“I only get a few hours of sleep every night.” Kevin stated this when I asked what brought him into treatment at his intake appointment. He was a 28-year-old soldier who had been deployed eight times. Kevin isn’t alone in his problems with sleep. Many service members report similar problems when they come to therapy. But unless you specialize in sleep disorders, it can be difficult to know what the recommended treatments for insomnia are, or how to differentiate between various sleep disorders in order to know what to treat first. You can always refer such patients to a local sleep clinic but often patients are dealing with a cluster of intertwined disorders.
With Kevin, we determined that he was not only dealing with primary insomnia, but he also had posttraumatic stress disorder (PTSD). Kevin and I grappled with what to treat first. Was the PTSD causing the poor sleep or was the poor sleep exacerbating the PTSD? It was likely both. Kevin had a hard time understanding how all these issues could be related.
Many of my patients come into treatment once their symptoms are out of control. They have tried to fix their symptoms themselves and only decide to pursue mental health treatment when their spouse threatens to leave them or they get chewed out at work. It is often difficult to explain various disorders and the best treatment options, and to remember all the current evidence-based treatments for each disorder. When I have such questions, I turn to resources like clinical support tools (CSTs) offered by the Psychological Health Center of Excellence (PHCoE). These CSTs are practical and digestible compendiums of various VA and DoD clinical practice guidelines. They include tools for providers outlining the current evidence-based treatments for disorders prevalent in the military and tools to help patients and their families understand the disorder(s) and treatments.
When treating Kevin, I found two tools that informed me about the current evidence-based treatments for insomnia. One helped clarify questions on sleep medication, which Kevin was interested in. The other tool helped me identify which behaviorally-based treatments had the most research support. I was able to provide Kevin with a patient-facing CST which explained these treatment options. Once we decided on which treatment to employ for his insomnia, we talked about PTSD and those treatment options. Again, I used CSTs to help me identify evidence-based behavioral treatments and medication recommendations. I then provided Kevin with a CST explaining PTSD treatment options and a guide he could give his family so they could better understand what he was dealing with.
What did Kevin and I end up doing about his insomnia and PTSD? I had him start tracking his sleep patterns for a week and he agreed to tackle his PTSD symptoms once we established a baseline for his sleep problems. When he came back the following week, his sleep diary showed he was only getting an average of 4-5 hours of sleep each night. Therefore, we started treating his insomnia with cognitive behavioral therapy for insomnia, as it is a relatively short treatment, and then we started prolonged exposure for PTSD. It took us about 18 weeks of treatment. Kevin terminated treatment with improved sleep, a reduction in his PTSD symptoms, and a family with a better understanding of his symptoms and how to support him.
When you are trying to determine what treatment is best for various disorders as well as how to help educate your patient and their family on their symptoms and treatment options, consider using clinical support tools created by PHCoE. The tools support the latest clinical practice guidelines and PHCoE develops new tools as guidelines are updated. There are CSTs for Major Depressive Disorder, Posttraumatic and Acute Stress Disorders, Suicide, Opioid Therapy for Chronic Pain, Substance Misuse, Insomnia, and Pregnancy. Check them out today!
Dr. Edwards-Stewart is a board certified, licensed, clinical psychologist with specialties in trauma and substance use disorders. She currently works as a research psychologist for the Psychological Health Center of Excellence.
The views expressed in Clinician's Corner blogs are solely those of the author and do not necessarily reflect the opinion of the Psychological Health Center of Excellence or Department of Defense.