Guideline-Concordant Cognitive Behavioral Therapy for Insomnia in the Veterans Health Administration Polytrauma/Traumatic Brain Injury System of Care.

Abstract

Objectives: Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment over medication. However, its use among Veterans in the Polytrauma/Traumatic Brain Injury System of Care (PSC) - a high-riskgroup for insomnia and medication complications - remains unclear. We describe CBT-I utilization in the PSC and identify predictors of receiving CBT-I.

Method: We analyzed medical records of Veterans who initiated PSC services after 10/1/2019 and received either first-line CBT-I or sleep medications within one year. We modeled the likelihood of receiving first-line CBT-I vs. medications based on sociodemographic, clinical, spatial access (e.g. drive time), and facility-level factors (e.g. patient-reported access).

Results: Veterans who received insomnia treatment after initiating PSC services (N = 18,293) were 85% male, 61% White, 21% Black or African American,14% Hispanic, and 8% age 65 or older. Only 11% received first-line CBT-I. Older Veterans; Native Hawaiian/Pacific Islander and Hispanic Veterans; those with bipolar disorder, depression, and alcohol use or other substance use disorders; and those with extended drive times were less likely to receive CBT-I. Findings were consistent in the sensitivity analysis.

Conclusions: Veterans were approximately eight times more likely to receive medications than CBT-I. Implementation strategies that overcome barriers toguideline-concordant care in the PSC are needed.