MIRECC / CoE

VISN 4 MIRECC Newsflash

Spring 2023

Five Questions with Adam Bramoweth, Ph.D., DBSM

Dr. Bramoweth is an investigator and Associate Fellowship Director (Psychology Track, Pittsburgh) at the VISN 4 MIRECC and an investigator at the Center for Health Equity Research and Promotion. He provides behavioral sleep services as a staff psychologist at the VA Pittsburgh Healthcare System. His research is focused on improving access to behavioral sleep care through implementation science, clinical trials, and exploring electronic health data. An alumnus of the Advanced Fellowship in Mental Illness Research and Treatment and Career Development Awardee, Dr. Bramoweth is now principal investigator for VA-funded studies on implementing Brief Behavioral Treatment for Insomnia (BBT-I) in primary care (EASI Care) and helping Veterans decrease their use of sleep medications (SEDATIVE).

Q. What do you see as the greatest barriers to access to care for sleep problems?

As with much of health care, it’s a numbers game. To improve access, we need more trained providers, and providers also need the time and infrastructure to provide care consistent with their training. Almost all providers in Sleep Medicine and Behavioral Sleep Medicine (BSM) wear several hats. Many Sleep Medicine physicians also practice in Pulmonology, Neurology, Psychiatry, and Internal Medicine.

BSM providers are a relatively new breed. There are around 50 self-identified BSM providers in VA and around 20 have board certification in BSM. However, VA’s fantastic training program in Cognitive Behavioral Therapy for Insomnia (CBT-I) has trained over 1,300 providers since 2011 and trains more every year, so VA’s roster of providers who can treat chronic insomnia and other behavioral sleep problems will continue to grow.

It’s also important that providers are located where the patients are. Even with our advances in telehealth, many patients choose not to engage in technology-assisted care like VA Video Connect, struggle to use technology, or may face barriers such as lacking reliable internet or a compatible device. For these reasons, we need more trained providers accessible to patients in suburban and rural areas, as many VA Medical Centers are located in more densely populated areas.

Q. What are some promising ways technology is changing the way behavioral sleep care can be delivered?

Technology helps improve our patient reach. As noted above, there are simply not enough providers to meet the demand. VA’s growth in telehealth capabilities has greatly expanded engagement in CBT-I. Also, free mobile apps and browser-based programs are widely available, and VA has several options. CBT-I Coach (mobile app) is intended to be used in conjunction with clinician-delivered care, Insomnia Coach (mobile app) is for self-management (but can also be used with clinician-delivered care), and SleepEZ, part of VA’s Path to Better Sleep program, is a browser-based digital insomnia intervention, also for patients interested in self-management. Several for-cost applications are also on the market for self-management of insomnia and other digital tools to help providers deliver more efficient care.

Q. How does a precision mental health care approach apply to behavioral sleep treatment?

We still don’t know a lot about sleep. What we do know is that sleep is a biological requirement and sleep plays a role in many psychiatric disorders, with insomnia/disrupted sleep as a symptom of many disorders but also as an independent risk factor for development of disorders. The more we know about sleep and the role it plays in mental health, the better we can develop and/or adapt our assessments and interventions across the psychiatric spectrum to improve patient clinical and functional outcomes as well as improve our ability to deliver care efficiently and effectively.

Q. It was widely reported that during the COVID-19 pandemic, more people began experiencing insomnia. Do you think the events of the past few years will have any lasting effects on general attitudes and knowledge about sleep or prioritizing healthy sleep behaviors?

I certainly hope so. The pandemic helped illuminate the importance of sleep. For many, sleep worsened due to anxiety, fear, and isolation, not to mention those who acquired COVID and those still struggling with long-COVID. But for others, the pandemic was an opportunity to improve their sleep. Less travel to and from work and working from home both contributed to expanded sleep opportunity and duration for many and helping align sleep need with circadian rhythm. However, with an increase in insomnia during the pandemic, and a lack of access to first-line behavioral interventions, many relied on sleep medications.

Q. Are there any unique advantages to conducting behavioral sleep research within VA?

VA offers a fantastic setting for behavioral sleep research. Some of the foundational CBT-I studies (e.g., randomized controlled trials) were conducted in VA, as was research on nightmares.

VA’s Corporate Data Warehouse is an excellent resource. There is a wealth of behavioral sleep-related variables that can be examined cross-sectionally, longitudinally, and integrated into complex modeling to explore their clinical and functional impact.

Importantly, change at scale is very realistic in VA. Research findings can be put into practice, not just at one VA but potentially all VAs. The development of VA’s CBT-I training program is a prime example of this, allowing for real-world observations on treatment effectiveness, but also training methods, service delivery, and implementation. My EASI Care study on implementing BBT-I in Primary Care Mental Health clinics is another example of how a single-site research trial can lead to clinical uptake at other sites within VA. Finally, research conducted in VA is often translated to the community as well, not just benefitting Veterans.

Matthew Chinman, Ph.D. received an HSR&D Research Career Scientist Award, which provides up to five years of funding for established investigators who have distinguished themselves through scientific achievements and contributions to the VA research program such as training, mentoring, and functioning as resources for the research community.

Isabella Soreca, M.D. received notice of RR&D funding for her study, “Bright Light Therapy for Residual Daytime Symptoms Associated with Obstructive Sleep Apnea.”

Mark Thomas, Ph.D. received MIRECC pilot funding for his project, “Effect of CPAP Adherence and MOVE! Program Participation on Depression and Weight Loss Using EHR Data.”

