Prevalence of insomnia disorder and sleep apnea in a sample of veterans at risk for cardiovascular disease.

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Study objectives

The objectives of this study were to examine the proportion of study participants screening positive for insomnia disorder and/or sleep apnea in veterans engaged in routine health care and known to be at risk for cardiovascular disease and to compare these proportions with those previously documented in medical records.


This was a cross-sectional analysis of baseline data from a randomized clinical intervention trial for patients at risk of cardiovascular disease and a review of study participants' medical records. Participants were veterans ≥ 40 years of age, enrolled in Veterans Affairs primary care, and diagnosed with hypertension and/or hypercholesterolemia. Self-report outcomes were the proportion of patients screening positive for an insomnia disorder and sleep apnea, self-reporting a sleep apnea diagnosis, and endorsing undertreated sleep apnea. Medical record outcomes were the proportion of patients diagnosed with insomnia and sleep apnea.


Participants (n = 420) were veterans (84.8% male) with a mean age of 61.1 years. More than half of the sample (52.1%) screened positive for sleep apnea without prior self-reported diagnosis. More than one-third of the sample (39%) screened positive for an insomnia disorder. Medical records revealed considerably lower rates, with 3.8% diagnosed with insomnia, 20.5% diagnosed with sleep apnea, and about 1% diagnosed with both conditions.


Undiagnosed and undertreated sleep disorders are common among veterans at risk for cardiovascular disease. Most of the sample (82%) screened positive for, or met, study criteria for sleep apnea or an insomnia disorder. Limitations include the use of self-reported sleep apnea treatment adherence, an insomnia disorder diagnosis based on questionnaire score, and a sample comprised primarily of male veterans. Routine sleep disorders screening in veterans at risk for cardiovascular disease could help to identify those at even greater risk because of the adverse effects of undiagnosed or undertreated sleep disorders.

Clinical trial registration

Registry;; Name: Cardiovascular Intervention Improvement Telemedicine Study; URL:; Identifier: NCT01142908.





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Publication Info

Ulmer, Christi S, Felicia McCant, Karen M Stechuchak, Maren Olsen and Hayden B Bosworth (2021). Prevalence of insomnia disorder and sleep apnea in a sample of veterans at risk for cardiovascular disease. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 17(7). pp. 1441–1446. 10.5664/jcsm.9228 Retrieved from

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Christi S Ulmer

Associate Professor in Psychiatry and Behavioral Sciences

I am an Associate Professor at Duke University School of Medicine and clinical research psychologist at the Durham VA Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT). My research is focused on increasing our understanding of the health correlates of sleep disorders, increasing patient access to behavioral sleep medicine, and developing and disseminating behaviorally-based treatments for sleep disorders. I am a Behavioral Sleep Medicine Diplomate who has been treating patients with sleep disturbances for the past 17 years. I serve as faculty on the Durham VA Health Psychology fellowship training program; the first accredited BSM training program in the VA healthcare system. I served as a VA Co-Chair for the development of VA/DOD Clinical Practice Guidelines for insomnia and sleep apnea, and served as a consultant on the VA Dissemination of training in Cognitive Behavioral Therapy for Insomnia for more than 8 years. I am committed to expanding patient access to and provider knowledge of effective behavioral sleep medicine interventions, and increasing the recognition of sleep’s role in patient health.     


Maren Karine Olsen

Professor of Biostatistics & Bioinformatics

Health services research, longitudinal data methods, missing data methods


Hayden Barry Bosworth

Professor in Population Health Sciences

Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT)  at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities. 

Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.

Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy

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