Ee et al.

J Sleep Disord Manag 2016, 2:012

Volume 2 | Issue 2

Journal of
Sleep Disorders and Management
Research Article: Open Access

Soldiers’ Perspectives of Insomnia Behavioral Treatment in a Primary

Care Setting
Juliana S Ee1, Cristóbal S Berry-Cabán2*, Dana R Nguyen3, Madina Boyd1, Nick Bennett4,
Thomas Beltran2 and Michele Williams2
1
Department of Family Medicine, Womack Army Medical Center, NC, USA
2
Department of Clinical Investigation, Womack Army Medical Center, NC, USA
3
Department of Family Medicine, Uniformed Services University, MD, USA
4
Farrelly Health Clinic, KS, USA
*Corresponding author: Cristóbal S Berry Cabán, Department of Clinical Investigation, Womack Army Medical
Center, Fort Bragg, NC, USA, E-mail: [email protected]

Abstract Introduction
Introduction: Insomnia is a highly prevalent sleep disorder in the Unaddressed sleep disorders such as insomnia have been
US. Among the military population, 41% of active duty service recognized as having potentially serious consequences on an
members reported less than 5 hours sleep per night, and there was individual’s functioning and overall quality of life, leading to
nearly a 20-fold increase in incidence of insomnia among service increased risk of developing hypertension, obesity, and cardiac disease
members between 2000 and 2009. Given that most soldiers with
[1-4]. Insomnia can exist as a primary disorder or comorbid with
insomnia seek initial treatment in the primary care setting, an
understanding of soldiers’ treatment expectations and preferences other psychiatric conditions such as depression, anxiety, and other
may contribute to treatment success. This study examines soldiers’ psychiatrically related impairments [5,6]. Thus, sleep disruption can
perspectives on behavioral insomnia treatment in the primary care be a major contributor to the development of a significant psychiatric
setting. condition that is considered a leading cause of disability among men
Methods: This was a cross-sectional survey study conducted at and women in the United States and one of the 10 leading disorders
two outpatient clinic waiting areas in a military treatment facility. for global disease [6].
The survey assessed soldiers’ experience of insomnia, treatment
expectations and preferences, and willingness to practice Insomnia is a highly prevalent sleep disorder in the US. Around
behavioral techniques. Participation was voluntary and responses 30% of the adult population reported intermittent symptoms of
were anonymous. insomnia, while 5% to 10% have been identified as having insomnia
Results: Two hundred active duty service members (177 males; specific disorders [7,8]. The National Sleep Foundation’s annual Sleep
mean age = 29 years) completed the survey. More than 40% of the in America survey found that two-thirds of Americans feel their sleep
respondents reported trouble falling or staying asleep on most days needs are not being met during the week, and that they are searching
during a typical week; the average sleep time reported was 5.7 for ways to cope [7-9]. Among the military population, 41% of active
hours (SD = 1.4) during a 24-hour period over the previous 30 days. duty service members reported an average of less than 5 hours sleep
More than 80% of the respondents indicated interest in learning per night, and there has been a nearly 20-fold increase in incidence
behavioral skills to sleep better, in being taught good sleep habits,
or in getting assistance with developing and sticking to a behavioral
of insomnia among service members between 2000 and 2009 [10,11].
treatment plan. Willingness to practice behavioral techniques was When compared to their civilian counterparts, military personnel
moderately strong. Fifty-nine percent of the respondents indicated face unique sleep-architecture altering experiences and are often
preference for behavioral treatment only or behavioral first and then
subject to continuous sleep disruption due to mission requirements,
medications.
combat-simulation exercises such as night missions and early
Discussion: Cognitive-behavioral treatment for insomnia is an
morning wake-up calls, deployments, unit activities at remote
alternative to short-term sedative-hypnotic treatment. Soldiers’
interest and willingness to practice behavioral sleep techniques
geographical locations, and frequent separations from the family
are strong. Primary care providers should move beyond providing [12]. Furthermore, the rapid operational tempo and varying degrees
sleep hygiene by adding education on ways to strengthen the bed of combat exposure, as well as continuous shifts in the demands of
and sleep association and to establish a consistent and regular multiple missions have been linked to difficulties with sleep onset
sleep-wake schedule. latency and sleep duration [12,13].
Keywords Regular sleep disruptions were reported by active duty service
Insomnia, Sleep, Soldiers, Military, Cognitive-behavioral, Primary members as concentration difficulty, which was reflected in decreased
care marksmanship scores, diminished physical abilities, and reduced

