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

   

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 depression^17, 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

Assess your veteran patients for insomnia and related sleep disturbances

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

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

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

Educate your patients

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.

Explain that cognitive behavioural therapy for insomnia is effective

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/handi/handi-interventions/mental-health/brief-behavioural-therapy-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

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

Emphasise the importance of starting to reduce the dose

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		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		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 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		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) To access a psychologist in your area at Australian Psychological Society, go to: www.psychology.org.au/Find-a-Psychologist or at Healthdirect, go to: www.healthdirect.gov.au/psychologists-and-psychology Most psychologists trained in cognitive behavioural therapy can deliver CBTi. To access online CBTi at SleepHub go to: http://sleephub.com.au/cognitive- behavioural-therapy-for-insomnia/

Veteran-specific resources To access the Veteran Health Check, go to: www.dva.gov.au/health-and-treatment/work-and-social-life-programs/help-plan-your-care/veterans-health-check To contact Open Arms – Veterans & Families Counselling, contact them 24/7 on 1800 011 046 or go to the DVA website at: https://www.openarms.gov.au/ Information, assessment and online resources are available at the DVA At Ease Professional website at: https://at-ease.dva.gov.au/professionals /assessment-and-treatment/other-common-complaints To find a mental health provider, other specialist referrals or a group program, go to the Open Arms - Veterans and Families Counselling referral website at: www.openarms.gov.au/health-professionals/referral-options The Centenary of Anzac Centre Practitioner Support Service – run by Phoenix Australia and funded by DVA is staffed with on-call psychologists, psychiatrists, a GP and a social worker. Practitioners and people working with veterans with mental and physical health issues, including complex PTSD or pain can contact the service for guidance and support by phoning 1800 838 777 or at: http://anzaccentre.org.au/practitioner-support-service/

General insomnia resources To access the ‘RACGP handbook of non-drug interventions (HANDI)’ go to: www.racgp.org.au/clinical-resources/clinical-guidelines/handi To access the ‘Insomnia Severity Index’, a widely used questionnaire designed to assess the severity and impact of insomnia and to monitor treatment responses in adult patients,46 go to: www.ons.org/sites/default /files/InsomniaSeverityIndex_ISI.pdf Australasian Sleep Association is a sleep centre that specialises in the treatment of insomnia. A referral for your patient may be required to access the services available. To find a sleep service, go to: https://sleep.org.au/Public/Resources/Sleep-Directory/Public/Resource-Centre/Sleep-services.aspx?hkey=046a0d7d-338b-46c7-a94c-f65cbc950f17 For specialist advice or management of complex patients or to find a psychiatrist in your area, go to: www.yourhealthinmind.org/find- a-psychiatrist ‘Insomnia Management Kit for GPs’ provides a general guide for health professionals in the management of patients with sleep problems and is provided by the Government of South Australia at: www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+programs+and+practice+guidelines/substance+misuse+and+dependence/sleep+problems+-+insomnia+management+kit

For extra support when your patient is tapering and ceasing hypnotic use Reconnexion is an Australian not-for-profit organisation that offers programs and support for people with benzodiazepine dependence. Phone 1300 273 266 or go to: www.reconnexion.org.au ‘Benzodiazepines. Information for GPs’ was developed by the Drug and Alcohol Services in South Australia and provides practical information about how to taper and cease benzodiazepine use, available at: www.sahealth.sa.gov.au/wps/wcm/connect /dbd6d500407749f193d6bb222b2948cf /Benzodiazepines+-+GPs+2017.pdf?MOD=AJPERES& amp;CACHEID=ROOTWORKSPACE-dbd6d500407749f193d6bb222b2948cf- m08aBgI Drug and Alcohol Services in South Australia is provided through the Alcohol and Drug Information Service (ADIS) and can be contacted by phoning 1300 13 1340.

Resources for veterans

Cognitive behavioural therapy for insomnia (CBTi) ‘The Healthy Sleeping tool’ provides advice and tips for improving sleep, and is available on the DVA High Res website at: https://at-ease.dva.gov.au/highres/#!/tools/healthy-sleeping Open Arms – Veterans and Families Counselling veterans and their immediate family members may access free confidential mental health support services. Phone 1800 011 046 or go to: www.openarms.gov.au the webinar ‘Sleep Disturbance – Getting a good night’s sleep’ can be viewed at: https://www.youtube.com/watch?v=AKlSyfXTkxM& The ‘Sleeping Better program’ aims to assist DVA patients understand the sleep process and how to effectively manage sleep disturbances at: www.openarms.gov.au/get-support/group-programs/sleeping-better To access online CBTi at SleepHub go to: http://sleephub.com.au/cognitive-behavioural-therapy-for-insomnia/

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/

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