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CDA 09-218 – HSR&D Study

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CDA 09-218
A Stepped Care Model for Treating Sleep Disturbance in OEF/OIF Veterans
Christi S. Ulmer PhD
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: January 2010 - August 2017

BACKGROUND/RATIONALE:
Sleep disturbance is one of the most common complaints among recently deployed Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn, with some research suggesting that more than sixty percent return from deployment with insomnia; further complicating the difficult process of re-integration into civilian society. Insomnia is associated with a range of mental health conditions that are common among recently deployed Veterans, including, PTSD, depression suicidality, substance abuse, and traumatic brain injury, to name only a few. Insomnia and short sleep duration are also associated with significant health risks, including increased risk for obesity, hypertension, metabolic syndrome, Type 2 diabetes mellitus, and all-cause mortality.

Healthcare costs associated with insomnia, which are estimated to be in the billions of US dollars annually, are largely associated with the increased risk of various psychiatric and medical conditions. In spite of the prevalence of sleep difficulties in recently deployed Veterans, VA resources for addressing insomnia using empirically established non-pharmacological therapies are very limited. Cognitive-Behavioral Therapy for Insomnia has demonstrated efficacy for improving sleep in those with both primary insomnia, and insomnia that is comorbid with both medical and mental health conditions.

OBJECTIVE(S):
Efforts are underway to increase access to insomnia treatment by training mental health providers to provide Cognitive-Behavioral Therapy for Insomnia. However, when considering the combined needs of recently deployed Veterans and those serving in earlier service eras, treatment resources will remain limited. Thus, innovative treatment approaches are imminently needed to address these concerns and impede the progression of the adverse mental and physical health sequelae of untreated insomnia. A stepped model of care may be a cost-effective method for achieving these objectives. By first addressing the needs of those who are receptive and responsive to entry level home-based self-guided approaches, higher level, clinic-based resources can be reserved for those whose symptoms require the attention of an individual health care provider.

The proposed projects are design to increase access to behavioral sleep medicine in recently deployed Veterans. My CDA2 specific research aims are as follows:

Specific Aim 1: Identify current treatment practices; available resources; and providers' insomnia knowledge, treatment preferences, and their perceptions of the importance of treating insomnia.

Specific Aim 2: Identify patients' preferred self-guided treatment modalities and preferred group-based treatment venue/s.

Specific Aim 3: Evaluate the feasibility of a Telehealth-Supported Self-Guided CBTI (Tele-Self-CBTI) in recently deployed Veterans, which considers both patient and provider perspectives.

Specific Aim 4: Write, submit, and revise an IIR grant application to assess the effectiveness of a Tele-Self-CBTI.

METHODS:
Preliminary projects are proposed to elicit patient and provider perspectives to inform the design of the Primary Projects. The Primary projects include a feasibility study and preparation of a grant application for full-scale trial of Tele-Self-CBTI in recently deployed Veterans.

Preliminary Projects:

Project 1A: Conduct a survey of health care providers about current treatment practices, available resources, treatment preferences, insomnia knowledge, and their perceptions of the importance of treating insomnia in RD Veterans.

Project 1B: Conduct focus groups with local providers to further explore the structure, knowledge and importance themes which emerged from the nationwide survey of providers.

Project 2: Conduct focus groups with Veterans to determine patients' attitudes towards and preferences regarding Tele-Self-CBTI.

Primary Projects:

Project 3: Evaluate the feasibility and acceptability of a Telehealth-Supported Self-Guided CBTI (Tele-Self-CBTI).