Citation: Ee JS, Berry-Cabán CS, Nguyen DR, Boyd M, Bennett N, et al. (2016) Soldiers’
Perspectives of Insomnia Behavioral Treatment in a Primary Care Setting. J Sleep Disord

ClinMed Manag 2:012

Received: August 14, 2016: Accepted: October 17, 2016: Published: October 20, 2016
International Library Copyright: © 2016 Ee JS, et al. This is an open-access article distributed under the terms of
the Creative Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original author and source are credited.
overall fitness performance [14,15]. Finally, poor sleep quality and current duties (e.g., flight status, airborne status, deployment,
identified in soldiers prior to deployment has been associated with an specialty schools, etc.) thus, more conservative approaches as a first-
increased risk of developing subsequent psychiatric difficulties and an line treatment of choice are recommended.
increase in risky health behaviors post-deployment, thus potentially
Sleep experts agree that short-term sedative-hypnotic treatment
highlighting sleep complaints as an early indicator of vulnerability
should be supplemented with psychological and behavioral therapies
[13,15].
whenever possible [23]. The effectiveness of cognitive-behavioral
Continuous sleep deprivation and poor sleep practices prior treatment (CBT-I) has been well-documented and recommended
to deployment have been linked as positive screens for new-onset as standard first-line treatment for insomnia [23-30]. Furthermore,
posttraumatic stress disorder, depression, and other anxiety related behavioral approaches appear to be a preferred treatment for
disorders; hence they have been identified as potential risk factors insomnia patients suffering with comorbid conditions such as
in the active duty personnel for experiencing impaired functioning chronic pain and heart failure, due to longer efficacy and absence of
post-deployment [16]. side-effects when compared to pharmacological interventions [24].
Additionally, behavioral interventions have produced reductions in
Sleep problems have also been associated with mild traumatic
sleep-related symptoms for up to 73% of insomnia patients referred
brain injury (mTBI) and the development of mental health symptoms
for treatment, and they appear to have much longer lasting efficacy
after returning from deployments. According to Macera, et al. military
following treatment termination [25,27].
personnel who experienced mTBI complained of sleep difficulties
immediately after their return from deployment and endorsed Cognitive-behavioral interventions for insomnia (CBT-I)
psychiatric difficulties, to include posttraumatic stress disorder and comprised four core components that include: sleep hygiene
major depressive disorder several months later [15]. practices; stimulus control; sleep restriction; and stress management
and cognitive techniques to reduce sleep-interfering arousal and to
These data further strengthens evidence that identifying sleep
prepare the mind and body for sleep. CBT-I has been found to be
disruption early in the process can be a preventative measure that
effective in as little as a single session group treatment [31].
might aid in addressing the latent onset of psychiatric conditions in
military personnel [12]. Finally, identified but potentially overlooked, Despite its effectiveness, CBT-I has been under-utilized by
insomnia has been noted as a risk factor in suicidal ideation and primary care providers due in part to perceived or real barriers
suicide attempts in the military [12,17]. Lentino, et al. identified that that include time efficiency, physicians’ perceptions of patients’
“emotional health as measured by the Army GAT [Global Assessment expectations, patients’ acceptance of the treatment modality, and the
Tool], was highly dependent on sleep quality, with poor sleepers skills experience of the primary care practitioners [32]. Most clinical
being 23 times more likely to have scored in the lowest quartile for encounters involve a dyadic interaction between the physician and
emotional health” [14]. the patient. The providers’ role is to bring to the encounter their
respective expert knowledge, beliefs, preferences, and expectations
Insufficient sleep and its impact on individual performance,
about how best to treat a condition. Clinicians’ understanding of
