Brief Behavioral Insomnia Therapy Kept Growing in VA Clinics Even After Support Ended

Veterans with insomnia continued to receive more behavioral treatment even after the implementation support designed to boost that care was withdrawn, according to a sustainment-phase pre-post analysis of a hybrid type 3 trial published in the Journal of General Internal Medicine. Across four Department of Veterans Affairs (VA) Medical Centers, delivery of a brief behavioral treatment for insomnia (BBTI) in Primary Care Mental Health Integration (PCMHI) clinics rose from 20.2 percent to 32.7 percent of Veterans with insomnia as the study moved from the implementation phase into the sustainment phase, an increase of 12.5 percentage points that corresponded to roughly a doubling of the odds of receiving the therapy (odds ratio 1.9, p < 0.001).

The trial, registered as NCT04350866, was designed to evaluate whether BBTI training plus implementation strategy support could expand the delivery of behavioral insomnia care within PCMHI clinics, and the sustainment phase specifically examined what happened when that external support was withdrawn. Total behavioral insomnia care, defined in the study as BBTI plus cognitive behavioral therapy for insomnia (CBT-I), also increased during the same transition, climbing from 25.5 percent to 37.9 percent of Veterans with insomnia (odds ratio 1.8, p < 0.001). The gain was attributable to BBTI: CBT-I delivery remained statistically stable across the two phases (p = 0.8), indicating that the expanded access came through the brief treatment rather than a shift between the two therapies.

The analysis also captured a change in prescribing behavior. In the associated Primary Care clinics at the same sites, prescriptions for sleep medications fell by 0.8 percent (n = 2158; odds ratio 0.9, p < 0.001) over the same period. The authors report this as a statistically significant association, meaning increased access to behavioral insomnia care through BBTI implementation was accompanied by a small reduction in sleep medication prescriptions. The study measures this association; it does not establish that BBTI delivery caused the prescribing change.

The design of this sustainment analysis is a pre-post comparison of the withdrawal of implementation strategy support, examining Veterans in Primary Care and PCMHI clinics at the four VA Medical Centers. Because the comparison relies on observed changes across phases rather than a randomized manipulation of support withdrawal for this specific question, the findings describe changes in care delivery associated with the transition into the sustainment phase. The authors nonetheless frame the results as showing that the gains achieved during implementation were maintained and even grew once facilitation ended, which is the central sustainment question the phase was designed to address.

The hybrid type 3 design places primary emphasis on implementation outcomes, in this case the delivery of BBTI, CBT-I, and total behavioral insomnia care in PCMHI clinics, while also collecting related clinical measures, here captured through sleep medication prescribing in Primary Care. The authors conclude that BBTI training combined with implementation strategy support in PCMHI clinics increased both BBTI delivery and total behavioral insomnia care, including during the sustainment phase when support was withdrawn, and they position the findings as consistent with the VA/Department of Defense Clinical Practice Guidelines for insomnia disorder. For health systems, the reported message is that the increased delivery of brief behavioral insomnia care built during active implementation persisted after the external support was removed, alongside a modest decline in sleep medication prescribing.

Subject of Research: Sustainment of brief behavioral insomnia treatment delivery in VA Primary Care Mental Health Integration clinics after withdrawal of implementation support

Article Title: Delivery of Behavioral Insomnia Care in VA Primary Care Mental Health Integration Clinics: Sustainment Outcomes of a Hybrid Type 3 Trial

Article References: Bramoweth, A. D., Ulmer, C. S., Klingaman, E. A., O’Brien, E. M., Deininger, C. J., Boudreaux-Kelly, M. Y., & Youk, A. O. (2026). Delivery of Behavioral Insomnia Care in VA Primary Care Mental Health Integration Clinics: Sustainment Outcomes of a Hybrid Type 3 Trial. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10950-1

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10950-1

Keywords: insomnia, BBTI, CBT-I, Veterans Affairs, implementation science, primary care mental health integration, behavioral therapy, sleep medication prescribing, hybrid type 3 trial, sustainment, VA/DoD clinical practice guidelines, Delivery