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Lack of Emphasis on Sleep Screening

As mentioned earlier, there have been various initiatives to screen for sleep disturbances in the military across the deployment cycle. However, sleep was generally perceived to be a low institutional priority in military communities, or it simply fell "behind other areas" of war-related health issues. One interviewee suggested that the military inherently has little incentive to identify sleep problems among its forces and thereby disqualify personnel from certain critical jobs or activities, particularly when there is not always a clear treatment path.

Others indicated that servicemembers rarely come forward with only a sleep problem; rather, they tended to present with another health or mental health condition that was induced or exacerbated by a sleep problem. They noted that the resulting condition could be more severe—or perceived as more severe—than the underlying sleep disturbance and, thus, act as a catalyst to treatment-seeking or other means of detection. Similarly, our interviewees suggested that sleep problems are often identified only after accidents and subsequent investigations. Although screening was perceived as an important tool for detecting sleep problems, it is worth noting that line leader and servicemember self-identification was also considered a critical method for identifying these problems.

Continuity of Care Challenges

Our interviews addressed continuity of care in terms of sleep problems. Specifically, servicemembers can experience a "gap" during the post-deployment transition period wherein sleep issues may not be detected or treated. According to an Army medical staff member,

[The] general gap is the health care in that transition period. Whatever the health care needs are, it's hard to make it a clean transition. Post-Deployment Health Assessment is a self-report. What's done in theater may or may not transition over. [A] health care provider may not catch it right away.

A common theme described the concerns about continuity of care for certain veterans. VA treatment providers are a likely means for detecting sleep issues, either through primary care visits or through other treatment or screening encounters. However, after a servicemember's separation from the military, he or she may either choose not to or be unable to use VA services due to limited access, long wait times, or a lack of awareness about eligibility for services.

As for concerns about continuity of care for the treatment of sleep problems, the military's electronic medical records system, the Armed Forces Health Longitudinal Technology Application, may address gaps by making diagnosis and treatment information available to a range of providers across the deployment cycle. However, some of our interviewees stressed that even with this system in place, prescriptions for sleep medications and other treatments can be handwritten or otherwise not recorded in the electronic medical record.

A lack of universal documentation of prescriptions presents challenges for health care providers who may be unaware of the full range of medications a servicemember is taking or whether he or she has been prescribed a given medication by another provider.

Sleep Clinic and Provider Shortages

Another theme mentioned a different type of treatment concern: a shortage of specialized providers at sleep clinics and a shortage of sleep clinics themselves.

In terms of specialists that deal with sleep issues, those people certainly have a backlog for people to access them, so you're talking, often, 30 days from referral to a specialty service.

Numerous examples in the sleep medicine literature corroborate this issue and emphasize that the shortage of trained providers in evidence-based interventions for treating sleep disorders is a critical issue in the civilian health care system, as well as in the military health care system (Manber, Carney, et al., 2012; Troxel, Germain, and Buysse, 2012). According to a previously published report by a leader in academic sleep medicine,

[I]n an ideal health care system, one would expect behavioral treatment for insomnia to be widely disseminated because of the data showing efficacy, the cost savings that would accrue from reduced pharmacy costs, and reduced morbidity from sedative hypnotic-related falls and injuries. The message repeatedly finds its way into the scientific literature but not into practice settings. (Neylan, 2011)

Amidst these reported shortages, we also heard about recent efforts to bolster the number of sleep providers and clinics in the military, including the VHA CBT-I clinician training program (discussed in greater detail in Chapter Four).

 
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