adverse physical consequences, and potential increase in mortality in
patients’ attitudes and beliefs about insomnia and its treatment
the military and population at large has increasingly become a focus
is perceived to be closely related to the successful outcome of
of research [14]. Notably, development of more effective, evidence-
therapeutic approach. Attempts have been made to investigate
based interventions, including the use of both medication and
treatment preference and satisfaction with group treatment in the
behaviorally-based treatments, have been a particular area of interest
individual with chronic insomnia, and comparison of acceptance for
in evaluating current trends for making first contact with any given
psychological and pharmacological therapies for insomnia have been
provider.
conducted among those in treatment at specialty sleep clinics [33-37].
The importance of understanding the nature of sleep disorders
The purpose of this exploratory study was to survey active
and addressing their underlying symptoms for military personnel
duty service members’ perspectives and preferences on behavioral
operating in high-risk environments and technically demanding
insomnia treatment in the primary care setting. Given that most
occupations cannot be over-emphasized [18]. The level of impairment
soldiers with insomnia seek initial treatment in the primary care
as well as subjective and objective perception of health-related decline
setting, an understanding of soldiers’ expectations and preferences
in quality of life have been well-documented as leading to increased
regarding treatment may contribute to treatment success. The
emergency room visits, laboratory testing requests, and overall
information can also be used to shape training curriculum for
increase in health care utilization when compared to patients with
physician residents.
no insomnia [19].
Insomnia is one of the most common conditions presented in Methods
primary care setting, with patient estimates ranging from 10% to This was a cross-sectional survey study performed at the
50% [20]. Most patients with insomnia seek initial treatment in a Womack Army Medical Center (WAMC) outpatient clinics. A
primary care setting and discuss their concerns with their primary survey instrument was assembled, using information from relevant
care provider (PCP); thus, given the prevalence of insomnia and insomnia treatment studies. The final survey contained items that
patients’ potential desire to obtain sleep aids or any other assistance, assessed respondents’ self-reported total hours of sleep in a 24-hour
most PCP can expect to encounter these patients in their practice period over the past 30 days; their experience of trouble falling asleep
[21]. Furthermore, the military population is more likely to seek and trouble staying asleep; their perception of their health status;
sleep-related treatment through their PCP due to potential stigma their expectations about what interventions they want their primary
associated with approaching a behavioral healthcare provider [22]. care physicians to provide; their willingness to practice a series of
Most PCP typically treat the problem by recommending behavioral techniques that have been established in the sleep literature
sleep hygiene practices and prescribing medications [23]. The as the “standard” for insomnia treatment; and their treatment
pharmacologic therapy includes short- to intermediate-acting preferences (e.g., medications only, behavioral only, medications
benzodiazepine hypnotics, non-benzodiazepine hypnotics, or then behavioral, behavioral then medications, and concurrent
sedating low-dose antidepressants. These medications, however, combination of medications and behavioral). Respondents also
present their own risks, including excessive drowsiness, and physical provided socio-demographic data including gender, age, marital
and psychological dependence with long-term use [23]. status, race/ethnicity, highest educational level, and number of
deployments.
Notably, for the military population the ability to receive and
remain on medication for the long term might present specific Two hundred responses to the survey were collected via
hosts of issues depending on the individual’s occupational specialty convenience sampling from active duty soldiers in the waiting areas

Ee et al. J Sleep Disord Manag 2016, 2:012  Page 2 of 5 

of the Physical Examination and Family Medicine outpatient clinics. Table 1: Treatment expectations (proportion reporting “slightly agree” to “strongly
agree”; n = 200).
A power analysis was conducted to estimate the number of survey
respondents required for examination of mean differences. That Expectations Percent
analysis indicated that 128 respondents were required for an 80% Find out why I have sleep problems 85%
chance of rejecting null hypotheses (two-tailed, one-way ANOVA) Teach me behavioral skills to sleep better 85%
at the alpha level of 0.05. Since the sample was drawn from an army Teach me good sleep habits 83%
medical center, it was anticipated that the sample would be composed Help me develop a behavior plan to treat my sleep problem 82%
of approximately 80% male respondents. We inflated the number Ask about my stress 82%
surveyed for a more adequate sampling of female respondents. Ask about my progress in sticking to the behavioral plan 80%
Help me find out what difficulties interfere with sticking to the plan 80%
Participation in the study was voluntary. Respondents’ Coach me on behavioral skills until I get them right 78%
information, including names that could link an individual to the Prescribe sleep medication 57%
data was not recorded to assure confidentiality and anonymity. All
active duty soldiers above 18 years of age were included. Active
Table 2: Willingness to practice behavioral techniques (proportion of respondents
duty soldiers who declined to participate and civilian patients were rating their willingness “frequently” or “usually”; n = 200).
excluded. The survey objectives were explained and an informed
Techniques Percent
verbal consent was obtained prior to distribution of the survey. The
Make bedroom comfortable for sleep 78%
survey took approximately 10-15 minutes to complete. This project
Exercise regularly 66%
was approved by the WAMC Institutional Review Board.
Avoid alcohol before bedtime 66%
Statistical analyses were conducted using IBM SPSS Statistics 22 Avoid nicotine before bedtime 62%
(IBM Corporation, Armonk, NY). Descriptive statistics including Avoid caffeine before bedtime 61%
frequencies, means, standard deviations (SD), and range were Use the bed only for sleep (and sex) 58%
calculated, and, where appropriate, chi-square and ANOVA were Stop watching TV in bed while waiting to fall asleep 57%
used to examine group differences. Stay on a regular sleep-wake schedule 51%
Avoid naps during the daytime 48%
Results Get out of bed when unable to fall asleep within 15-20 minutes 38%
Practice relaxation before bedtime 37%
A total of 200 active duty soldiers completed the survey, 88.5%
Go to another room and not return to bed until feeling sleepy 33%
were males (n = 177); the mean age was 29 years (SD = 7.03). Ethnic
or racial identity reported by the respondents was as follows: white,
non-Hispanic white 61% non-Hispanic blacks 18.5%, Hispanics 13%,
35 33
and Asian/Pacific Islander or other 7.5%.
30
26
Respondents were asked to assess their perceived health status 25 23
using a 5 point Likert-type scale with ratings of poor, fair, good,
Percent

20
very good, and excellent. Two individuals (1%) reported being in 15 13
poor health; 18 individuals (9%) reported fair health; 73 individuals 10
(36.5%) reported good health; 81 individuals (40.5%) reported very 5
5

good health, and 26 individuals (13%) reported excellent health. No 0

group differences were found for perceived health status based on
gender, race/ethnicity, marital status, level of education, or number of
deployments (P > 0.05). A Kruskal-Wallis test compared respondents’
treatment preferences with their self-evaluated health status showed
no relationship (P = 0.62).
Figure 1: Treatment preferences.
Overall, respondents reported an average total sleep time of 5.7
hours during a 24-hour period over the previous 30 days (SD = 1.4;
range = 2.0-11.0 hours). Forty percent of the respondents reported they want their healthcare provider to “find out why I have a sleep
trouble falling asleep ‘more than half the week’ during a typical week problem”; 85% “slightly agree” to “strongly agree” that they want their
in the past 30 days while 46% reported trouble staying asleep. A one- healthcare provider to “teach me behavioral skills to sleep better”;
way ANOVA was conducted to examine differences in the amount 83% “teach me good sleep habits”; 82% “ask about my stress”; 80%
of sleep individuals’ reported based on gender and race. A significant “ask about my progress in sticking to the behavioral plan”; 80% “help
difference was found between males and females (mean = 5.7 vs. 6.4 me find out what difficulties interfere with sticking to the plan”; 78%
hours; P = 0.04) which indicated that females reported getting more “coach me on behavioral skills until I get them right”; and 57% “prescribe
sleep than males. However, results indicated there was no difference sleep medication” (Table 1). Respondents’ self-rated willingness to
in the number of hours slept based on reported race/ethnicity (P practice behavioral techniques is summarized in table 2.
= 0.47), level of education (P = 0.13), marital status (P = 0.70), or Respondents’ preferences for treatment approaches were as
number of deployments (P = 0.44). follows: 13% (n = 26) indicated preferences for medications only;
No differences were found between individuals’ preferred 26% (n = 52) behavioral methods only; 5% (n = 10) medications first,
treatment for sleep problems based on the frequency of their then behavioral; 33% (n = 66) behavioral first, then medications; and
experience having trouble falling asleep or trouble staying asleep 23% (n = 46) selected a concurrent combination of medications and
(P > 0.05). Additionally, there was no difference in treatment behavioral methods (Figure 1).
preference and number of hours respondents were willing to devote
to treatment (P = 0.30) or between treatment preference and number Discussion
of deployments (P = 0.71). This aim of this exploratory study was to investigate the treatment
Respondents’ treatment expectations were assessed via the preferences of active duty service members consulting their primary
statement: “If I see my doctor for treatment of my sleep problems, care providers for insomnia, in particular, their expectations,
I would like my doctor to…”. A list of options was provided and willingness to practice behavioral techniques, and preferences for
respondents selected responses, using a 6-point Likert scale, which insomnia treatments in the primary care setting. The importance of
ranged from “strongly disagree” to “strongly agree”. Eighty-five patients’ involvement in their healthcare is increasingly recognized
percent of the respondents “slightly agree” to “strongly agree” that by the medical profession. For patients to be involved, their priorities,

Ee et al. J Sleep Disord Manag 2016, 2:012  Page 3 of 5 

expectations, and preferences must be identified and addressed. A the fellowship learning activities. The views expressed herein are those
favorable acceptance of behavioral treatments will provide data-driven of the authors and do not reflect the official policy of the Department
support for the development of an insomnia behavioral treatment of the Army, Department of Defense, or the US Government.
curriculum for physician residents in training and for expanding the
insomnia treatment tool box of primary care providers. References
1. Chang P, Ford D, Mead L, Cooper-Patrick L, Klag M (1997) Insomnia in young
Our study demonstrates that soldiers have a strong interest in men and subsequent depression: The John Hopkins Precursors Study. Am J
learning behavioral treatments for their sleep difficulties. Up to 85% Epidemiol 146: 105-114.
of the respondents expect their physician to teach them behavioral 2. Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A (2009)
skills to sleep better or to assist them in developing a behavioral Insomnia with objective short sleep duration is associated with a high risk for
treatment plan for their sleep problems. Behavioral treatment first hypertension. Sleep 32: 491-497.
and then medications was selected by 33% of the respondents whereas 3. Zammit G, Weiner J, Damato N, Sillup G, McMillan C (1999) Quality of life in
medications first and then behavioral treatment was preferred by only people with insomnia. Sleep 22: S379-385.
5% of the respondents. About 23% of the respondents indicated a 4. Bonnet MH, Arand DL (2007) Cardiovascular implications of poor sleep.
preference for a concurrent combination of both pharmacologic and Sleep Medicine Clinics 2: 529-538.
behavioral treatments.
5. Mitchell MD, Gehrman P, Perlis M, Umscheid CA (2012) Comparative
effectiveness of cognitive behavioral therapy for insomnia: a systematic
Cognitive-behavioral interventions for sleep comprised four
review. BMC Family Practice 13: 40.
essential components: sleep hygiene, stimulus control (strengthening
the association between bed and sleep), sleep restriction, and training 6. Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, et al.
(2011) Insomnia as a predictor of depression: a meta-analytic evaluation of
the mind and body for sleep through muscle relaxation, articulatory longitudinal epidemiological studies. J Affect Disord 135: 10-19.
suppression, and cognitive control. Less than 40% of the respondents
7. National Sleep Foundation (2010) 2010 Sleep in America ® Poll.
indicated that they were “frequently” or “usually” willing to practice
techniques that strengthen the association between the bed and sleep 8. National Sleep Foundation (2011) 2011 Sleep in America ® Poll.
(e.g., getting out of bed when unable to fall asleep, going to another 9. Brems C (2015) A yoga stress reduction intervention for university faculty,
room and not return to bed until feeling sleepy). Clearly, more staff, and graduate students. Int J Yoga Therap 25: 61-77.
attention must be devoted to explaining the rationale for engaging in 10. Mysliwiec V, Gill J, Lee H, Baxter T, Pierce R, et al. (2013) Sleep disorders in
actions that strengthen the link between bed and sleep. Additionally, US military personnel: a high rate of comorbid insomnia and obstructive sleep
more attention must also be directed toward explaining the rationale apnea. Chest 144: 549-557.
for staying on a regular and consistent sleep-wake schedule as only 11. (2010) Armed Forces Health Surveillance Center. Insomnia, active
51% of the respondents indicated their willingness to practice this component, U.S. Armed Forces, January 2000-December 2009. Medical
technique “frequently” or “usually.” Surveillance Monthy Report 17: 12-15.

12. Lande RG, Gragnani C (2013) Sleep trends of active-duty service members
Given the strong preference for behavioral treatments, more referred for psychiatric care: a descriptive study. J Am Osteopathic Assoc
interest should be directed toward providing behavioral treatments 113: 144-150.
in the primary care setting. Edinger and Sampson have demonstrated
13. Swinkels CM, Ulmer CS, Beckham JC, Buse N, Calhoun PS (2013) The
successful outcomes using an abbreviated 2-session CBT model association of sleep duration, mental health, and health risk behaviors among
for insomnia in the primary care setting [38]. Researchers have US Afghanistan/Iraq era veterans. Sleep 36: 1019-1025.
demonstrated favorable outcomes for a one-session CBT-I delivered 14. Lentino CV, Purvis DL, Murphy KJ, Deuster PA (2013) Sleep as a component
in a group format [31]. Thus, CBT-I can be effectively and efficiently of the performance triad: the importance of sleep in a military population. US
provided in the primary care setting. Army Med Dep J 98-108.

This study has several limitations. First, this was a cross-sectional 15. Macera CA, Aralis HJ, Rauh MJ, MacGregor AJ (2013) Do sleep problems
mediate the relationship between traumatic brain injury and development of
survey study that utilized a convenience sample of active duty mental health symptoms after deployment? Sleep 36: 83-90.
service members in two outpatient clinic waiting areas in a military
treatment facility. Second, the survey instrument, though constructed 16. Gehrman P, Seelig AD, Jacobson IG, Boyko EJ, Hooper TI, et al. (2013)
Predeployment sleep duration and insomnia symptoms as risk factors for
from the sleep studies literature, is currently not validated, given the new-onset mental health disorders following military deployment. Sleep 36:
exploratory nature of the study. Third, the findings relied on self- 1009-1018.
report and no attempts were made to clinically diagnose insomnia
17. Ribeiro JD, Pease JL, Gutierrez PM, Silva C, Bernert RA, et al. (2012) Sleep
disorder or to examine co-morbid conditions that may have an problems outperform depression and hopelessness as cross-sectional and
impact on respondents’ treatment expectations or preferences. These longitudinal predictors of suicidal ideation and behavior in young adults in the
limitations diminished the generalizability of the study findings. military. J Affect Disord 136: 743-750.
Future studies should consider surveying a wide range of active duty 18. Mysliwiec V, McGraw L, Pierce R, Smith P, Trapp B, et al. (2013) Sleep
service members in other settings as well as non-military population, disorders and associated medical comorbidities in active duty military
collecting data from primary care providers regarding patients’ personnel. Sleep 36: 167-174.
selection of insomnia treatment modalities, and examining co- 19. Roth T, Franklin M, Bramley TJ (2007) The state of insomnia and emerging
morbid conditions that may influence expectations and preferences. trends. Am J Manag Care 13: S117-120.

