Contents
Key Points
  • Consider using the DVA-funded Australian Defence Force (ADF) Post-discharge GP Health Assessment to help identify mental and physical health problems
  • Consider cognitive behavioural therapy for insomnia (CBTi) as the first-line treatment
  • Review medicines and other substances your patient is using to help them sleep
  • With your patient, plan to stop benzodiazepine or related hypnotic use

Helping veterans learn to sleep well

Insomnia and related sleep disturbances are common among veterans.1-4 Unique military-specific factors and post-deployment mental and physical health issues, including post-traumatic stress disorder (PTSD), contribute to many veterans experiencing sleep disturbances.2, 3, 5

Key symptoms of insomnia include having difficulty falling asleep or staying asleep, or waking earlier than intended, which causes distress, tiredness and impaired daytime functioning.6 Chronic insomnia occurs when this persists on at least three nights a week for three months.6

Often veterans seek help only when insomnia has become chronic, and cognitive, behavioural and social habits contribute to its persistence.7, 8 Cognitive behavioural therapy for insomnia (CBTi) is evidence based and an effective therapy for treating insomnia.5, 9, 10 Benzodiazepines and related (Z) hypnotics are less effective than CBTi in the long-term,11, 12 and are associated with adverse effects, dependence, tolerance and misuse.13 Guidelines recommend CBTi as the first-line treatment.13, 14

  What-veterans-told-us  

The health consequences of insomnia can be substantial

Insomnia affects cognitive, occupational, emotional, social and physical health.6, 7 It can reduce a veteran’s ability to cope with daily stressors and health-related issues, and to fully reintegrate into civilian life after deployment.16

Chronic insomnia is associated with:

  • a two-fold risk of developing depression17, 18
  • a three-fold risk of developing anxiety19 and hypertension20
  • an increased risk of developing cardiometabolic diseases, including obesity, diabetes, stroke and coronary heart disease.21
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Assess your veteran patients for insomnia and related sleep disturbances

About veterans and sleep
  • Sleep disturbances experienced by veterans can include insomnia, hypersomnia, circadian rhythm sleep disorders or poor sleep quality due to sleep apnoea, restless legs syndrome or nightmares.3, 4
  • Insomnia can be complex in veterans; it is often a symptom of other disorders including depression, anxiety, PTSD, substance misuse, or somatic disorders, such as pain, nocturia or dyspnoea.2, 14, 22-25
  • Sleep disturbances are highly prevalent in veterans who have PTSD with many reporting insomnia, nightmares, sleep avoidance, sleep terrors, fragmented sleep or hypervigilance.3, 26-28
  • Some veterans with underlying mental health issues may be hesitant to seek treatment.1, 22, 29
  • Insomnia and comorbid disorders have a bidirectional relationship, with each influencing the other and needing specific clinical attention and treatment.7

When assessing for insomnia or other sleep disturbances, consider sleep history, typical sleep patterns, and medical, substance and mental health history.8, 22 In particular, ask your patient if they have nightmares or avoid sleep for fear of having nightmares. If they do, ask them if they have experienced any recent or past stressful or traumatic situations (see symptom clusters of PTSD).5, 30

Review medicines, those prescribed and purchased over-the-counter, and other substances taken that may disturb sleep, including alcohol, caffeine, beta blockers, diuretics, selective serotonin reuptake inhibitors (SSRIs) and selective and noradrenaline reuptake inhibitors.13, 31

Symptom clusters of post-traumatic stress disorder

Veterans with PTSD may present differently, but they have at least one symptom from each of the following clusters:22

  • The traumatic event/s is re-experienced through distressing memories, dreams or nightmares.22, 28
  • The veteran avoids reminders of the trauma, including thoughts, feelings, people, places and activities.22, 28
  • Negative moods and thoughts persist. The veteran may blame themselves or others with regard to the trauma, they may have diminished interest in activities, or feel numb or detached from others.22, 28
  • Veterans may experience hyperarousal, including irritable or self-destructive behaviour, hypervigilance, exaggerated startle response, anger, insomnia or an inability to concentrate.22, 28

For detailed information about PTSD and treatment options, refer to the ‘Australian guidelines for the treatment of acute stress disorder & posttraumatic stress disorder’ at: www.phoenixaustralia.org/resources/ptsd-guidelines/

Ask your patient to keep a sleep diary. For some patients, a sleep diary can show that they get more sleep than they think which can help relieve some of their anxiety about not sleeping.7 Download a sleep diary at: http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf

