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RRP 07-309 – QUERI Project

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RRP 07-309
Modifications To Insomnia Treatments for OIF/OEF Veterans with TBI
Dana R Epstein PhD RN
Phoenix VA Health Care System, Phoenix, AZ
Phoenix, AZ
Funding Period: August 2007 - February 2008

BACKGROUND/RATIONALE:
Although there is strong evidence for the efficacy and durability of cognitive-behavioral treatments for insomnia (CBT-I) in the general population, the interventions require motivation, attention, and adherence from patients to achieve successful outcomes. Given the unique characteristics of OEF/OIF veterans with traumatic brain injury (TBI), CBT-I for these patients may require modifications, including alternative delivery and measurement methods, to ensure effective implementation and positive outcomes.

OBJECTIVE(S):
The objectives of this pre-implementation project were to: (a) determine veterans', significant others', and providers' perceived needs for, facilitators of, and barriers to existing CBT-I; and (b) examine the veterans' ability to use and complete self-report and objective sleep measures.

METHODS:
This study focused on mild TBI which included OEF/OIF veterans who had experienced a blast exposure or other injury resulting in a brief period of altered consciousness, and complained of sleep onset and/or sleep maintenance insomnia of at least one month duration with daytime impairment. Veterans received a one-time structured interview using validated insomnia severity and treatment acceptability and preference measures, and open-ended questions. A parallel treatment acceptability and preference instrument was given to significant others and healthcare providers (HCPs). The veterans were asked to take home, use, and complete daily sleep diaries and wear a wrist actigraph nightly over a two week period as is typically done in insomnia treatment studies. Descriptive analysis methods were employed.

FINDINGS/RESULTS:
Analyses of data from eighteen veterans indicated preferences for relaxation therapy (72%) and pharmacological therapy (56%) followed by mindfulness training (50%), sleep education/hygiene (44%), sleep restriction therapy (44%), and stimulus control instructions (39%). Electronic treatment delivery methods were preferred with a short treatment frequency and duration. Nine veterans took home the significant other questionnaire packet, and three significant others completed it. Their treatment preferences matched the veterans' preferences. The nineteen HCPs preferred treatments with well validated support (stimulus control instructions, sleep restriction therapy). Electronic delivery methods, supplemented by therapist contact to ensure comprehension and application, were preferred by HCPs. Fifteen veterans took sleep diaries home and three called the responses to a voice mail service daily for 2 weeks. Nine veterans completed 2 weeks of hard copies of diaries. Seventeen veterans took a wrist actigraph home and 14 veterans wore it, one for the full two week period and the remainder for 2 to 13 days.

IMPACT:
The insomnia treatment preferences determined by this study have the potential to impact the success of future insomnia interventions in VHA, and to enhance the rehabilitation process and improve the quality of life for OEF/OIF veterans.

PUBLICATIONS:

Journal Articles

  1. Epstein DR, Babcock-Parziale JL, Haynes PL, Herb CA. Insomnia treatment acceptability and preferences of male Iraq and Afghanistan combat veterans and their healthcare providers. Journal of rehabilitation research and development. 2012 Oct 1; 49(6):867-78.
  2. Epstein DR, Babcock-Parziale JL, Haynes PL. Insomnia Treatment Preferences of Operation Enduring Freedom/Operation Iraqi Freedom Veterans: Preliminary Findings. Sleep. 2008 Jan 1; 31:A241.


DRA: Military and Environmental Exposures, Acute and Combat-Related Injury
DRE: Treatment - Observational
Keywords: Sleep disorders, Traumatic Brain Injury
MeSH Terms: none

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