specific aims of this project were: AIM 1: to establish the national prevalence of insomnia among women Veterans who receive VA healthcare, and AIM 2: to evaluate insomnia treatment preferences among women Veterans with insomnia across the nation. Two exploratory aims were: AIM 3: identify differences in rates of insomnia across age groups and period of service cohorts, and AIM 4: identify differences in insomnia treatment preferences across age groups and period of service cohorts. In addition, we requested a modification to the project to add two more exploratory aims: AIM 5: explore predictors of engagement with healthcare providers regarding insomnia; and AIM 6: explore predictors of insomnia treatment preferences and potential barriers and facilitators to accessing evidence-based care.
This descriptive survey study of women Veterans who use VA services across the nation was carried out in three phases. In Phase I, an expanded version of our previously developed and validated insomnia postal survey was pilot tested in a sample of 100 women Veterans from our existing database, and a subset of respondents completed cognitive interviews to assess face validity of survey items and obtain feedback about the structure and length of the survey. In Phase II, a Technical Advisory Panel, including local experts in sleep, women's health and implementation science, met and reviewed the pilot survey responses. The survey was finalized, and in Phase III it was distributed to a national random sample of women Veterans (n=4,000). Nonresponders were mailed a second survey, followed by an opportunity to complete the survey over the telephone. The survey included questions to assess the International Classification of Sleep Disorders (ICSD) diagnostic criteria for an insomnia disorder (A: disturbed sleep; B: despite adequate opportunity/circumstances; C: with daytime consequence; D: disturbed sleep lasting > 3 months), plus demographics, health-related factors, psychiatric comorbidities, psychosocial factors, and insomnia treatment preferences. In this report, unadjusted percentages are used for all findings.
Response rate and respondent characteristics: Surveys were mailed to a random sample of 4,000 women Veterans, and 1,559 surveys were returned by mail or completed by telephone (response rate = 39%). Respondents had a mean age of 52 (15 SD) years, 41% were married, 41% were employed for wages, and 38% indicated a racial or ethnic category other than white.
AIM 1: Respondents were asked if they had problems with sleep and to indicate the duration of their sleep problem. Using this single item, 81.6% of respondents reported sleep problem for 3 months or longer, 46.5% reported sleep problems lasting more than 5 years, and 28.1% more than 10 years.
Using ICSD insomnia criteria, we calculated the percentage of respondents that met each criterion. Overall, 94.6% met Criterion A, of whom 78.2% had adequate circumstances for sleep (Criterion B). Of those, 97.1% reported daytime consequences (Criterion C), and 91.5% of women meeting criteria A-C reported sleep problems lasting more than 3 months for an overall rate of insomnia of 65.1% [95% CI = (62.7%, 67.5%00].
Using the Insomnia Severity Index items, 42% of respondents had moderate to severe insomnia, 33% had subthreshold insomnia, and 25% had no insomnia.
AIM 2: Respondents were asked to rate the acceptability of medication and non-medication treatments for insomnia using select items from the Treatment Acceptability Profile (TAP). Insomnia treatment preferences were categorized as: 1) both behavior therapy and medication equally acceptable (46.4% of respondents); 2) only behavior therapy acceptable (35.2%); 3) only medication acceptable (9.5%); and 4) neither behavior therapy or medication acceptable (8.8%). Overall, more respondents rated behavior therapy than medication as acceptable (81.6% vs. 55.2%, p<.01).
When asked where they would prefer to receive treatment for insomnia, over half of respondents selected primary care (55.6%) or women's clinic (54.4%), while only 27.1% selected mental health. When asked from whom they would prefer to receive treatment for insomnia, the majority of respondents (80%) chose physician while less than one third chose psychiatrist or psychologist.
AIMS 3 & 4 (EXPLORATORY): insomnia rates varied as a quadratic function of age with predicted insomnia rates at ages 20, 40, 50, and 80 years of 60.4%, 67.5%, 65.7%, and 54.3%, respectively. The maximum predicted insomnia rate was at age 29 (67.5%). The results of the period of service cohort analysis aligned closely with the age-based results.
There were differences in treatment acceptability across age groups. Respondents younger than 65 years rated both behavior therapy and medication as acceptable (49.7%), followed by behavior therapy only (34.3%). For respondents 65 years and older, their greatest acceptability was for behavior therapy only (40.0%) followed by behavior therapy and medication (29.4%). Only 10% of respondents (regardless of age) reported medication as the only acceptable treatment. Interestingly, 20% of respondents aged 65 years and older found neither treatment approach acceptable.