A useful tool to help identify mental or physical health problems, including insomnia or PTSD in former serving members of either the permanent or reserve forces is the DVA-funded ADF Post-discharge GP Health Assessment. It is available once per lifetime and is funded under health assessment items 701, 703, 705 and 707 on the Medicare Benefits Schedule.32 It can be accessed from some GP practice software packages or from the DVA At Ease professional portal at: https://at-ease.dva.gov.au/professionals/assessment-treatment/veteran-health-check

Consider referring your patient to a health professional who specialises in sleep if there is suspicion of sleep apnoea or other sleep disorders, the diagnosis is unclear, for advice about treatment, or if your patient has a long history of sleep difficulties or fails to respond to therapy.14

For veterans with PTSD, consider early referral to a health professional trained in trauma-focused psychological interventions for treatment.22

DVA funds treatment for any mental health condition, including insomnia and PTSD, without the need for the condition to be accepted as related to service. Further information on eligibility for this Non-Liability Health Care is available on the DVA website at: www.dva.gov.au/health-and-wellbeing/mental-health/non-liability-health-care

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Educate your patients

About sleep
  • The need for sleep varies from person to person, but the average amount of sleep for an adult is seven to nine hours.33
  • It is normal to wake briefly several times a night.34
  • With increasing age, the need for sleep lessens and sleep patterns change to include waking up more often and staying awake for longer periods.34
  • For people with insomnia, these normal awakenings can cause anxiety about being awake and not being able to get back to sleep.34

Many people over-estimate their sleep disruption and under-estimate their actual sleep time.7 Explain to your patient that it is possible to wake up from light sleep at the end of a sleep cycle and not realise they have slept at all.34

Reassure your patient that brief awakenings during the night will not necessarily affect how they feel or function the following day.35 Ask them how they function during the day.36

Naps taken during the day, especially if longer than 30 minutes, can reduce the amount of sleep needed during the night.34 Ask about daytime naps, and include this time when calculating your patient’s total sleep time.31

Refer your patients to Resources for veterans in the insert to access advice and tips for improving sleep.

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Explain that cognitive behavioural therapy for insomnia is effective

About cognitive behavioural therapy for insomnia
  • The core components include educational, cognitive and behavioural interventions that aim to change unhelpful thoughts, habits and beliefs about sleep (see core components of CBTi).8
  • In-person and internet-based CBTi are more effective than pharmacotherapy in the long-term, without the side effects associated with pharmacotherapy.12, 37, 38
  • Improvements in sleep are sustained and may even increase after treatment.37
  • Quality of sleep may be better than with pharmacotherapy.12

Most psychologists trained in cognitive behavioural therapy can deliver CBTi. See the insert to find a psychologist in your area.

If your patient is undertaking in-person CBTi, inform them that typically four to eight sessions are needed over four to eight weeks.7, 38 Consider the CBTi Coach app which is designed to be used in conjunction with face-to-face therapy. See insert for further details. If your patient is undertaking internet-based CBTi, support them during therapy by maintaining contact to monitor their progress and to encourage completion of treatment.39 See the insert to find an internet-based CBTi program.

If in-person CBTi is unavailable in your area, or your patient is not comfortable with or has no access to internet-based CBTi, or if it suits your patient better, consider offering Brief Behavioural Therapy for Insomnia. Brief Behavioural Therapy for Insomnia, which includes stimulus control, sleep restriction and sleep hygiene can be delivered by a GP or a practice nurse.40, 41 It requires no specialist training and is usually delivered over four consecutive weeks.41 Further information can be accessed from the Royal Australian College of General Practitioners’ website at: www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/mental-health/brief-behavioural-therapy-for-insomnia-in-adults

 

Core components of cognitive behavioural therapy for insomnia

Stimulus control

  • Aims to build and strengthen the association between the bedroom environment and sleep by avoiding activities not related to sleep in the bedroom, and by excluding sleep from living areas.7

Sleep restriction

  • Aims to induce natural sleepiness and give a sense that the bedroom is a safe place to sleep by limiting the time spent in bed to actual sleep time.7, 40

Relaxation therapy

  • Promotes muscle relaxation and quietens a ‘chattering’ mind by using breathing, self-hypnosis, mindfulness and meditation techniques and visual imagery.7, 39

Cognitive therapy

  • Aims to identify unhelpful beliefs, thoughts and behaviours about sleep, introduce thoughts and beliefs that promote sleep, and reduce tension and worries through a range of behavioural interventions.7

Sleep hygiene education

  • Emphasises environmental factors and habits that promote sound sleep, including exercise, but not immediately before bedtime, avoiding caffeine and alcohol and not napping or using electronic devices before bedtime.7
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Is there a place for medicines in the treatment of insomnia?

