Since 2010, the Army has supported the implementation of Army Medical Homes across Army Medicine which included the requirement for all medical homes to provide integrated behavioral health services. This has increased the quality and availability of preventive care and behavioral health services to all beneficiaries through our primary care clinics.
Commander (Dr.) Aditya Bhagwat, Program Manager for Primary Care Behavioral Health (PCBH), in Army Medical Homes, explains that integrating behavioral health providers into the Army Medical Home has resulted in substantial changes in the way Army Medicine delivers healthcare. By integrating Internal Behavioral Health Consultants (IBHC) directly into primary care clinics, IBHCs can directly collaborate with the Army Medical Home team to address sleep disturbances, anxiety, depression, chronic pain, obesity, tobacco use and many other problems with which patients struggle.
Bhagwat, a United States Public Health Service officer and Board Certified Clinical Neuropsychologist explained currently IBHCs are receiving training on Brief Behavioral Treatment of Insomnia (BBTI) in Primary Care. Insomnia is a prevalent disorder among older adults and a frequent complaint encountered in primary care clinics. According to a study published in the Journal of Clinical Sleep Medicine more than 75 percent of patients with insomnia receive treatment in primary care settings Finding effective interventions for this population that could be delivered in primary care settings is an important goal for mental health services. Insomnia is defined by difficulty falling asleep, difficulty staying asleep, nonrestorative sleep, and waking symptoms such as fatigue, impaired concentration, and mood disturbance.
In a study published in Military Medicine, increased sleep latency, increased duration of wakefulness after sleep onset, short sleep duration, and increased sleep fragmentation are some of the common forms of sleep disturbances of military personnel during military deployment. Many patients only know about medication interventions for sleep problems, but medications should only be used in the short term, and are not as effective at treating long standing sleep difficulties. The American College of Physicians recommends cognitive behavioral interventions as the first line treatment for insomnia. BBTI is a cognitive behavioral treatment for insomnia available in primary care clinics that allows active duty, family members and retirees to take control of their sleep.
BBTI is a five, 30 minute appointment model to assess and treat sleep difficulties. Two of the appointments can be telephonic, for patient convenience. The initial appointment consists of a focused sleep assessment and explanation of the BBTI process. Patients will then have approximately four additional appointments over the course of the next couple of months. BBTI has a behavioral focus and is linked to a physiological model of sleep regulation. It utilizes a sleep diary, workbook, and behavioral interventions, to provide patients with an individualized plan to correct their sleep difficulties. BBTI focuses on four principles for good sleep: Reduce your time in bed; don't go to bed unless sleepy; don't stay in bed unless you are asleep; and get up at the same time every day. IBHCs will work closely with patients to address any barriers to implementing their plans and with their PCMs to consider all treatment possibilities.
Bhagwat explained currently, 49 IBHCs are trained in BBTI and are helping patients improve their sleep. A recent example of a BBTI experience included a retired male patient in his early forties who was referred to the IBHC for chronic back and knee pain and sleeps problems. He had a long term history of only three to four hours total sleep time, with an inconsistent bedtime due to apprehension about sleep problems at night and many awakenings. His original time in bed was ten hours, but only sleeping three to four hours; by only the third BBTI follow-up appointment he had decreased that to 7 1/2 hours in bed and was asleep most of that time, with a much more consistent schedule. He still had awakenings he attributed to his pain, but could return to sleep quickly. Moreover, he reported an overall improvement in pain and he attributed this to his IBHC's recommendations. Patients can make direct appointments with their Medical Home IBHC, but know that the IBHC will be communicating closely with the patient's primary care manager to ensure coordinated care.
Positioning behavioral health care as a routine element of primary medical care reduces the barrier of stigma associated with receiving any form of behavioral health care and can assist with the prevention and treatment of numerous medical diagnoses. Bhagwat also stated an even larger percentage of the population could benefit from treatment by IBHCs, and primary care providers are strongly encouraged to incorporate IBHCs into their standard treatment plans. Sleep is vital for health, performance, and well-being and the better the sleep, the greater its benefits.
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