CBT-I Beyond the VA:
Telehealth, Peer Support, and Digital Tools for Veterans
Only 10–20% of veterans who need CBT-I can access it locally. VA TeleSleep, SleepEZ, and the Insomnia Coach app close that gap, what the evidence shows.
Key Takeaways
- Only an estimated 10–20% of veterans who need CBT-I can access it at their local VA, the access gap is structural and will not be solved by in-person capacity alone.
- VA TeleSleep (launched 2017) delivers CBT-I via VA Video Connect from Clinical Resource Hubs to rural veterans. By 2023 it served veterans across all 50 states.
- Gehrman et al. 2021 non-inferiority RCT (n=203): telehealth CBT-I is equivalent to in-person: comparable ISI improvement, sleep efficiency, and wake after sleep onset.
- SleepEZ (free VA web CBT-I) had 90,000+ users by FY2023. Digital CBT-I meta-analyses document d=0.39. Smaller than therapist-delivered but meaningful and immediately accessible.
The Access Gap Problem
Who needs CBT-I but can’t get it
Insomnia affects an estimated 30–50% of veterans. Sleep apnea affects more than 1.7 million enrolled VA patients (33%). VA’s own data from 2021 documented that 76% of military personnel did not get the recommended 7–9 hours of sleep. Against this background, VA has approximately 800 providers trained to deliver CBT-I, a ratio that makes the access problem structurally unsolvable with in-person delivery alone.
The gap is not evenly distributed. Rural veterans, veterans who work full-time, veterans with transportation barriers, and veterans who live outside VA catchment areas for specialty care face the greatest access barriers. These are also the veterans most likely to end up with prescription sleep medications, not because pharmacotherapy works better, but because it is available same-day.
Why telehealth closes this gap
VA’s TeleSleep program was specifically designed to solve the geographic access problem: Clinical Resource Hubs provide CBT-I delivery via VA Video Connect to rural veterans who cannot travel to a VA medical center. The veteran connects from home or from their nearest CBOC; the sleep specialist is physically located at a hub. The protocol, session structure, and outcomes are the same as in-person CBT-I.
Telehealth CBT-I non-inferiority
The Gehrman trial
Gehrman et al. (2021[1], Journal of Clinical Psychiatry) randomized 203 veterans to telehealth CBT-I[1] or in-person CBT-I in a fully powered non-inferiority trial, the first to directly compare the two modalities in veteran populations.
The outcome equivalence
Both groups achieved comparable improvements in Insomnia Severity Index scores, sleep efficiency, and wake after sleep onset. The non-inferiority margin was met at all timepoints. Telehealth CBT-I is not a compromise, it is equivalent care at greater distance.
What it means for access
The RCT evidence removes the primary clinical rationale for requiring in-person CBT-I. A veteran 200 miles from the nearest CBT-I-trained provider has no clinical reason to accept a medication prescription instead of a telehealth referral.
Who this applies to most
- Veterans in rural areas more than 60 minutes from a VA medical center: TeleSleep referral is the primary access pathway; VA Video Connect is available at any VA CBOC.
- Veterans who have left VA care: SleepEZ and the Insomnia Coach app are publicly available, no VA enrollment required.
- Veterans with insomnia co-occurring with PTSD, depression, or TBI: VA/DoD CPG prioritizes CBT-I before sedative-hypnotics even in complex comorbidity. Telehealth delivery maintains this priority.
- Veterans on CBT-I waitlists: Digital CBT-I (SleepEZ, Insomnia Coach) is an evidence-based bridge while waiting; not a substitute for therapist-delivered CBT-I, but better than waiting passively.
The Digital Options
SleepEZ; VA’s web-based digital CBT-I
Developed by VA researcher Christi Ulmer, PhD, SleepEZ is a free web-based digital CBT-I course available at va.gov/health/programs/sleep. As of FY2023, it had been accessed more than 90,000 times by nearly 50,000 users, with 950 new users per month. It provides sleep restriction, stimulus control, sleep hygiene, and cognitive restructuring, the full core CBT-I package, in a self-directed online format with veteran-specific content.
CBT-i Coach and Insomnia Coach
CBT-i Coach (co-developed by VA, Stanford, and DoD) is a treatment companion app for veterans currently engaged in CBT-I with a provider. It provides a digital sleep diary, sleep prescription calculator, stimulus control and sleep restriction tools, and psychoeducational content. It is most effective as a supplement to therapist-delivered CBT-I.