While CBTi is the most effective intervention for insomnia, it may not suit all veterans across all circumstances.8

Short-term or intermittent pharmacotherapy may be required for some people, especially at the start of treatment and in conjunction with cognitive behavioural therapies, for patients unable or unwilling to pursue cognitive behavioural therapies or for patients whose insomnia is severe or resistant.8, 36

If pharmacotherapy is required, be clear that it will be a time-limited component of a broader treatment plan and not a sole treatment.8, 13, 31 Use for the shortest possible time at the lowest effective dose, monitor for adverse effects, check your patient’s response and assess the need for its ongoing use at each visit.36 Be aware that your patient may have been started on a hypnotic while in hospital.

It is uncertain how newly marketed medicines for sleep compare with older hypnotics. But like older hypnotics, new medicines should only be used for a short period of time and not as a sole treatment.13 If starting a newly marketed medicine for sleep, monitor for long-term adverse effects, dependence or misuse potential as these are unknown.13

Some veterans have complex physical or mental comorbidities, such as PTSD, domestic violence, gambling, and alcohol or substance use disorders.22 Management of these patients can be extremely complex and may need referral for specific treatment.22

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Emphasise the importance of starting to reduce the dose

About the harms of benzodiazepine use in Australia
  • For every 17 DVA patients aged 80 years and over who start a benzodiazepine and an SSRI together, there will be one extra hip fracture a year.42
  • For every 32 DVA patients aged 80 years and over who add a benzodiazepine to a current SSRI, there will be one extra hip fracture a year.42
  • Almost 37% of unintentional and suicidal drug-related deaths in 2016 involved the misuse of benzodiazepines alone or in combination with other drugs, including opioids and alcohol.43
  • Benzodiazepines and alcohol, when used together, are associated with an almost eight-fold increased risk of having an accident while driving or using machinery.44

Explain that the benefits of reducing the dose are worthwhile.36

With your patient, discuss and agree to trial a dose reduction. Explain that the dose will be reduced slowly to minimise withdrawal symptoms.36

Acknowledge that reducing the dose can be stressful for some people and might take some time, especially if hypnotics have been used long-term or at high doses.36

Explain that undertaking psychological interventions including CBTi,45 and relaxation techniques,36 and involving family22 can help make the process easier.

For extra support and information about tapering any hypnotic, refer to the insert Resources for helping veterans learn to sleep well.

A guide to tapering hypnotic use36

Duration of use

Duration of tapering

Comments

Less than
6 to 8 weeks

Taper-down
  • Consider tapering if your patient is using a high dose or the hypnotic has a short or intermediate half-life.

8 weeks to 6 months

Taper-down
  • Base the tapering rate on the medicine used, duration of use, dose, possible withdrawal symptoms, underlying issues and patient-specific factors.

6 months to 1 year

Taper-down
  • Taper the dose slowly with a pause between each dose reduction to allow withdrawal symptoms to resolve. Withdrawal symptoms may include anxiety, dysphoria, agitation, sweating, hypertension, rebound insomnia, nightmares or vivid dreams. Seizures are rare.

More than 1 year

Taper-down
  • Tapering may not eliminate all withdrawal symptoms completely.
  • Go slower during the latter half of tapering.
  • Advise your patient to avoid alcohol and stimulants.

For further information about withdrawal symptoms and guidance to tapering schedules for benzodiazepines and other hypnotics, refer to ‘Prescribing Drugs of Dependence in General Practice, Part B, Benzodiazepines’ at: www.racgp.org.au/download/Documents/Guidelines/Addictive-drugs/Addictive-drugs-guide-B.pdf

Resources for helping veterans learn to sleep well

Resources for health professionals

Cognitive behavioural therapy for insomnia (CBTi)
Veteran-specific resources
General insomnia resources
For extra support when your patient is tapering and ceasing hypnotic use

Resources for veterans

Cognitive behavioural therapy for insomnia (CBTi)
Apps that may be helpful
  • CBTi Coach is a free smartphone app developed by the US Department of Veterans Affairs, designed to be used in conjunction with face-to-face therapy. It is available from iTunes on the App Store for iOS devices and from Google Play.
  • The High Res App helps veterans and families manage daily stresses and transition to civilian life, available on the DVA At Ease website at:
    http://at-ease.dva.gov.au/veterans/resources/mobile-apps/high-res-app/