Project 4: Write, submit, and revise an IIR grant application to assess the effectiveness of Tele-Self-CBTI.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Considering the high prevalence of sleep difficulties among Veterans (>50%), the mental health risks of poor sleep (e.g., anxiety, depression, and suicide), and Veterans' desire for assistance with sleep, addressing Veterans' sleep difficulties should be a central goal of VA efforts to achieve Veteran-centered care. The objectives of the research conducted pursuant to this VA Career Development Award are aligned with the following HSR&D High Priority Research domains: Healthcare Access-using telehealth to increase rural Veteran access to care; and Mental and Behavioral Health-testing new models of care (i.e., PACT and PC-MHI) to effect improved mental health outcomes. Since CBTI has demonstrated efficacy for reducing suicidal ideation in Veterans, this line of research is also responsive to an ORD-wide priority area; suicide prevention.

A recently published report sponsored by the DOD on sleep in military service members states, "Policy changes are needed within the military health system and VHA to address this inconsistency between health care practice and the empirical evidence. Continued dissemination efforts, greater education about CBTI for primary care providers, and more training for mental health care providers are needed in both the military health system and VHA to make CBT a front-line treatment for insomnia (pg. 121)13." As summarized above, insomnia treatment in Veterans has the potential to improve outcomes across virtually all life domains, including mental and physical health, psychosocial functioning, and quality of life. Moreover, successfully treated insomnia produces cost savings in excess of $400 per person. The nurse-supported self-help strategy for insomnia (Project 3), if found to be efficacious, may help to bridge the gap between unavailable resources and high demand for services, and can serve as an entry level intervention in a stepped model of care for insomnia treatment.

The manuscript summarizing the primary care provider surveys (Project 1) received considerable attention when published, including an invited commentary in the issue and subsequent contacts from the press. In addition, qualitative information collected from both PCPs and Veterans is being used to inform development of VA/DOD Clinical Practice Guidelines for insomnia. During focus groups, Veterans have described in great detail the essential components of an acceptable insomnia approach. These data will be seminal to VA efforts to increase Veteran access to behaviorally-based insomnia treatments, and behavioral sleep medicine services more generally. With our increasing knowledge of the role of sleep disturbance in the development of mental health and chronic disease conditions, we have an opportunity with our younger Veteran population to impede the development of many conditions which have plagued our older Veterans. A stepped care approach which includes an entry level self-guided intervention will maximize our limited VA sleep specialty resources.

PUBLICATIONS:

