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IIR 00-091 – HSR&D Study

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IIR 00-091
Behavioral Insomnia Therapy in Primary Care
Jack D. Edinger PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: October 2001 - September 2005

BACKGROUND/RATIONALE:
Insomnia reduces quality of life, increases risks for other illnesses, and enhances health care costs/utilization. Several efficacy studies have shown that Cognitive-Behavioral Therapy (CBT) for insomnia improves sleep and diurnal complaints among highly screened samples; however, its effectiveness among “real-world” primary care patients is yet to be tested. This project is highly relevant to the VA health care mission, given the high prevalence of insomnia in middle-aged and older adults. Pilot data from this VA suggest that 40% of primary care patients report trouble sleeping.

OBJECTIVE(S):
This project tests the incremental benefits of adding CBT to usual primary care for reducing sleep disturbance, diurnal dysfunction, quality of life concerns and health care utilization among veterans enrolled in the DVAMC Primary Care Clinics. Study hypotheses predict that patients who receive CBT along with usual care will show greater improvements in sleep, mood, and quality of life, as well as larger reductions in health care utilization than will those who receive usual care alone.

METHODS:
This is a single-blind, randomized, parallel group, clinical effectiveness study of 106 veteran insomnia sufferers. Eligibility criteria include: meeting structured interview criteria for insomnia, mean subjective total wake time of > 60 minutes per night, mental status score > 27 on Folstein MMSE, no unstable medical or psychiatric disorder, no polysomnographic evidence of sleep apnea or periodic limb movements, and approval of primary provider. Participants are randomly assigned to CBT + Usual Care or to Usual Care Control condition which provides therapist contact but no active behavioral treatment. Measures of sleep, mood, and quality of life are obtained before and after treatment and at a 6-month follow up. Computerized utilization data is obtained for the six months preceding and following treatment. A series of multivariate and univariate statistical tests will be conducted.

FINDINGS/RESULTS:
As a preliminary analysis, we compared the accuracy of sleep log (SL), actigraphy (ACT), and REMview (RV) for estimating polysomnographic sleep measures in 95 participants. These findings replicate our previous findings that 1) alternative sleep assessment methodologies show moderate to high correlations with sleep measures obtained from PSG in a varied sleep-disordered sample; 2) the accuracy of different devices varies depending on the sleep parameter of interest; and 3) while subjective sleep logs were less accurate than objective devices for most sleep measures, SL provided the best estimate for wake time after sleep onset, while RV and ACT significantly underestimated this measure.

IMPACT:
Study findings should provide important new information about managing both the sleep problems and overall health care utilization patterns of those veteran insomnia sufferers who present in VA primary care settings. If CBT-treated patients show substantial reductions in their VA inpatient/outpatient utilization, this finding could have important cost-saving implications to the VA system.

PUBLICATIONS:

Journal Articles

  1. Edinger JD, Olsen MK, Stechuchak KM, Means MK, Lineberger MD, Kirby A, Carney CE. Cognitive behavioral therapy for patients with primary insomnia or insomnia associated predominantly with mixed psychiatric disorders: a randomized clinical trial. Sleep. 2009 Apr 1; 32(4):499-510.
  2. Edinger JD, Means MK, Stechuchak KM, Olsen MK. A pilot study of inexpensive sleep-assessment devices. Behavioral sleep medicine. 2004 Jan 1; 2(1):41-9.
  3. Edinger JD, Glenn DM, Bastian LA, Marsh GR, Dailey D, Hope TV, Young M, Shaw E, Meeks G. Daytime testing after laboratory or home-based polysomnography: comparisons of middle-aged insomnia sufferers and normal sleepers. Journal of Sleep Research. 2003 Mar 1; 12(1):43-52.
Journal Other

  1. Stechuchak KM, Woolson R, Ulmer CS, Edinger JD, Olsen MK. Inclusive Multiple Imputation for Missing Data in a VA Longitudinal Trial Assessing Cognitive Behavioral Therapy in Patients with Sleep Disorders. [Editorial]. Sleep. 2011 Oct 30; 34(Suppl):A329,0962.
Conference Presentations

  1. Stechuchak KM, Olsen MK, Woolson R, Ulmer CS, Edinger JD. Inclusive Multiple Imputation for Missing Data in a VA Longitudinal Trial Assessing Cognitive Behavioral Therapy in Patients with Sleep Disorders. Poster session presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2011 Jun 13; Minneapolis, MN.
  2. Edinger JI. Effectiveness of Cognitive Behavior Therapy for Primary and Co-Morbid Insomnia. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 15; Arlington, VA.


DRA: Health Systems
DRE: Epidemiology, Treatment - Observational
Keywords: Chronic disease (other & unspecified), Primary care, Sleep disorders
MeSH Terms: none

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