References

  1. Plumb T, Peachey J, Zelman D. Sleep disturbance is common among servicemembers and veterans of Operations Enduring Freedom and Iraqi Freedom. Psychol Serv. 2014; 11: 209-19.
  2. Lew H, et al. Impact of the "polytrauma clinical triad" on sleep disturbance in a department of veterans affairs outpatient rehabilitation setting. Am J Phys Med Rehabil. 2010; 89: 437-45.
  3. Baird T, et al. Sleep disturbances in Australian Vietnam veterans with and without posttraumatic stress disorder. J Clin Sleep Med. 2018; 14: 745-752.
  4. Alexander M, et al. The National Veteran Sleep Disorder Study: descriptive epidemiology and secular trends, 2000-2010. Sleep. 2016; 39: 1399-410.
  5. Phelps A, Varker T, Metcalf O, Dell L. What are effective psychological interventions for veterans with sleep disturbances? A rapid evidence assessment. Mil Med. 2017; 182: e1541-e1550.
  6. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association, Arlington, VA. 2013.
  7. Cunnington D, Junge M, Fernando A. Insomnia: prevalence, consequences and effective treatment. MJA. 2013; 199(8): S36-S40.
  8. Ree M, Junge M, Cunnington D. Australasian Sleep Association position statement regarding the use of psychological/behavioral treatments in the management of insomnia in adults. Sleep Med. 2017; 36 Suppl 1: S43-S47.
  9. Alessi C, et al. Cognitive behavioral therapy for insomnia in older veterans using nonclinician sleep Coaches: randomized controlled trial. J Am Geriatr Soc. 2016; 64: 1830-8.
  10. Karlin B, Trockel M, Spira A, Taylor C, Manber R. National evaluation of the effectiveness of cognitive behavioral therapy for insomnia among older versus younger veterans. Int J Geriatr Psychiatry. 2015; 30: 308-15.
  11. Jacobs G, Pace-Schott E, Stickgold R, Otto M. Cognitive behaviour therapy and pharmacotherapy for insomnia. A randomized controlled trial and direct comparison. Arch Intern Med. 2004; 164: 1888-1896.
  12. Smith M, et al. Comparative meta-analysis of pharmacotherapy and behaviour therapy for persistent insomnia. AM J Psychiatry. 2002; 159: 5-11.
  13. Australian Medicines Handbook. Adelaide. Australian Medicines Handbook Pty Ltd. 2019.
  14. Therapeutic Guidelines. Melbourne: Therapeutic Guidelines Limited. March 2019. Available at: http://online.tg.org.au/Ip/desktop/index.htm [Accessed March 2019].
  15. Australian Government Department of Veterans' Affairs Health Claims Database. University of South Australia, QUMPRC. [Accessed February 2019].
  16. Hughes J, Ulmer C, Gierisch J, Hastings S, Howard M. Insomnia in United States military veterans: an integrated theoretical model. Clin Psychol Rev. 2018; 59: 118-125.
  17. Li L, Wu C, Gan Y, Qu X, Lu Z. Insomnia and the risk of depression: a metaanalysis of prospective cohort studies. BMC Psychiatry. 2016; 16: 375.
  18. Baglioni C, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011; 135: 10-9.
  19. Hertenstein E, et al. Insomnia as a predictor of mental disorders: a systematic review and meta-analysis. Sleep Med Rev. 2018; 43: 96-105.
  20. Bathgate C, Edinger J, Wyatt J, Krystal A. Objective but not subjective short sleep duration associated with increased risk for hypertension in individuals with insomnia. Sleep. 2016; 39: 1037-45.
  21. Grandner M, Jackson N, Pak V, Gehrman R. Sleep disturbance is associated with cardiovascular and metabolic disorders. J Sleep Res. 2012; 21: 427-33.
  22. Australian Centre for Posttraumatic Mental Health (2012). Mental Health Advice Book for Practitioners Helping Veterans with Common Mental Health Problems. Department of Veterans' Affairs, Canberra.
  23. Dobson A, et al. 2012. The Middle East Area of Operations (MEAO) Health study: census study report. The University of Queensland, Centre for Military and Veterans Health, Brisbane, Australia.
  24. Bonnet M, Arand, D. UpToDate. Behavioral and pharmacological therapies for chronic insomnia in adults. 2018. Available at: www.uptodate.com [Accessed March 2019].
  25. O'Toole B, et al. The Australian Vietnam Veterans Health study: III. Psychological health of Australian Vietnam veterans and its relationship to combat. International Journal of Epidemiology. 1996; 25(2): 331-340.
  26. Maher M, Rego S, Asnis G. Sleep disturbances in patients with post-traumatic stress disorder. CNS Drugs. 2006; 20(7): 567-590.