Journal Articles

  1. Ulmer CS, Hall MH, Dennis PA, Beckham JC, Germain A. Posttraumatic stress disorder diagnosis is associated with reduced parasympathetic activity during sleep in US veterans and military service members of the Iraq and Afghanistan wars. Sleep. 2018 Dec 1; 41(12).
  2. Koffel E, Bramoweth AD, Ulmer CS. Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. Journal of general internal medicine. 2018 Jun 1; 33(6):955-962.
  3. Taylor SS, Hughes JM, Coffman CJ, Jeffreys AS, Ulmer CS, Oddone EZ, Bosworth HB, Yancy WS, Allen KD. Prevalence of and characteristics associated with insomnia and obstructive sleep apnea among veterans with knee and hip osteoarthritis. BMC musculoskeletal disorders. 2018 Mar 9; 19(1):79.
  4. Dedert EA, Dennis PA, Cunningham KC, Ulmer CS, Calhoun PS, Kimbrel N, Hicks TA, Neal JM, Beckham JC. Roles of Guilt Cognitions in Trauma-Related Sleep Disturbance in Military Veterans With Posttraumatic Stress Disorder. Behavioral sleep medicine. 2019 Sep 1; 17(5):595-604.
  5. Sherwood A, Ulmer CS, Beckham JC. Waking up to the importance of sleeping well for cardiovascular health. Journal of clinical hypertension (Greenwich, Conn.). 2018 Mar 1; 20(3):606-608.
  6. Hughes JM, Ulmer CS, Gierisch JM, Mid-Atlantic VA MIRECC Workgroup, Howard MO. Single-Item Measures for Detecting Sleep Problems in United States Military Veterans. Journal of general internal medicine. 2018 May 1; 33(5):698-704.
  7. Hughes JM, Ulmer CS, Gierisch JM, Nicole Hastings S, Howard MO. Insomnia in United States military veterans: An integrated theoretical model. Clinical Psychology Review. 2018 Feb 1; 59:118-125.
  8. Bravo AJ, Kelley ML, Swinkels CM, Ulmer CS. Work stressors, depressive symptoms and sleep quality among US Navy members: a parallel process latent growth modelling approach across deployment. Journal of Sleep Research. 2018 Jun 1; 27(3):e12624.
  9. Ulmer CS, Bosworth HB, Beckham JC, Germain A, Jeffreys AS, Edelman D, Macy S, Kirby A, Voils CI. Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2017 Aug 15; 13(8):991-999.
  10. Martindale SL, Farrell-Carnahan LV, Ulmer CS, Kimbrel NA, McDonald SD, Rowland JA, VA Mid-Atlantic MIRECC Registry Workgroup. Sleep quality in returning veterans: The influence of mild traumatic brain injury. Rehabilitation Psychology. 2017 Nov 1; 62(4):563-570.
  11. Rissling MB, Dennis PA, Watkins LL, Calhoun PS, Dennis MF, Beckham JC, Hayano J, Ulmer CS. Circadian Contrasts in Heart Rate Variability Associated With Posttraumatic Stress Disorder Symptoms in a Young Adult Cohort. Journal of traumatic stress. 2016 Oct 1; 29(5):415-421.
  12. Rissling MB, Gray KE, Ulmer CS, Martin JL, Zaslavsky O, Gray SL, Hale L, Zeitzer JM, Naughton M, Woods NF, LaCroix A, Calhoun PS, Stefanick M, Weitlauf JC. Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women. The Gerontologist. 2016 Feb 1; 56 Suppl 1:S54-66.
  13. Edinger JD, Grubber J, Ulmer C, Zervakis J, Olsen M. A Collaborative Paradigm for Improving Management of Sleep Disorders in Primary Care: A Randomized Clinical Trial. Sleep. 2016 Jan 1; 39(1):237-47.
  14. Ulmer CS, Van Voorhees E, Germain AE, Voils CI, Beckham JC, VA Mid-Atlantic Mental Illness Research Education and Clinical Center Registry Workgroup. A Comparison of Sleep Difficulties among Iraq/Afghanistan Theater Veterans with and without Mental Health Diagnoses. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2015 Sep 15; 11(9):995-1005.
  15. Ulmer CS, Bosworth HB, Germain A, Lindquist J, Olsen M, Brancu M, VA Mid-Atlantic Mental Illness Research Education and Clinical Center Registry Workgroup, Beckham JC. Associations between sleep difficulties and risk factors for cardiovascular disease in veterans and active duty military personnel of the Iraq and Afghanistan conflicts. Journal of behavioral medicine. 2015 Jun 1; 38(3):544-55.
  16. Dennis PA, Ulmer CS, Calhoun PS, Sherwood A, Watkins LL, Dennis MF, Beckham JC. Behavioral health mediators of the link between posttraumatic stress disorder and dyslipidemia. Journal of psychosomatic research. 2014 Jul 1; 77(1):45-50.
  17. Crum-Cianflone NF, Bagnell ME, Schaller E, Boyko EJ, Smith B, Maynard C, Ulmer CS, Vernalis M, Smith TC. Impact of combat deployment and posttraumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces. Circulation. 2014 May 6; 129(18):1813-20.
  18. Gehrman P, Seelig AD, Jacobson IG, Boyko EJ, Hooper TI, Gackstetter GD, Ulmer CS, Smith TC. Predeployment Sleep Duration and Insomnia Symptoms as Risk Factors for New-Onset Mental Health Disorders Following Military Deployment. Sleep. 2013 Jul 1; 36(7):1009-1018.
  19. Swinkels CM, Ulmer CS, Beckham JC, Buse N, