Implementation of Brief Treatments for Insomnia in Primary Care

 描述(由申请人提供)： 慢性失眠是退伍军人和军事人员被转介到心理健康服务机构报告最多的投诉之一。它与医疗和精神疾病高度并存，并与显著增加的医疗利用率和成本有关。尽管失眠的影响很大，但它仍然得不到治疗。在确诊后，失眠通常在初级保健环境中通过药物治疗来治疗，而不是基于证据的心理治疗--认知行为治疗失眠(CBTI)--这是有效的，并推荐超过处方睡眠药物。然而，一些系统、提供者和患者层面的障碍，以及与治疗有关的障碍，造成了失眠症的高患病率与获得CBTI之间的差距。为了提高退伍军人事务部失眠行为疗法的可行性，关键是要确定哪些行为疗法最有效，以及哪些实施因素(如护理障碍和促进剂)对患者和提供者将治疗纳入常规临床实践的影响最大。与CBTI相比，更短的治疗(≤4个疗程)，允许电话提供治疗，也可以由非博士级别的临床医生(例如护士)提供，可能有助于克服限制获得失眠护理的障碍。失眠症的简要行为治疗(BBTI)提供了治疗的灵活性，可以增加获得机会，并在退伍军人和军事人员中有效。此外，BBTI的上述特点使其成为在退伍军人管理局以患者为中心的初级保健团队(PACTS)和初级保健-精神卫生一体化(PC-MHI)倡议的协作、综合初级保健的背景下提供的理想干预措施。将BBTI纳入PACTS可以有效和高效地增加获得失眠治疗的机会，从而减少与慢性失眠相关的风险和负担。虽然有效，但BBTI是否达到了与CBTI相同的临床结果尚不清楚，CBTI是一种由VA支持的循证心理疗法。此外，从提供者和患者的角度来看，与在PACTS中交付BBTI相关的实施因素仍不清楚。在初级保健协议中广泛实施BBTI可能会对退伍军人的健康和医疗保健产生重大影响，但有必要确定哪种治疗-CBTI或BBTI-以最少的患者、提供者和系统障碍产生最佳结果。我的长期职业目标是成为退伍军人事务部HSR&D调查员，研究失眠行为疗法的传播和实施，以及减少失眠对退伍军人健康影响的方法。我提议的CDA将支持新研究方法和分析策略的培训，以及向独立过渡所必需的研究活动的开展。我建议的研究目标是：(1)进行BBTI与CBTI的比较有效性试点试验；以及(2)进行定性需求评估，以确定与初级保健协定中实施失眠行为治疗相关的因素。我建议的培训目标是：(1)熟练掌握比较有效性研究的量化方法和分析策略，包括：招募、结果测量和等效性分析；(2)发展卫生服务研究和实施科学方面的专业知识，包括理论框架的应用，以及实施试验的设计、进行和评估；以及(3)学习用于卫生服务研究的定性方法和分析方面的高级技能，包括：数据收集方法(例如，访谈、焦点小组)、数据分析方法，以及使用软件进行数据分析。

 DESCRIPTION (provided by applicant): Chronic insomnia is among the most reported complaints of Veterans and military personnel referred for mental health services. It is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Despite the significant impacts of insomnia, it remains under-treated. When identified, insomnia is most often treated in the primary care setting with pharmacotherapy, rather than evidence-based psychotherapy-Cognitive Behavioral Treatment for Insomnia (CBTI)-which is effective and recommended over prescription sleep medications. However, a number of system-, provider-, and patient-level barriers, as well as treatment-related barriers, contribute to the gap between the high prevalence of insomnia and access to CBTI. To increase the viability of behavioral treatments for insomnia in the VA, it is critical to determine which behavioral treatments are most effective, and which implementation factors (e.g., barriers and facilitators to care) most impact uptake of treatments by patients and providers into routine clinical practice. Compared to CBTI, a treatment that is shorter (≤4 sessions), allows for phone delivered treatment, and can also be delivered by non-doctoral level clinicians (e.g., nurses) may help to overcome barriers that limit access to insomnia care. Brief Behavioral Treatment of Insomnia (BBTI) offers the treatment flexibility that can increase access and is efficacious among Veterans and military personnel. Furthermore, BBTI's aforementioned characteristics make it an ideal intervention for delivery in the context of collaborative, integrated primary care within VA's Primary Care Patient-Aligned Care Teams (PACTs) and Primary Care-Mental Health Integration (PC-MHI) initiatives. Uptake of BBTI into PACTs could effectively and efficiently increase access to insomnia treatment and thus decrease the risks and burdens associated with chronic insomnia. Although efficacious, it is not known if BBTI achieves the same clinical outcomes as CBTI, a VA supported evidence-based psychotherapy. Additionally, the implementation factors associated with the delivery of BBTI in PACTs from the perspective of providers and patients remains unknown. Broad implementation of BBTI in Primary Care PACTs could have a significant impact on Veteran health and healthcare, but it is necessary to determine which treatment-CBTI or BBTI- yields the best outcomes with the least patient, provider, and system barriers. My long-term career goal is to be a VA HSR&D Investigator with a program of research on the dissemination and implementation of behavioral treatments for insomnia, and methods to decrease the impact of insomnia on Veteran health. My proposed CDA will support training in new research methods and analytic strategies, and the conduct of research activities necessary for transition to independence. My proposed Research Aims are: (1) to conduct a pilot comparative effectiveness trial of BBTI vs. CBTI; and (2) to conduct a qualitative needs assessment to identify factors associated with the implementation of behavioral treatments for insomnia in Primary Care PACTs. My proposed Training Aims are: (1) to gain proficiency in quantitative methods and analytic strategies for comparative effectiveness research, including: recruitment, measurement of outcomes, and equivalency analysis; (2) to develop expertise in health services research and implementation science, including the application of theoretical frameworks, and the design, conduct, and evaluation of implementation trials; and (3) to learn advanced skills in qualitative methods and analyses for use in health services research, including: data collection methods (e.g., interviews, focus groups), data analytic methods, and the use of software for data analysis.