US Veterans: The Biggest Gap in Sleep Access

Amongst Vietnam Veterans with posttraumatic stress disorder (PTSD), a staggering 90-100 percent report insomnia. Insomnia was the most common symptom of PTSD reported by veterans from Afghanistan and Iraq, and 92 percent of active duty military with PTSD reported clinically significant insomnia. The US Department of Veterans Affairs/Department of Defense recommends cognitive behavioral treatment for insomnia (CBT-I) as the first-line treatment for chronic insomnia.

When sleep problems are left unmanaged, mood disorders, substance relapse, and health comorbidities are significantly more challenging to gain control over. The challenge is an access to care issue—there are still fewer than 300 of us who are board-certified in behavioral sleep medicine (BSM).

When I treated sleep disorders at the VA Hospital in San Diego, I learned firsthand how complex insomnia was for the veterans.

Key Lessons Learned

1. You can’t simply jump into CBT-I like you can for other insomnia patients.
2. When patients had prolonged nighttime awakenings or sleep avoidance, they often had nightmares underlying and impacting their insomnia.
3. Nightmare disorder must be managed by a trained BSM specialist via imagery rehearsal therapy (IRT), and only after PTSD has been effectively treated.
4. We were fortunate to have an evidence-based PTSD program at the VA Hospital. Outside of the VA hospitals, I learned that most patients who told me that their PTSD had been managed had actually only had “talk therapy.” The evidence-based treatments for PTSD are cognitive processing therapy (CPT) and prolonged exposure (PE), and other variants of such protocols. If a patient had only had talk therapy, I stop everything and help the patient get set up with a CPT- or PE-trained clinician before I will start sleep treatment.
5. Once I’m convinced that the PTSD was effectively managed, then I can see what level of nightmares remain, and how much such symptoms are impacting the insomnia presentation.
6. We are also screening for sleep apnea symptoms, as this is highly common in the veteran population as well and can mimic sleep maintenance insomnia. If a patient has already been diagnosed with sleep apnea and is not adherent to their treatment, it’s essential to work through these adherence issues and/or refer back to the sleep physician for alternative treatment options.
7. Given the high prevalence of substance use disorders, we are also carefully screening for such symptoms, as the impact of alcohol and illicit drugs on sleep is significant. Furthermore, if a veteran is freshly clean and sober, untreated insomnia puts them at significant risk for relapse.
8. As well, chronic pain, depression, and hypertension are common comorbidities that need customization in this population.

Closing the Gap in Veteran Sleep Care

This crisis isn’t just about individual struggles—it’s about systemic accessibility. With too few trained BSM specialists, many veterans are left untreated, misdiagnosed, or prescribed medications that don’t address the root cause. Better training, more certified specialists, and stronger outreach are critical to ensuring every veteran receives the sleep care they deserve.

If we truly want to support veterans in mental health recovery, physical health, and reintegration into civilian life, we must prioritize sleep health as the foundation for better outcomes in PTSD treatment, substance recovery, and long-term well-being.