Insomnia Coach is a standalone app providing a 5-week CBT-I-based training program designed for independent use without a provider. It includes sleep diary functions, personalized recommendations, and progressive CBT-I techniques.
Digital CBT-I meta-analytic evidence
A 2022 meta-analysis of digitally delivered CBT-I programs found a pooled effect size of d=0.39[10] on the Insomnia Severity Index. A 2023 network meta-analysis (Scientific Reports, Simon et al.) found comparable efficacy across onsite, digital, and other settings, digital CBT-I was not significantly inferior to in-person delivery for ISI reduction.
What the critics say
Digital CBT-I has lower effect sizes than therapist-delivered CBT-I, d=0.39 vs. d=0.80–1.00 in traditional RCTs. Critics argue that digital delivery cannot replicate the motivational components, real-time troubleshooting, and personalized adjustments that make therapist-delivered CBT-I so effective. For veterans with complex comorbidity (PTSD, TBI, severe depression), self-directed digital CBT-I may produce insufficient benefit. These are legitimate limitations: digital CBT-I works for mild-to-moderate uncomplicated insomnia better than for severe, comorbid presentations. Therapist-delivered telehealth CBT-I remains the preferred option when available.
What the Evidence Doesn’t Say
Whether peer-delivered CBT-I is effective. Peer support models for CBT-I in veteran settings are under investigation but not yet validated. Peer coaches can serve as motivational support alongside digital programs, but peer delivery of the full CBT-I protocol is not established.
Which digital format produces the best outcomes. Direct head-to-head comparisons of SleepEZ vs. Insomnia Coach vs. other digital CBT-I formats are not available.
Whether telehealth CBT-I works equally for all veteran subgroups. The non-inferiority trial’s veteran population was predominantly male, OIF/OEF era. Generalizability to women veterans, Vietnam-era veterans, and veterans with severe PTSD comorbidity is not fully established.
Clinical Implications
| Application | Evidence | Strength | Notes |
|---|---|---|---|
| Refer for TeleSleep CBT-I rather than pharmacotherapy when in-person CBT-I is unavailable | Telehealth CBT-I non-inferior to in-person; superior to pharmacotherapy as first-line | Strong (VA/DoD CPG; Gehrman 2021) | TeleSleep referral process: request through VA primary care or mental health |
| Provide SleepEZ as a bridge while patients await therapist-delivered CBT-I | Free, no wait, available immediately; d=0.39 effect size for digital CBT-I | Moderate (2022 digital CBT-I meta-analysis) | Set expectation: digital CBT-I is helpful but not equivalent to therapist-delivered |
| Recommend Insomnia Coach for veterans not enrolled in VA care | Publicly available, free, standalone, no VA enrollment required | Moderate (CBT-i Coach evidence; general digital CBT-I literature) | Ensure veterans understand the app is not a substitute for clinical evaluation if symptoms are severe |
| Document telehealth CBT-I as equivalent to in-person in clinical notes | Non-inferiority established by RCT evidence | Strong (Gehrman 2021) | Useful for benefits documentation and treatment justification |
What Can You Do?
