‘Missing an Opportunity’: Why Behavioral Health Providers Should Treat Sleep Disorders

Lack of sleep can increase a person’s chance of developing hypertension, diabetes, heart attack and stroke. There’s an intrinsic link to mental health and well-being, too.

Sleep loss and behavioral health conditions can lead to a feedback loop in which lack of sleep worsens behavioral health conditions, and behavioral health conditions lead to lack of sleep.

Behavioral health providers have an opportunity to improve patient outcomes, decrease overall costs of care and get more patients into treatment by offering evidence-based sleep disorder treatment, according to industry insiders.

“A behavioral health provider who is not providing support around sleep is missing an opportunity to have a significant positive impact on helping their client live a longer, happier, more engaged life,” Dr. Alethea Varra, senior vice president of clinical care at Lyra Health, told Behavioral Health Business.

Burlingame, California-based Lyra is a virtual workforce mental health platform with more than 17 million covered lives. The provider offers coaching, therapy, medication management and acute mental health care. Lyra has raised a total of $680 million including a $200 million Series C raise in 2021. 

Sleep disorders are distinct from an occasional bad night’s sleep. Chronic and long-standing sleep problems can become a clinical concern, however.

Insomnia is considered the most common co-occurring sleep disorder and the need for treatment usually arises after three months of problems. 

Other sleep disorders include sleep apnea, in which a person struggles to breathe during the night and therefore wakes up regularly, leading to poor sleep quality. A less common sleep problem is hypersomnia, in which a person is excessively sleepy throughout waking hours.

Why sleep disorder treatment matters

These sleep disorders have a bidirectional relationship with mental health, meaning that sleep disorders worsen mental health symptoms and vice versa. Sleep disorders are especially common among people with mental health conditions.

About 30% of Lyra’s patients have sleep challenges, Varra said, many of which overlap with mental health conditions.

At American Addiction Centers, the “majority” of patients have sleep disturbances, Dr. Lawrence Weinstein, the organization’s chief medical officer, told BHB.

Brentwood, Tennessee-based American Addiction Centers provides inpatient and outpatient treatment for SUD and co-occurring mental health and behavioral health conditions. The provider operates centers in seven states according to its site; it named new co-CEOs in December 2023. 

While sleep disorders are common among people with behavioral health conditions, an effective, non-pharmaceutical treatment modality exists that significantly improves insomnia symptoms for about 70% to 80% of patients. 

Cognitive behavioral therapy for insomnia (CBT-I) is broadly considered as the gold standard treatment for insomnia. The American College of Physicians, the American Academy of Sleep Medicine, Veterans Affairs and the Department of Defense (DoD) all recommend CBT-I as the first-line treatment.

“[Cognitive behavioral therapy for insomnia] involves targeting the behaviors and thoughts that impact how a person sleeps at night,” Dr. Jennifer Martin, professor of medicine at the University of California, Los Angeles and spokesperson for the American Academy of Sleep Medicine (AASM), told BHB. “I like to think about it as setting up a series of experiments, trying a sleep plan with a person, sending them home with a sleep diary for a week or two. Then I have them come back, we reassess the plan and make adjustments.”

AASM is a professional society dedicated to sleep medicine. The organization sets standards for sleep medicine health care and works with policymakers to reduce sleep health disparities. It has a membership of 11,000 sleep centers, physicians, scientists and other health care professionals.

Patients usually receive CBT-I over the course of five to six sessions, usually spread over the course of a few months.

For patients who have co-occurring behavioral health conditions and sleep disorders, CBT-I can also be a gateway into care.

“Since sleep support often carries less stigma than mental health treatment, it can serve as an approachable entry point for starting a conversation about someone’s overall well-being,” Jenna Glover, chief clinical officer at Headspace, told BHB.

Santa Monica, California-based Headspace provides mental health resources and services through both business-to-business and direct-to-consumer avenues. Its clinical offerings include therapy, coaching and psychiatry services. The company recently named Tom Pickett its new CEO. Pickett previously worked as chief revenue officer at food delivery company DoorDash.

