Insomnia disorder is common among U.S. military personnel and negatively impacts health and military readiness. Among civilians, insomnia is associated with substantial economic burden; yet, little is known about the burden of insomnia within the US Military Health System (MHS). The MHS is a large, integrated healthcare delivery system with worldwide operations and thus ideal for health services research. This study aimed to determine the association between insomnia disorder and healthcare resource utilization (HCRU) in the MHS. Our data source was the Military Data Repository (MDR) between years 2016-2021. This large data repository includes encounter, procedure, medication, and durable medical equipment information for active-duty military personnel, military dependents, National Guard, and Reserves. Demographic and military information was obtained from the MDR. Inclusion criteria were age < 65 years, active-duty military personnel, 12 months of continuous enrollment before and after first insomnia diagnosis (i.e., the index date), and no evidence of insomnia during the 12 months prior to first diagnosis. Insomnia and comorbid medical and psychiatric conditions were defined based on International Classification of Disease-10th Edition codes. Beneficiaries with insomnia were matched 1:1 with non-insomnia controls on >20 demographic, military, and medical and psychiatric comorbidity variables. Mixed effects models were used to compare non-insomnia related HCRU between groups across multiple points of service: outpatient, inpatient, and emergency department (ED). We identified 40,978 MHS beneficiaries with insomnia and 40,978 matched non-insomnia controls. Most (35.9%) beneficiaries with insomnia were between ages 25-34 years, and 20.7% were women. 4.2% of beneficiaries with insomnia had one comorbid medical or psychiatric condition, and 1% had >2 comorbid conditions. Relative to matched non-insomnia controls, beneficiaries with insomnia demonstrated greater 12-month HCRU at every point of service (all p values< 0.001). The incident rate ratio for non-insomnia inpatient visits was RR (95% CI) = 1.96 (1.85,2.08); for non-insomnia outpatient visits was 2.24 (2.23,2.24); and for non-insomnia related ED visits was 1.60 (1.57,1.63). Insomnia is associated with substantially increased healthcare resource utilization in the US military health system. Future research should seek to advance personalized medicine approaches to improve outcomes of evidence-based insomnia care. U.S. Department of Defense HT94022210006.

Comorbid insomnia and obstructive sleep apnea (COMISA) are prevalent conditions with significant physical and mental health comorbidities. Our study sought to estimate the effect of COMISA vs. obstructive sleep apnea (OSA) alone on subjective and objective sleep, daytime symptoms including cognition, and healthcare resource utilization (HCRU) among military service members (SMs). Military SMs (n = 201) completed research questionnaires and then an intensive 10-day remote monitoring assessment, including wearing a commercial sleep tracker, completing daily sleep diaries, and completing twice-daily symptom surveys via a mobile application. Subjective cognition was measured using 3 self-report items assessing memory, concentration, and executive function. Between-groups (COMISA vs. OSA) differences in subjective and objective sleep, daytime symptoms, and HCRU were examined using a series of one-way ANOVAs. Compared to participants with OSA alone (n = 98; 48.8%), participants with COMISA (n = 81; 40.3%) demonstrated poorer subjective sleep and daytime symptoms as measured by traditional questionnaires (i.e., Epworth Sleepiness Scale and Insomnia Severity Index) and twice-daily symptom surveys, as well as increased HCRU. No between-groups differences were observed in objectively measured sleep. Among military SMs and relative to OSA alone, COMISA was associated with worsened subjective but not objective sleep, worsened daytime symptoms including cognition, and greater HCRU.

Description: The U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) updated the 2019 joint clinical practice guideline (CPG) for assessing and managing patients who are at risk for suicide. This synopsis provides primary care physicians with a summary of the updated 2024 recommendations regarding evaluation and management of military members and veterans at risk for suicide. Methods: In 2023, the VA/DOD Evidence-Based Practice Work Group convened to develop a joint VA/DOD guideline, including clinical stakeholders, which conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The Work Group drafted 12 key questions, reviewed systematically identified literature (1 April 2018 to 15 March 2023), evaluated the evidence, created algorithms, and advanced 24 recommendations in accordance with the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: Despite insufficient evidence to recommend for or against suicide risk screening programs as a means for reducing suicide attempts or deaths, the VA/DOD Work Group identified validated tools that could be used to identify populations at higher risk for suicide-related behaviors. Cognitive behavioral therapy was also recommended for reducing the risk for suicide attempts and decreasing suicidal ideation among those with a history of suicidal behavior or a history of self-directed violence. Periodic communications after previous suicide attempts were also recommended as a prevention strategy. Pharmacologic treatments, such as clozapine or ketamine infusion, also have a role in the management of suicide risk among those with schizophrenia or major depressive disorder, respectively.

BACKGROUND AND OBJECTIVES:Insomnia is highly prevalent among military personnel, with many gaps in knowledge. The purpose of this study was to quantify the medical, psychiatric, and utilization burden of insomnia among active-duty military personnel. We hypothesized that insomnia is associated with worsened health and economic outcomes. METHODS:This was a retrospective case-control study. Data were derived from the Military Data Repository (2016-2021). Active-duty service members (ADSMs) younger than 65 years, with 12 months of continuous enrollment before and after first insomnia diagnosis and no evidence of previous insomnia or insomnia treatment, were matched 1:1 on demographic, clinical, and military characteristics to ADSMs without insomnia. Insomnia and psychiatric and medical comorbidities were defined using International Classification of Diseases, 10th Revision diagnostic codes. The impact of newly diagnosed insomnia on psychiatric and medical outcomes within 12 months was examined using time-to-event models. The impact of newly diagnosed insomnia on 12-month health care resource utilization (HCRU) was examined using generalized linear models. RESULTS:A total of 40,978 ADSMs met insomnia criteria and were matched to 40,978 ADSMs without insomnia. Participants were 78.6% male and 61.8% identified as White, with most younger than 44 years (90.3%). Insomnia was associated with increased risk of almost every studied physical and psychological health outcomes; relative to those without insomnia, ADSMs with insomnia demonstrated a 6-fold increased risk of post-traumatic stress disorder (hazard ratio [HR] 6.51, 95% CI 5.95-7.12, p < 0.001), as well as elevated risk of traumatic brain injury (HR 5.32, 95% CI 4.53-6.24, p < 0.001). ADSMs with insomnia demonstrated greater all-cause HCRU across all points of service (all p's < 0.001). DISCUSSION:Among active-duty personnel, new-onset insomnia was associated with substantially increased risk of adverse medical and psychiatric burden, as well as increased utilization, over 12 months. Key limitations include our observational study design.

Background Despite the significant health and economic burden associated with OSA among civilians, little is known about this burden among active-duty military personnel. Research Question What is the health and utilization burden of OSA among active-duty service members in the United States? Study Design and Methods Data were derived from the Military Data Repository (2016-2021). Participants included active-duty service members aged < 65 years with 12 months of continuous enrollment prior to and following a new OSA diagnosis and no evidence of prior OSA or OSA treatment. They were matched 1:1 on demographic, clinical, and military characteristics to those without OSA. OSA and medical and psychiatric comorbidities were defined based on International Classification of Diseases, 10th Revision, codes. The impact of newly diagnosed OSA on psychiatric and medical outcomes was examined by using time-to-event models. The impact on 12-month health care resource utilization was examined by using generalized linear models. Results A total of 59,203 service members with OSA were matched to 59,203 service members without OSA. Participants were 83% male and 65% White, with most < 44 years old (81%). OSA was associated with an increased risk for all physical and psychological health outcomes; relative to those without OSA, service members with OSA exhibited a fourfold increased risk for posttraumatic stress disorder (hazard ratio, 4.41; 95% CI, 4.04-4.82). In terms of utilization, OSA was associated with an additional 170,511 outpatient, 66 inpatient, and 1,852 emergency department encounters per year. Interpretation Our findings show that among US active-duty military personnel, OSA is associated with substantially increased risk for adverse physical and psychological health outcomes, as well as utilization burden over 12 months. Screening, triage, and treatment efforts could have broad impact in this population.