| How to Implement | Expected Benefit (and Why) | Evidence Strength | Context Notes |
|---|---|---|---|
| Request a TeleSleep referral specifically | |||
| Tell your VA primary care or mental health provider: “I have insomnia and want a CBT-I referral through VA TeleSleep. I understand I can see a specialist via VA Video Connect.” | Connects you to therapist-delivered CBT-I without geographic barrier, because TeleSleep Clinical Resource Hubs can serve veterans in any state via VA Video Connect | Strong (Gehrman 2021; VA TeleSleep program) | Can be initiated from primary care, does not require mental health referral first |
| Start SleepEZ tonight | |||
| Go to va.gov and search “SleepEZ” or navigate to va.gov/health/programs/sleep; the course is free and begins immediately | Provides the core CBT-I protocol in self-directed format while you wait for therapist delivery, because sleep restriction and stimulus control, the active ingredients in CBT-I, can begin improving sleep efficiency within 1–2 weeks even when self-directed | Moderate (digital CBT-I meta-analysis, d=0.39) | Works best for straightforward insomnia; complex comorbidity benefits from provider guidance |
| Download Insomnia Coach if you are not currently in VA care | |||
| Available free on iOS and Android; search “VA Insomnia Coach” | Provides a 5-week CBT-I-based self-management program with no registration or VA enrollment required, because Insomnia Coach contains the behavioral components (sleep restriction, stimulus control) that produce insomnia improvement, it is more than a sleep hygiene app | Moderate (CBT-I evidence base; general digital CBT-I) | Not a substitute for evaluation if you have sleep apnea symptoms |
| Ask specifically about PTSD + insomnia combined treatment | |||
| Tell your VA provider: “I have both PTSD and insomnia. I want CBT-I started alongside or after my PTSD treatment, not deferred until PTSD remission.” | Gets CBT-I initiated before insomnia becomes entrenched, because insomnia and PTSD are separate conditions requiring separate treatment, waiting for PTSD to resolve before treating insomnia misses the window and allows conditioned arousal to consolidate | Strong (VA/DoD CPG for PTSD) | VA/DoD guidelines explicitly support concurrent treatment |
How to Use AI With This Information
When to Work With a Professional
Seek clinical evaluation before starting self-directed CBT-I if:
- You snore loudly, wake with choking or gasping, or have been told you stop breathing in your sleep, these are signs of obstructive sleep apnea, which requires different evaluation and treatment
- Your excessive daytime sleepiness is severe and not fully explained by short sleep duration, this may indicate narcolepsy or other primary hypersomnia
- You have severe psychiatric symptoms that require stabilization before initiating sleep restriction
FAQ’s
Is SleepEZ as effective as seeing a CBT-I therapist?
No, digital CBT-I produces effect sizes roughly half those of therapist-delivered CBT-I (d=0.39 vs. d=0.80+). But half the effect of a highly effective treatment is still clinically meaningful, and SleepEZ is available immediately with no wait, no co-pay, and no appointment. It is an excellent bridge or standalone option for uncomplicated insomnia.
Can I use the apps without being enrolled in VA?
Yes. Insomnia Coach and CBT-i Coach are publicly available on iOS and Android without VA enrollment. SleepEZ is available on the VA website and does not require VA enrollment to access.
What if my insomnia doesn’t respond to digital CBT-I?
Escalate to therapist-delivered CBT-I (in-person or TeleSleep) and to clinical evaluation. Non-response to digital CBT-I may indicate comorbidity (sleep apnea, circadian rhythm disorder, PTSD-hypervigilance) that requires tailored clinical management.
REFERENCES
- Gehrman P et al. (2021). Randomized noninferiority trial of telehealth delivery of cognitive behavioral treatment of insomnia vs. in-person care. J Clin Psychiatry, 82(5), 20m13723. doi:10.4088/JCP.20m13723
- Nicosia FM et al. (2021). Leveraging telehealth to improve access to care: veterans’ experience with the VA TeleSleep program. BMC Health Serv Res, 21(1), 77. doi:10.1186/s12913-021-06079-y
- VA HSR. (2024). Digital Cognitive Behavioral Therapy for Insomnia. VA Health Services Research & Development. https://www.hsrd.research.va.gov/impacts/digital-cbt-for-insomnia.cfm
- Simon L et al. (2023). Comparative efficacy of onsite, digital, and other settings for CBT for insomnia: network meta-analysis. Sci Rep, 13, 1929. doi:10.1038/s41598-023-28853-0
- Morin CM. (2020). Profile of Somryst prescription digital therapeutic for chronic insomnia. Expert Rev Med Devices, 17(12), 1239–1248. doi:10.1080/17434440.2020.1852929
- Edinger JD et al. (2021). Behavioral and psychological treatments for chronic insomnia disorder: AASM clinical practice guideline. J Clin Sleep Med, 17(2), 255–262. doi:10.5664/jcsm.8986
- VA News. (2024, June 5). Telehealth increases accessibility to VA sleep medicine programs. Veterans Affairs. https://news.va.gov/131710/telehealth-accessibility-to-va-sleep-medicine/
- Troxel WM et al. (2015). Sleep in the Military. RAND Corporation. RAND Health Quarterly, 5(2):19
- Granberg RE et al. (2021). Patient and provider experiences with CBT-I administered in-person or via telemedicine. Cogent Psychology.
- Hasan MF et al. (2022). Meta-analysis of digital delivery of CBT-I for insomnia. doi:10.1016/j.smrv.2021.101567