How behavioral health providers approach sleep disorder treatment

CBT-I may be the most evidence-based treatment for insomnia, but most behavioral health providers do not offer the therapy, Martin said.

“Unfortunately, what most behavioral health providers do is sleep hygiene,” Martin said. “Sleep hygiene recommendations almost never work.”

Sleep hygiene is the practice of improving basic sleep practices, including setting a consistent sleep schedule and creating a bedtime routine.

But in the long term, CBT-I is still the gold standard.

“While sleep hygiene is important, clinically validated tools, such as CBT-I techniques, are more rigorously tested and backed by evidence,” Glover said. “For long-term success, CBT-I is the best way to achieve lasting sleep improvement.”

For patients with co-occurring mental health and sleep conditions, order of operations matters.

Lyra clinicians generally treat mental health conditions before tackling sleep conditions specifically.

“It really is that mental health challenge in the first place that we want to work on,” Varra said. “If we change your relationship to that symptom, you might be able to find yourself going to sleep.”

Research suggests that tackling sleep promotes mental health, can improve physical health and reduce overall cost. Even without treatment for specific mental health conditions, improved sleep quality has been demonstrated to improve mental health conditions including depression. 

“The data tell us now that you’re better off to start by treating the sleep disorder,” Martin said. “It’s very counterintuitive. It’s not how I learned 25 years ago, but as more and more research is coming out, if you can only start with one treatment, the data would show that you should treat the sleep disorder first.”

The caveat to treating sleep disorders first, Martin said, is that some mental health conditions can prevent patients from engaging in insomnia treatment. In these cases, she recommends treating both conditions simultaneously.

While CBT-I is the gold standard, behavioral health providers may choose to treat sleep pharmacologically, through sleeping pills.

According to clinical practice guidelines, clinicians should only offer medication after a patient is offered a non-pharmacological approach, Martin said. Even then, sleeping medications are only recommended for a short period of time.

Only about 10% of patients fail to respond to CBT-I, Martin said, and in those cases another mental health condition or sleep disorder was interfering with patients’ ability to engage with treatment.

Most SUD treatment providers approach sleep issues pharmacologically, Weinstein said, despite the fact that a non-pharmacological approach has the best long-term impact.

“I am not sure how well versed the majority of providers are in non-pharmacological approaches,” Weinstein said. “The problem with that is that a lot of medications that are being used acutely to improve sleep have long-term consequences. A non-pharmacological approach [provides] tools that people could take with them when they’re discharged.”

Integrating sleep treatment

Incorporating CBT-I or other evidence-based sleep treatments offers clear clinical benefits for patients and reduces overall costs of care. It also offers benefits to providers’ bottom lines.

“There are a lot of people out there with untreated sleep problems,” Martin said. “The practices that I know of that focus on this are very, very busy. There’s a big need. There are a lot of people out there who need and want treatment.”

Certain barriers can make it difficult for behavioral health providers to offer CBT-I, however.

Few behavioral health clinicians are trained in CBT-I.

“That’s partially because there’s a lot of providers out there who are trained before the research and support for that treatment in particular was really clear,” Varra said. “They just haven’t had the opportunity to have the training, or they haven’t circled back to get that training in addition to their original training so that they can expand their offerings.”

Lack of available, trained clinicians can also make CBT-I expensive for patients, Glover said.

The expense and clinician shortage make the field of CBT-I ripe for technological innovation, Varra said. One notable example of virtual CBT-I treatment is a free app created by the Department of Veterans Affairs that can be used on its own or in addition to treatment. 

Headspace also operates a virtual program utilizing CBT-I techniques, called the Finding Your Best Sleep program. The offering is a three-week course involving daily 10-minute sessions including CBT-I tactics, reflection exercises and self-administered check-ins. 

Education about the importance of quality sleep could help improve access to treatment.

Payers are increasingly interested in sleep treatment as a way to promote overall health, especially in value-based contracts, according to Weinstein. But sleep treatment is still a “step child” and more still should be done to improve reimbursement, he said.

Increased education of the behavioral and physical impacts of poor sleep quality will lead health plans to pay more attention to sleep disorders and the need for widely available non-pharmacological treatment, Weinstein said.