  27. Straus L, Drummond S, Nappi C, Jenkins M, Norman S. Sleep variability in military-related PTSD: a comparison to primary insomnia and healthy controls. J Trauma Stress. 2015; 28: 8-16.
  28. Phoenix Australia - Centre for Posttraumatic Mental Health. Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. Phoenix Australia, Melbourne, Victoria. 2013.
  29. University of Adelaide. Mental Health in the Australian Defence Force. 2010 ADF Mental Health Prevalence and Wellbeing Study report. Adelaide, South Australia. 2011.
  30. Hodson S, McFarlane A. Australian veterans - identification of mental health issues. AFP. 2016; 45(3): 98-101.
  31. Australian Medicines Handbook Aged Care Companion. Adelaide. Australian Medicines Handbook Pty Ltd. 2018.
  32. Australian Government Department of Veterans' Affairs. ADF Post Discharge GP Health Assessment. Available at: https://at-ease.dva.gov.au/professionals/assessment-and-treatment/adf-post-discharge-gp-health-assessment [Accessed December 2018].
  33. Hirshkowitz M, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health. 2015; 1: 40-43.
  34. Department of South Australian Health, Insomnia Management Kit, Sleep: Facts and hygiene. Updated 2017. Available at: https://www.sahealth.sa.gov.au/wps/wcm/connect/da8f7a004033fcc699a4bbd30eb2c8cd/5+-+Sleep+facts+and+hygiene+2017.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-da8f7a004033fcc699a4bbd30eb2c8cd-mbcjswH [Accessed February 2019].
  35. Australasian Sleep Association. Insomnia: for health professionals. Available at: www.sleep.org.au [Accessed March 2019].
  36. The Royal Australian College of General Practitioners. Prescribing Drugs of Dependence in General Practice, Part B - Benzodiazepines. Melbourne: The Royal Australian College of General Practitioners, 2015.
  37. Zachariae R, Lyby M, Ritterband L, O'Toole M. Efficacy of internet-delivered cognitive-behavioral therapy for insomnia - a systematic review and metaanalysis of randomized controlled trials. Sleep Med Rev. 2016; 30: 1-10.
  38. Taylor D, et al. Internet and in-person cognitive behavioral therapy for insomnia in military personnel: a randomized clinical trial. Sleep. 2017; 40(6). pii: 3796564. doi: 10.1093/sleep/zsx075.
  39. Royal Australian College of General Practitioners Handbook of Non-drug Interventions (HANDI). Available at: https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/mental-health/cognitive-behavioural-therapy-for-chronic-insomnia [Accessed November 2018].
  40. Fernando A, Arroll B. A double-blind randomised controlled study of a brief intervention of bedtime restriction for adult patients with primary insomnia. Journal of Primary Health Care. 2013; 5(1): 5-10.
  41. Troxel W, Germain A, Buysse D. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012; 10: 266-79.
  42. Leach M, Pratt N, Roughead E. Risk of hip fracture in older people using selective serotonin reuptake inhibitors and other psychoactive medicines concurrently: a matched case-control study in Australia. Drugs Real World Outcomes. 2017; 4: 87-96.
  43. Australian Bureau of statistics. Causes of Death, Australia, 2016. Released 2017. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/3303.0main+features12016# [Accessed February 2019].
  44. Dassanayake T, Michie P, Carter G, Jones A. Effects of benzodiazepines, antidepressants and opioids on driving: a systematic review and meta-analysis of epidemiological and experimental evidence. Drug Saf. 2010; 34(2): 125-156.
  45. Morin C, et al. Randomised clinical trial of supervised tapering and cognitive behavior therapy to facilitate benzodiazepine discontinuation in older adults with chronic insomnia. American Journal of Psychiatry. 2004; 161: 332-342.
  46. Morin C, Belleville G, Belanger L, Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011; 34(5): 601-608.

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Key Points
  • Consider using the DVA-funded Australian Defence Force (ADF) Post-discharge GP Health Assessment to help identify mental and physical health problems
  • Consider cognitive behavioural therapy for insomnia (CBTi) as the first-line treatment
  • Review medicines and other substances your patient is using to help them sleep
  • With your patient, plan to stop benzodiazepine or related hypnotic use