Background and Objectives Insomnia affects about one-third of patients with traumatic brain injury and is associated with worsened outcomes after injury. We hypothesized that higher levels of plasma neuroinflammation biomarkers at the time of TBI would be associated with worse 12-month insomnia trajectories. Methods Participants were prospectively enrolled from 18 level-1 trauma centers participating in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury study from February 26, 2014, to August 8, 2018. Plasma glial fibrillary acidic protein (GFAP), high-sensitivity C-reactive protein (hsCRP), S100b, neuron-specific enolase (NSE), and ubiquitin carboxyl-terminal hydrolase-L1 (UCH-L1) were collected on days 1 (D1) and 14 (D14) after TBI. The insomnia severity index was collected at 2 weeks, 3, 6, and 12 months postinjury. Participants were classified into insomnia trajectory classes based on a latent class model. We assessed the association of biomarkers with insomnia trajectories, controlling for medical and psychological comorbidities and demographics. Results Two thousand twenty-two individuals with TBI were studied. Elevations in D1 hsCRP were associated with persistent insomnia (severe, odds ratio [OR] = 1.33 [1.11, 1.59], p = 0.002; mild, OR = 1.10 [1.02, 1.19], p = 0.011). Similarly, D14 hsCRP elevations were associated with persistent insomnia (severe, OR = 1.27 [1.02, 1.59], p = 0.03). Of interest, D1 GFAP was lower in persistent severe insomnia (median [Q1, Q3]: 154 [19, 445] pg/mL) compared with resolving mild (491 [154, 1,423], p < 0.001) and persistent mild (344 [79, 1,287], p < 0.001). D14 GFAP was similarly lower in persistent (11.8 [6.4, 19.4], p = 0.001) and resolving (13.9 [10.3, 20.7], p = 0.011) severe insomnia compared with resolving mild (20.6 [12.4, 39.6]. Accordingly, increases in D1 GFAP were associated with reduced likelihood of having persistent severe (OR = 0.76 [95% CI 0.63-0.92], p = 0.004) and persistent mild (OR = 0.88 [0.81, 0.96], p = 0.003) compared with mild resolving insomnia. No differences were found with other biomarkers. Discussion Elevated plasma hsCRP and, surprisingly, lower GFAP were associated with adverse insomnia trajectories after TBI. Results support future prospective studies to examine their utility in guiding insomnia care after TBI. Further work is needed to explore potential mechanistic connections between GFAP levels and the adverse insomnia trajectories.

BackgroundThere is a gross shortage of sleep specialist providers within the military health system. Telehealth and mobile health represent promising approaches to increase access to high quality, cost-effective care in the U.S military.ObjectivesThis paper reports findings from a mixed-methods clinical implementation study of a novel sleep telehealth platform at two military treatment facilities in the National Capitol Region. The platform includes a mobile app and integrated wearable sensors (i.e., a commercial off-the-shelf sleep tracker [Fitbit]). The primary purpose was to evaluate the implementation of a 10-day remote monitoring assessment and provision of evidence-based sleep treatment recommendations to patients and providers. In addition, we sought to observe, in an exploratory manner, subsequent engagement with the app during 5 days of personalized sleep education and training.MethodsPatients with sleep problems completed an intensive 10-day remote monitoring assessment that included a baseline intake questionnaire, daily sleep diaries, twice daily symptom surveys, and Fitbit. Based on this assessment, patients received personalized assessment results. Concurrently, a provider report was generated that included provisional diagnoses and evidence-based treatment recommendations. Next, participants gained access to personalized sleep education and trainings within the mobile app. Within an established implementation science framework, outcomes were assessed via behavioral adherence (engagement with the app) and separate questionnaires for patients and providers. Last, we conducted four focus groups with patients and 12 key informant interviews with primary care managers (PCMs) and economic stakeholders to seek feedback and recommendations for future directions.ResultsTwo hundred and seventy patients participated in the study. Using validated research questionnaires, participants reported high-risk for obstructive sleep apnea (65.6%), moderate to severe insomnia (38.2%), and moderate to severe daytime sleepiness (38.5%), and moderate to severe anxiety (14.1%) and depressive (20.4%) symptoms. Total sleep time was 6.6 (SD = 1.8) h based on sleep diaries and 6.1 (SD = 1.8) h based on Fitbit. Regarding implementation, reach, effectiveness, adoption, implementation, and maintenance were all notably high, based on quantitative and qualitative data from participants and PCMs.ConclusionsSleep telehealth and mobile health represent promising approaches to increase access to cost-effective, evidence-based care for sleep disorders in the U.S. military.