Judith Callan, Ph.D., RN received Competitive Career Development funding (CCDF) for her project, “Feasibility of CBT Mobilework-V Smartphone App Augmentation to CBT Group Therapy.”

Gabriela Khazanov, Ph.D. of the Philadelphia Center of Excellence in Substance Addiction Treatment and Education (CESATE) received notice of HSR&D funding for her study, “Incentivizing Lethal Means Safety among Veterans at Risk for Suicide.”

Matthew Chinman, Ph.D. presented his poster, “Veterans with Mental Illness Who Engage with Mental Health Peer Specialists More Get More Benefit,” at the 2023 HSR&D/QUERI National Meeting in Baltimore.

Gretchen Haas, Ph.D. was appointed president of the American Foundation for Suicide Prevention.

Rachel Bachrach, Ph.D. was selected as a “Rising Star” by the Association for Psychological Science. Dr. Bachrach was also named a 2023 Implementation Research Institute Fellow.

Henry Kranzler, M.D. spoke to NBC News for an article about a rise in alcohol-related liver disease among younger patients. He has also recently spoken about the health risks of drinking alcohol to CBC News, Bloomberg, USA Today, and Parade, and about the use of naltrexone for people who binge drink to the New York Times and Everyday Health.

Philip Gehrman, Ph.D. and colleagues published an article in Science Advances in which they identified a new genetic link to sleep regulation in humans by studying fruit flies and zebrafish. The findings were featured by The Jerusalem Post, Texas A&M Today, and Front Line Genomics. He also spoke to the Guardian for a story about “circadian-rhythm shaming” of night owls and to the New York Times about the potential risks associated with mixing melatonin and alcohol.

A study of a machine-learning model to predict how well Veterans respond to combined antidepressants and psychotherapy treatments for depression on which David Oslin, M.D. and Ruifeng Cui, Ph.D. were coauthors was highlighted in a news brief on the website of the VA Office of Research and Development.

An analysis coauthored by David Oslin, M.D., which found that pharmacogenetic testing can help with pain management for Veterans taking opioid medications, was also highlighted in a news brief on the website of the VA Office of Research and Development.

Gabriela Khazanov, Ph.D. co-wrote an op-ed in the Albany Times Union about efforts to improve firearm safety among Veterans at risk for suicide, including the development of a new website, www.worriedaboutaveteran.org.

A study recently published in Respiratory Research by Faith Luyster, Ph.D. about the link between insomnia and COPD-related health care costs was highlighted by HCP Live.

Our Center, in partnership with the National Pharmacogenomics Program and the VHA Institute for Learning, Education, and Development, recently hosted a webinar: "Incorporating Pharmacogenomics into Your Clinical Mental Health Practice." More than 200 clinicians across VA heard from experts on topics including an overview of pharmacogenomics (PGx), its role in mental health care, the latest research, and how to integrate it into practice. Find more information here, or to request a recording of the webinar, email sara.chapman@va.gov.

Katherine Miller, Ph.D. and planning committee held a very successful training, “Cognitive Behavioral Therapy for Nightmares: Clinical Workshop” (back by popular demand for the fourth time).

Martin JL, DeViva J, McCarthy E, Gehrman P, Josephson K, Mitchell M, de Beer C, Runnals J. In-person and telehealth treatment of Veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. Journal of Clinical Sleep Medicine. March 2023. [link]

Thomas MC, Kamarck TW. Does light physical activity reduce blood pressure responses to laboratory stressors? Psychophysiology. March 2023. [link]

Boland EM, Goldschmied JR, Gehrman PR. Does insomnia treatment prevent depression? Sleep. April 2023. [link]

Kranzler HR, Feinn R, Xu H, Ho BL, Saini D, Nicastro OR, Jacoby A, Toikumo S, Gelernter J, Hartwell EE, Kember RL. Does polygenic risk for substance-related traits predict ages of onset and progression of symptoms? Addiction. April 2023. [link]

Bonfils KA, Longenecker JM, Soreca I, Hammer LA, Tighe CA, Haas GL, Bramoweth AD. Sleep disorders in Veterans with serious mental illnesses: prevalence in VA health record data. Journal of Clinical Sleep Medicine. May 2023. [link]

Are you following @VA_MIRECC_OMHSP on Twitter for research updates from VA Mental Health Research Centers? Here are a few recent tweets highlighting VISN 4 MIRECC research:

• Early in the COVID-19 pandemic, some patients with serious mental illness (#SMI) faced barriers to adherence to long-acting injectable antipsychotics. Identifying those at elevated risk for such disruptions may improve outcomes in future emergencies. https://pubmed.ncbi.nlm.nih.gov/36355590/
  
• Patients with #schizophrenia have higher levels of the protein complement C4, which marks dendritic spines in the brain for phagocytosis by microglia. Microglia also have a higher molecular capacity for phagocytosis in these patients. A deeper understanding of the link between microglial phagocytosis and dendritic spine loss could help in the development of new approaches for patients with schizophrenia. https://pubmed.ncbi.nlm.nih.gov/36527956/
• Implementation facilitation leads to increased adoption and reach of Measurement Based Care (#MBC) for mental health conditions and helped VA PC-MHI clinics maintain focus on MBC implementation during the COVID-19 pandemic. https://pubmed.ncbi.nlm.nih.gov/36597698/

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