Insomnia is a highly prevalent problem that interferes with daily functioning and exacerbates symptoms such as cognitive deficits, irritability, pain, and fatigue in patients with traumatic brain injury (TBI). Sleep disturbance is common among suicide attempters, and unresolved insomnia is a risk factor for PTSD, depression, anxiety, and substance use. Findings from a recent pre-implementation RRP (07-309) indicated that Veterans had distinct preferences for insomnia treatment, delivery methods, and intervention dose. A salient finding was that Veterans wanted brief treatment delivered via electronic methods. Health care providers' preferences for treatment and its delivery were similar but had the added specification that insomnia treatment should include therapist contact to provide a 'hands on' approach for comprehension and application.
Based on the findings from our previous RRP, we developed a brief, preference-based insomnia intervention augmented by audio files (MP3) and web-based resources (the MyHealtheVet Healthy Sleep Center). The purpose of this study was to pilot test the intervention. The specific aims of the pilot test were:
1. Evaluate the feasibility of implementing preference-based insomnia treatment: attendance, attrition, adherence, participant evaluation, and health care providers' feedback.
2. Examine the preliminary effectiveness of preference-based insomnia treatment for improving self-reported insomnia and daytime functioning.
Veterans who experienced blast related injuries or other trauma that resulted in an altered level of consciousness were eligible for this one-group pre-post pilot study. Further eligibility included an insomnia complaint of one month duration, sleep-related daytime impairment, and an Insomnia Severity Index score of 10 or greater. The Veterans received one treatment session of multi-component insomnia intervention (sleep education and hygiene, stimulus control, sleep restriction). Treatment was augmented by three weeks of weekly phone intervention, MP3 audio files (guided imagery for sleep, breathing awareness, and body scan) and web-based resources (MyHealtheVet Healthy Sleep Center). Post-treatment assessment occurred one week after treatment completion. Treatment feasibility was determined through process and formative evaluation. Summative evaluation included the preliminary effect of brief, preference-based treatment on insomnia severity and daytime functioning.
Forty Veterans enrolled in treatment. Thirty-one Veterans completed the post-treatment assessment. Self-reported adherence to treatment was high. The most frequently used and helpful interventions were those delivered in-person during the initial treatment session i.e. stimulus control instructions, sleep restriction therapy, and sleep education and hygiene. The iPod "hit count" feature showed low usage of the audio files, supporting the Veterans' self-report. Sixty-six percent of the Veterans visited the MyHealtheVet Healthy Sleep Center. The majority of Veterans said they would recommend the treatment to other Veterans and thought it was important to make it available. The health care providers thought they would need training to be able to implement CBTI. From pre to post-treatment, there was a significant improvement in insomnia severity and daytime functioning, as well as sleep quality and sleep-related self efficacy. The reduction in insomnia severity from moderate severity to a sub-threshold level occurred by the second week of treatment and maintained to post-treatment.
This pilot study provides preliminary data to support the use of a brief cognitive-behavioral treatment for insomnia for OEF/OIF Veterans. Modifications of the intervention are necessary based on the findings. Further testing using a randomized controlled design and larger sample is needed.
- Epstein DR, Babcock-Parziale JL, Herb CA, Goren K, Bushnell ML. Feasibility test of preference-based insomnia treatment for Iraq and Afghanistan war veterans. Rehabilitation Nursing : The Official Journal of The Association of Rehabilitation Nurses. 2013 May 1; 38(3):120-32.