Insomnia is the most prevalent sleep disorder, affecting millions worldwide and taking a heavy toll on patient health with significant social and economic impact. Even though there are multiple different types of insomnia medications and behavioral therapies, there are still many individuals for whom treatment remains ineffective. The objective of this retrospective study was to analyze the effectiveness of daridorexant in a cohort of chronic insomnia patients largely transitioned from GABA-A positive allosteric modulators (benzodiazepines, zolpidem or eszopiclone) or other frequently prescribed insomnia medications (including trazodone, atypical antipsychotics or tricyclic antidepressants). A total of 86 patients were treated in the course of ordinary practice and the primary analytic endpoint was the change in Insomnia Severity Index (ISI) score following ≥ 30 nights of treatment with daridorexant. Results from 80 of the 86 patients with full data (65% female, mean age 53.5 years, 18.8% with comorbid obstructive sleep apnea, 91.3% transitioned from a different medication) showed a mean improvement in ISI score of 7.0 ± 0.54 points (SEM) (p < 0.0001) from 18.0 to 11.0. Overall, 78% of the cohort demonstrated a clinically meaningful improvement as defined by at least a six-point drop in ISI. Total sleep time increased by 54 ± 1.0 min (SEM) (p < 0.0001) from 6.0 h to 6.9 h. Mean sleep latency decreased by 23.9 ± 2.4 min (SEM) (p < 0.0001) from 58.8 min to 34.9 min. Wake after sleep onset decreased by 31.6 ± 3.2 min (SEM) (p < 0.001) from 42.8 min to 11.3 min. Sleep efficiency improved by 10.5 ± 1.1% (SEM) (p < 0.0001) from 79.3% to 89.8%. No significant adverse events were noted during the study duration. Keeping in mind this study's limitations, these data suggest that for insomnia patients with an incomplete response to current therapy, switching to daridorexant is safe and may be an effective alternative treatment.

We previously described five trajectories of insomnia (each defined by a distinct pattern of insomnia severity over 12 months following traumatic brain injury [TBI]). Our objective in the present study was to estimate the association between insomnia trajectory status and trajectories of mental health and neurocognitive outcomes during the 12 months after TBI. In this study, participants included N = 2022 adults from the Federal Inter-agency Traumatic Brain Injury Repository database and Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) study. The following outcome measures were assessed serially at 2 weeks, and 3, 6, and 12 months post-injury: Insomnia Severity Index, Patient Health Questionnaire, Post-Traumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Patient Reported Outcomes Measurement Information System-Pain, and Quality of Life After Brain Injury-Overall Scale. Neurocognitive performance was assessed at 2 weeks, and 6 and 12 months using the Wechsler Adult Intelligence Scales Processing Speed Index and the Trails Making Test Parts A and B. Results indicated that greater insomnia severity was associated with greater abnormality in mental health, quality of life, and neuropsychological testing outcomes. The pattern of insomnia over time tracked the temporal pattern of all these outcomes for all but a very small number of participants. Notably, severe insomnia at 3 or 6 months post-TBI was a risk factor for poor recovery at 12 months post-injury. In conclusion, in this well-characterized sample of individuals with TBI, insomnia severity generally tracked severity of depression, pain, PTSD, quality of life, and neurocognitive outcomes over 12 months post-injury. More intensive sleep assessment is needed to elucidate the nature of these relationships and to help inform best strategies for intervention.

BackgroundSleep problems are common and costly in the US military. Yet, within the military health system, there is a gross shortage of trained specialist providers to address sleep problems. As a result, demand for sleep medicine care far exceeds the available supply. Telehealth including telemedicine, mobile health, and wearables represents promising approaches to increase access to high-quality and cost-effective care. ObjectiveThe purpose of this study was to evaluate patient engagement and provider perceived effectiveness of a novel sleep telehealth platform and remote monitoring assessment in the US military. The platform includes a desktop web portal, native mobile app, and integrated wearable sensors (ie, a commercial off-the-shelf sleep tracker [Fitbit]). The goal of the remote monitoring assessment was to provide evidence-based sleep treatment recommendations to patients and providers. MethodsPatients with sleep problems were recruited from the Internal Medicine clinic at Walter Reed National Military Medical Center. Patients completed intensive remote monitoring assessments over 10 days (including a baseline intake questionnaire, daily sleep diaries, and 2 daily symptom surveys), and wore a Fitbit sleep tracker. Following the remote monitoring period, patients received assessment results and personalized sleep education in the mobile app. In parallel, providers received a provisional patient assessment report in an editable electronic document format. Patient engagement was assessed via behavioral adherence metrics that were determined a priori. Patients also completed a brief survey regarding ease of completion. Provider effectiveness was assessed via an anonymous survey. ResultsIn total, 35 patients with sleep problems participated in the study. There were no dropouts. Results indicated a high level of engagement with the sleep telehealth platform, with all participants having completed the baseline remote assessment, reviewed their personalized sleep assessment report, and completed the satisfaction survey. Patients completed 95.1% of sleep diaries and 95.3% of symptom surveys over 10 days. Patients reported high levels of satisfaction with most aspects of the remote monitoring assessment. In total, 24 primary care providers also participated and completed the anonymous survey. The results indicate high levels of perceived effectiveness and identified important potential benefits from adopting a sleep telehealth approach throughout the US military health care system. ConclusionsMilitary patients with sleep problems and military primary care providers demonstrated high levels of engagement and satisfaction with a novel sleep telehealth platform and remote monitoring assessment. Sleep telehealth approaches represent a potential pathway to increase access to evidence-based sleep medicine care in the US military. Further evaluation is warranted.

Importance:Insomnia is common after traumatic brain injury (TBI) and contributes to morbidity and long-term sequelae. Objective:To identify unique trajectories of insomnia in the 12 months after TBI. Design, Setting, and Participants:In this prospective cohort study, latent class mixed models (LCMMs) were used to model insomnia trajectories over time and to classify participants into distinct profile groups. Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a longitudinal, multisite, observational study, were uploaded to the Federal Interagency Traumatic Brain Injury Repository (FITBIR) database. Participants were enrolled at 1 of 18 participating level I trauma centers and enrolled within 24 hours of TBI injury. Additional data were obtained directly from the TRACK-TBI investigators that will be uploaded to FITBIR in the future. Data were collected from February 26, 2014, to August 8, 2018, and analyzed from July 1, 2020, to November 15, 2021. Exposures:Traumatic brain injury. Main Outcomes and Measures:Insomnia Severity Index assessed serially at 2 weeks and 3, 6, and 12 months thereafter. Results:The final sample included 2022 participants (1377 [68.1%] men; mean [SD] age, 40.1 [17.2] years) from the FITBIR database and the TRACK-TBI study. The data were best fit by a 5-class LCMM. Of these participants, 1245 (61.6%) reported persistent mild insomnia symptoms (class 1); 627 (31.0%) initially reported mild insomnia symptoms that resolved over time (class 2); 91 (4.5%) reported persistent severe insomnia symptoms (class 3); 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months (class 4); and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months (class 5). In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex (odds ratio [OR], 1.65 [95% CI, 1.02-2.66]), Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1. Conclusions and Relevance:These results suggest important heterogeneity in the course of insomnia after TBI in adults. More work is needed to identify outcomes associated with these insomnia trajectory class subgroups and to identify optimal subgroup-specific treatment approaches.

Description: In February 2022, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DoD) approved a joint clinical practice guideline (CPG) for the management of major depressive disorder (MDD). This synopsis summarizes key recommendations. Methods: Senior leaders within the VA and the DoD assembled a team to update the 2016 CPG for the management of MDD that included clinical stakeholders and conformed to the National Academy of Medicine's tenets for trustworthy CPGs. The guideline panel developed key questions, systematically searched and evaluated the literature, created two 1-page algorithms, and distilled 36 recommendations for care using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Select recommendations that were identified by the authors to represent key changes from the prior CPG are presented in this synopsis. Recommendations: The scope of the CPG is diverse; however, this synopsis focuses on key recommendations that the authors identified as important new evidence and changes to prior recommendations on pharmacologic management, pharmacogenomics, psychotherapy, complementary and alternative therapies, and the use of telemedicine.

INTRODUCTION:Sleep disorders' are highly prevalent among U.S. active duty service members (ADSMs) and present well-documented challenges to military health, safety, and performance. In addition to increased need for sleep medicine services, a major barrier to effective sleep management has been a lack of alignment among patients, health providers, and economic-decision-makers. To address this gap in knowledge, the purpose of the present study was to engage diverse stakeholders vested in improving sleep disorders' management in the military.MATERIALS AND METHODS:We elicited feedback from ADSMs with sleep disorders (five focus group discussion, n = 26) and primary care managers (PCMs) (11 individual semi-structured interview) in two military treatment facilities (MTFs) in the National Capitol Region, in addition to national level military and civilian administrative stakeholders (11 individual semi-structured interview) about their experiences with sleep disorders' management in U.S. MTFs, including facilitators and barriers for reaching a definitive sleep diagnosis, convenience and effectiveness of sleep treatments, and key desired outcomes from interventions designed to address effectively sleep disorders in the U.S. military health care system (MHS). Recordings from focus groups and semi-structured interviews were transcribed verbatim and analyzed using QSR International's NVivo 12 software using inductive thematic analysis. The study was approved by Walter Reed National Military Medical Center Department of Research Programs.RESULTS:Active duty service members with sleep disorders often fail to recognize their need for professional sleep management. Whereas PCMs identified themselves as first-line providers for sleep disorders in the military, patients lacked confidence that PCMs can make accurate diagnoses and deliver effective sleep treatments. Active duty service members cited needs for expeditious treatment, educational support and care coordination, and support for obtaining sleep treatments during deployment. Challenges that PCMs identified for effective management include insufficient time during routine care visits, delays in scheduling testing procedures, and limited number of sleep specialists. Primary care managers suggested offering evidence-based telehealth tools and enhanced care coordination between PCMs and specialists; standardized medical education, materials, and tools; patient preparation before appointments; self-administered patient education; and including behavioral sleep specialists as part of the sleep management team. For administrative stakeholders, key outcomes of enhanced sleep management included (1) improved resource allocation and cost savings, and (2) improved ADSM safety, productivity, and combat effectiveness.CONCLUSION:Current military sleep management practices are neither satisfactory nor maximally effective. Our findings suggest that solving the military sleep problem will require sustained effort and ongoing collaboration from ADSM patients, providers, and health systems leaders. Important potential roles for telehealth and technology were identified. Future research should seek to enhance implementation of sleep management best practices to improve outcomes for patients, providers, MHS, and the military as a whole.