Despite these limitations, the study findings showed that interest 20. Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake C, et al.
(2012) Prevalence of causes of insomnia in primary care: a cross-sectional
in and willingness to practice behavioral treatment for insomnia is study. Br J Gen Pract 62: e99-103.
strong among soldiers in the primary care setting. Coaching patients
in cognitive-behavioral skills to improve sleep should be considered 21. Simon GE, VonKorff M (1997) Prevalence, burden, and treatment of insomnia
in primary care. Am J Psychiatry 154: 1417-1423.
beyond merely providing sleep hygiene education. A focused
insomnia behavioral treatment curriculum could be developed and 22. Morin CM, LeBlanc M, Daley M, Gregoire J, Merette C (2006) Epidemiology of
insomnia: prevalence, self-help treatments, consultations, and determinants
training provided to physician residents and primary care providers
of help-seeking behaviors. Sleep Med 7: 123-130.
to expand their insomnia treatment toolbox.
23. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M (2008) Clinical
Acknowledgement guideline for the evaluation and management of chronic insomnia in adults. J
Clin Sleep Med 4: 487-504.
Dr. Ee wishes to thank Dr. Colleen Fogarty, University of 24. Andrews LK, Coviello J, Hurley E, Rose L, Redeker NS (2013) “I’d eat a
Rochester Medical Center and Dr. Michael Floyd, East Tennessee bucket of nails if you told me it would help me sleep:” Perceptions of insomnia
State University for their mentoring during her participation in the and its treatment in patients with stable heart failure. Heart Lung 42: 339-345.
Society of Teachers of Family Medicine, Behavioral Science/Family 25. Benca RM (2005) Diagnosis and treatment of chronic insomnia: a review.
Systems Educator Fellowship. This project was completed as part of Psychiatr Serv 56: 332-343.

Ee et al. J Sleep Disord Manag 2016, 2:012  Page 4 of 5 

 Vincent N, Lewycky S, Finnegan H (2008) Barriers to engagement in sleep
26. Brooks AT, Wallen GR (2014) Sleep disturbances in individuals with alcohol- restriction and stimulus control in chronic insomnia. J Consult Clin Psychol
related disorders: a review of cognitive-behavioral therapy for insomnia 76: 820-828.
(CBT-I) and associated non-pharmacological therapies. Subst Abuse 8: 55-
62. 34. Morin CM, Gaulier B, Barry T, Kowatch RA (1992) Patients’ acceptance of
psychological and pharmacological therapies for insomnia. Sleep 15: 302-
27. Chambers MJ, Alexander SD (1992) Assessment and prediction of outcome 305.
for a brief behavioral insomnia treatment program. J Behav Ther Exp
Psychiatry 23: 289-297. 35. Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW (2004) Cognitive behavior
therapy and pharmacotherapy for insomnia: a randomized controlled trial and
28. Edinger JD, Wohlgemuth WK, Radtke RA, Marsh GR, Quillian RE (2001) direct comparison. Arch Intern Med 164: 1888-1896.
Cognitive behavioral therapy for treatment of chronic primary insomnia.
JAMA 285: 1856-1864. 36. Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, et al. (2006)
Cognitive behavioral therapy vs zopiclone for treatment of chronic primary
29. Lichstein K, Wilson N, Johnson C (2000) Psychological treatment of insomnia in older adults: a randomized controlled trial. JAMA 295: 2851-2858.
secondary insomnia. Psychol Aging 15: 232-240.
37. Morin CM, Vallières A, Guay B, Ivers H, Savard J, et al. (2009) Cognitive
30. Morin C, Colecchi C, Stone J, Sood R, Brink D (1999) Behavioral and behavioral therapy, singly and combined with medication, for persistent
pharmacological therapies for late-life insomnia: A randomized controlled insomnia: a randomized controlled trial. JAMA 301: 2005-2015.
trial. JAMA 281: 991-999.
38. Edinger JD, Sampson W (2003) A primary care “friendly” cognitive behavioral
31. Brooks M (2013) Single-session group CBT effective for insomnia. Medscape. insomnia therapy. Sleep 26: 177-182.
32. Cockburn J, Pit S (1997) Prescribing behaviour in clinical practice: patients’
expectations and doctors’ perceptions of patients’ expectations - a
questionnaire study. BMJ 315: 520-523.
33.

Ee et al. J Sleep Disord Manag 2016, 2:012  Page 5 of 5 