What are the treatment guidelines for sleep disorders in patients covered under Tricare (United States military health care system)?

Tricare Sleep Medicine Guidelines

For patients covered under Tricare (United States military health care system), cognitive behavioral therapy for insomnia (CBT-I) is strongly recommended as first-line treatment for chronic insomnia disorder, while positive airway pressure (PAP) therapy is strongly recommended for obstructive sleep apnea (OSA). 1

Diagnosis and Assessment

Screening for Sleep Disorders

• Use the STOP questionnaire (Snoring, Tiredness, Observed apneas, high blood Pressure) to stratify risk of OSA (weak recommendation) 1
• Assess for sleep-disordered breathing in patients with:
  • History of cardiovascular or cerebrovascular events
  • Congestive heart failure
  • Chronic prescription opioid use 1
• For insomnia evaluation, use the Insomnia Severity Index or Athens Insomnia Scale as part of a comprehensive sleep assessment 1

Diagnostic Testing

• For patients with high pretest probability of OSA:
  • Use manually scored type 3 home sleep apnea test (HSAT) with respiratory disturbance index/AHI ≥15 events/h to diagnose moderate to severe OSA 1
  • If HSAT is nondiagnostic (technically inadequate or AHI <5 events/h), repeat testing (either HSAT or lab-based polysomnography) is strongly recommended 1

Treatment of Chronic Insomnia Disorder

First-Line Treatment

• CBT-I is strongly recommended as first-line treatment for chronic insomnia disorder 1
• Brief behavioral therapy for insomnia (BBT-I) is suggested as an alternative when CBT-I is not available 1
• CBT-I is recommended over pharmacotherapy as first-line treatment 1, 2
• CBT-I is also recommended for insomnia comorbid with psychiatric disorders 1

Pharmacotherapy (Second-Line)

When a short course of pharmacotherapy is needed:

• Low-dose doxepin (3mg or 6mg) is suggested (weak recommendation) 1
• Non-benzodiazepine benzodiazepine receptor agonists are suggested (weak recommendation) 1

Treatments NOT Recommended

• Sleep hygiene education as a stand-alone treatment (weak against) 1
• Diphenhydramine (weak against) 1
• Melatonin (weak against) 1
• Valerian and chamomile (weak against) 1
• Kava (strong against) 1
• Antipsychotic drugs (weak against) 1
• Benzodiazepines (weak against) 1
• Trazodone (weak against) 1
• Cranial electrical stimulation (weak against) 1

Complementary Approaches

• Auricular acupuncture with seed and pellet is suggested (weak recommendation) 1
• Insufficient evidence for other forms of acupuncture 1
• Insufficient evidence for mindfulness meditation, aerobic exercise, resistive exercise, tai chi, yoga, and qigong 1

Treatment of Obstructive Sleep Apnea

First-Line Treatment

• PAP therapy is strongly recommended for patients with OSA 1
• Patients should use PAP therapy for the entirety of their sleep periods (strong recommendation) 1
• Continue PAP therapy even if patient uses it <4 hours/night (weak recommendation) 1
• Educational, behavioral, and supportive interventions are strongly recommended to improve PAP adherence 1
• Special attention should be given to patients with PTSD, anxiety, or insomnia to improve PAP adherence 1

Alternative Treatments

• Mandibular advancement devices for mild to moderate OSA (AHI <30/h) (weak recommendation) 1
• Evaluation for nasal surgery if anatomical nasal obstruction is a barrier to PAP use 1
• Hypoglossal nerve stimulation therapy for patients with AHI 15-65/h and BMI <32 kg/m² who cannot adhere to PAP 1
• Maxillomandibular advancement surgery for severe OSA patients who cannot tolerate other recommended therapies 1

Treatments NOT Recommended

• Oxygen therapy as stand-alone treatment (weak against) 1
• Routine use of topical nasal steroids for patients without nasal congestion (weak against) 1

Clinical Considerations and Pitfalls

• Consultation with a sleep medicine specialist should be considered when diagnosis is uncertain or treatment proves challenging 1
• CBT-I and BBT-I are not equivalent - CBT-I has more robust evidence 1
• When referring patients for behavioral treatments, consider:
  • Treatment availability
  • Patient complexity and comorbidities
  • Provider training 1
• In cases requiring immediate intervention for insomnia, providers may exercise clinical judgment to determine if pharmacotherapy may be safely initiated, but should transition to CBT-I when available 1
• For patients with both OSA and insomnia, treatment of both conditions is necessary for optimal outcomes 1

The VA/DOD Clinical Practice Guidelines form the basis for Tricare sleep medicine treatment and are specifically designed for military service members and veterans, though they are applicable to all patients with chronic insomnia disorder and OSA 1.