INTRODUCTIONSleep disorders are common in the military, and there is a gross shortage of sleep specialists in the military health system. The purposes of the present study were to (1) understand perceptions and expectations surrounding sleep telehealth approaches and (2) solicit feedback to optimize and refine a proposed novel sleep telehealth management platform. To accomplish these objectives, we investigated the perceptions, expectations, and preferences of active duty service members (ADSMs) with sleep disorders, primary care managers (PCMs), and administrative stakeholders regarding sleep telehealth management.MATERIALS AND METHODSUsing convenience sampling, we conducted five focus groups with 26 ADSMs and 11 individual interviews with PCMs from two military treatment facilities in the U.S National Capital Region and 11 individual interviews with administrative sleep stakeholders (9 military and 2 civilian).RESULTSActive duty service members, PCMs, and administrative stakeholders provided insight regarding expectations for sleep telehealth as well as suggestions to optimize the novel sleep telehealth platform. In terms of outcomes, ADSMs expected sleep telehealth to improve sleep and convenience. Primary care managers expected improved sleep and other comorbidities, enhanced operational readiness, and reduced mortalities among their patients. Administrators expected increased access to care, optimized utilization of health services, realized cost savings, reduced accidents and errors, and improved military performance. In terms of the platform, for ADSMs, desired characteristics included delivery of timely clinical reports, improved patient-provider communication, and enhanced continuity of care. For PCMs and administrators,an ideal sleep telehealth solution will improve the diagnosis and triage of sleep patients, save PCM time, be easy to use, and integrate with the electronic health record system.CONCLUSIONThe proposed sleep telehealth platform appealed to nearly all participants as a significant force multiplier to enhance sleep disorder management in the military. Stakeholders offered valuable recommendations to optimize the platform to ensure its successful real-world implementation.

AbstractStudy ObjectivesTo describe initial insomnia-related encounters among a national sample of Medicare beneficiaries, and to identify older adults at risk for potentially inappropriate prescription insomnia medication usage.MethodsOur data source was a random 5% sample of Medicare administrative claims data (2006–2013). Insomnia was operationalized as International Classification of Disease, Ninth Revision, Clinical Modification diagnostic codes. Insomnia medications included FDA-approved insomnia-related medication classes and drugs. Logistic regression was employed to identify predictors of being “prescribed only” (i.e., being prescribed an insomnia medication without a corresponding insomnia diagnosis).ResultsA total of N = 60 362 beneficiaries received either an insomnia diagnosis or a prescription for an insomnia medication as their first sleep-related encounter during the study period. Of these, 55.1% (n = 33 245) were prescribed only, whereas 44.9% (n = 27 117) received a concurrent insomnia diagnosis. In a fully adjusted regression model, younger age (odds ratio (OR) 0.98; 95% confidence interval (CI) 0.98, 0.99), male sex (OR 1.15; 95% CI 1.11, 1.20), and several comorbid conditions (i.e., dementia [OR 1.21; 95% CI 1.15, 1.27] and anemia [OR 1.17; 95% CI 1.13, 1.22]) were positively associated with being prescribed only. Conversely, black individuals (OR 0.83; 95% CI 0.78, 0.89) and those of “other” race (OR 0.89; 95% CI 0.84, 0.94) were less likely to be prescribed only. Individuals who received care from a board-certified sleep medicine provider (BCSMP) were less likely to be prescribed only (OR 0.27; 95% CI 0.16, 0.46).ConclusionsFewer than half of Medicare beneficiaries prescribed insomnia medications ever received a formal sleep-related diagnosis.

In this brief report, the authors evaluate the effects of a possible association between different bupropion formulations and treatment-emergent insomnia in veterans with major depressive disorder prescribed bupropion based on provider discretion.

As evidenced throughout this volume, sleep and psychiatry are deeply intertwined. Sleep and psychiatric processes share multiple biologic underpinnings, and sleep and psychiatric disorders are highly comorbid, with an additive adverse impact. Yet, much remains unknown, and much work remains to optimize treatments of sleep disorders in psychiatric populations. This chapter is to consider these issues with an eye toward the future. The chapter briefly considers sleep medicine education in psychiatry, drug development and novel compounds, consumer wearables, behavioral and complementary approaches, telehealth, and sleep health economics. The authors argue for the need to a value-based approach to sleep and psychiatry.