A comparison of treatment acceptability by period of service cohort mirrored the results found with respect to age and no unexpected or notable patterns other than the trends associated with age were observed.
AIM 5 (EXPLORATORY): No demographic or health-related measures were associated with respondents' ratings of treatment acceptability. The availability of insomnia treatment within primary care and providing behavior therapy in individual sessions were identified as possible facilitators to treatment, while costs of treatment and distance from home were identified as possible barriers to access.
AIM 6 (EXPLORATORY): In total, 58.3% of respondents reported having spoken with a healthcare provider about sleep. Among respondents who reported a sleep problem for 3 months or longer, age was a significant predictor of speaking with a provider. Among those younger than 65 years, 70.8% reported having spoken to a provider about their sleep problem while only 56.1% of respondents aged 65 years and older had done so (p<.001). Other significant predictors of speaking to a provider about sleep included having chronic pain or a mental health condition and rating one's health as fair or poor.
Using a national sample and rigorous survey methodology, this study confirmed the high prevalence of insomnia among women Veterans. Depending upon the definition used, the most conservative estimate (ICSD diagnostic criteria) suggests that nearly 2/3 of respondents have clinically-significant insomnia. Respondents clearly indicated that they are interested in approaches to insomnia that include both behavioral (non-medication) and medication strategies. There was a clear indication that women want to receive these treatments from providers in primary care settings as opposed to mental health, and that they want this care to be convenient (i.e. close to where they live) and inexpensive. This is, in fact, consistent with VA's efforts to integrate mental health services into primary care. Evidence-based insomnia treatment could be considered a key target for such efforts. In particular, short-term cognitive-behavioral approaches are likely to be best-received by women Veterans, and women's health providers should be trained in this approach. Additional studies are needed to identify the optimal methods for implementation of best practices of care, including both medication and non-medication approaches, for the considerable segment of the women Veteran population with insomnia disorders.
- Martin JL, Carlson G, Kelly M, Fung CH, Song Y, Mitchell MN, Zeidler MR, Josephson KR, Badr MS, Zhu R, Alessi CA, Washington DL, Yano EM. Sleep apnea in women veterans: results of a national survey of VA health care users. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2021 Mar 1; 17(3):555-565.
- Schweizer CA, Hoggatt KJ, Washington DL, Bean-Mayberry B, Yano EM, Mitchell MN, Alessi CA, Martin JL. Use of alcohol as a sleep aid, unhealthy drinking behaviors, and sleeping pill use among women veterans. Sleep health. 2019 Oct 1; 5(5):495-500.
- Martin JL, Schweizer CA, Hughes JM, Fung CH, Dzierzewski JM, Washington DL, Kramer BJ, Jouldjian S, Mitchell MN, Josephson KR, Alessi CA. Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 May 1; 27(3):366-373.
- Culver NC, Song Y, Kate McGowan S, Fung CH, Mitchell MN, Rodriguez JC, Dzierzewski JM, Josephson KR, Jouldjian S, Washington DL, Yano EM, Schweizer CA, Alessi CA, Martin JL. Acceptability of Medication and Nonmedication Treatment for Insomnia Among Female Veterans: Effects of Age, Insomnia Severity, and Psychiatric Symptoms. Clinical therapeutics. 2016 Nov 1; 38(11):2373-2385.
- Song Y, Washington DL, Yano EM, McCurry SM, Fung CH, Dzierzewski JM, Rodriguez JC, Jouldjian S, Mitchell MN, Alessi CA, Martin JL. Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans. Behavioral sleep medicine. 2018 Jul 1; 16(4):371-379.
- Adachi M, Fung CH, Song Y, Dzierzewski JM, Rodriguez J, Mitchell MN, Jouldjian S, Washington DL, Yano EM, Badr M, Alessi C, Martin J. OSA and psychiatric symptoms in a national sample of women veterans. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2016 Jun 11; Denver, CO.
- Culver NC, McGowan MG, Fiorentino L, Fung CH, Song Y, Dzierewski JM, Rodriguez J, Mitchell M, Jouldjian S, Josephson K, Washington DL, Yano EM, Alessi C, Martin JL. Treatment preferences among women veterans with insomnia. Poster session presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2016 Jun 11; Denver, CO.
- Martin J, Alessi CA, Mitchell MN, Jouldjian S, Fung CH, Yano EM, Washington DL. Sleep Disorders among Women Veterans: Results of a National Survey. Presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
Mental, Cognitive and Behavioral Disorders