Jennifer Martin, PhD — Sleep Disorder and Subject-matter Expert for VA’s program to Disseminate Cognitive Behavioral Therapy for Insomnia
LOS ANGELES — We spend approximately one-third of our lives asleep, but it’s only been in the last couple of decades that the medical community has begun to understand in detail just how important sleep can be to our lives. It cannot only make your day seem sluggish and dull but can worsen existing chronic health conditions and increase the risk of developing others.
When Jennifer Martin, PhD—nationally renowned sleep disorder expert and subject-matter expert for VA’s program to disseminate cognitive behavioral therapy for insomnia—was beginning her clinical training 30 years ago, research into the importance of sleep was still in its infancy.
“There was a huge unmet need for treatment of sleep disorders, and at the time there was very little science to inform clinical decision-making,” Martin said. “There were still debates about whether it was necessary or important, or what the actual physical benefits were for a good night’s sleep.”
As a grad student, Martin was dissuaded from going into the field, with one professor actually telling her that “sleep was cute and everything, but if I wanted a long career in research, I should study something important.”
Luckily, Martin ignored their advice, and studies within 5 years began being published showing the significant negative consequences of sleep disorders.
Meanwhile, Martin found a home at the Los Angeles VA, home to a large sleep center, which in 2007 launched a clinical program focusing on treatment for insomnia disorder. It was that program that resulted in Martin becoming interested in the intersection of insomnia and women’s health.
“I had a smart post-doc fellow who was interested in women’s health and wanted to look at who the people were who were using our services,” Martin explained. “We know from studies in the population that insomnia disorders are twice as common in women as in men, but we weren’t seeing women in our clinic at all. We were only seeing a tiny fraction of women who probably had insomnia in our own VA.”
After searching the literature and failing to find a single published study looking at sleep disorders in women veterans, Martin and her colleagues decided to fill the gap. They went on to discover that women veterans experience insomnia disorder at twice the rate of the civilian population.
The first-line treatment for insomnia disorder is cognitive behavioral therapy (CBT), but not a lot of women veterans were getting that treatment. In a follow-up study, Martin also discovered that women were likely to not complete their treatment. CBT focusing on insomnia is a short course—only five or six sessions—but it asks patients to change their schedule and routines, to go to bed and get up at the same time every day.
“It’s very effective, but it’s not easy,” Martin said.
Because the therapy is based on basic biology, there wasn’t much they could do to change it without impacting its effectiveness. But they were able to recontextualize it.
“We changed how the therapy is presented and linked it back to the veterans’ individual values and why sleeping better might help those important things,” Martin explained. “Most people don’t go to see a psychologist for a good night of sleep. They go to a psychologist because not sleeping well is affecting other things in their life that they care about. We found that, by adjusting the treatment to meet the needs of women veterans, we were able to keep them in treatment, [and they] were more likely to follow the behavioral recommendations.”
Anyone who struggles with insomnia knows that they’re not operating at their best self. But, thanks to researchers like Martin, we now understand the cascade of effects is far more broad and severe.
Insomnia has been associated with high blood pressure and an increased risk for Type 2 diabetes, depression and Alzheimer’s. In a study of active duty servicewomen who had been exposed to trauma, poor sleep resulted in an increased risk for developing PTSD.
“Poor sleep and insomnia probably make it harder for you to cope with life’s challenges and increase risk for mental health conditions down the road,” Martin explained.
There’s also a rich literature documenting the link between insomnia disorder and chronic pain, Martin noted. “When people don’t sleep enough, their ability to cope with pain is significantly impaired.”
She added that, “if someone is not sleeping well, it’s probably easier to come up with the things it doesn’t affect than the list of things it does.”
Recently, Martin has turned her attention toward sleep apnea in women veterans and is discovering the same treatment patterns as with insomnia disorder, where patients are struggling to use the first-line treatment—wearing a continuous positive airway pressure (CPAP) when sleeping.
Using the same approach as before, she conducted a study where the focus was on patient values and the reasons they wanted to get better. While the study failed to get women to use CPAP, they did report sleeping better after the study was over.
“All of the other little recommendations we made—consistent sleep schedule, etc., etc.—women were very receptive to that and followed those recommendations,” Martin said. “It made us take a step back and consider whether we needed to present women with multiple treatment options from the very beginning.”
Looking to the future, Martin still has lingering questions when it comes to insomnia disorder—mainly around the 30% of people that CBT doesn’t benefit.
“I want to know how to help them. … I want to understand the best clinical-care pathways for delivering these treatments. Veterans should have easy access to them. Not just veterans—everyone should have easy access to them,” she said. “Given how common insomnia disorder is, I feel like we would solve this problem if every psychologist, social worker, therapist had some evidence-based treatment for ID in their clinical arsenal. There aren’t a lot of conditions out there that affect 10% of men and 20% of women where a provider in general practice doesn’t have something in their toolbox.”
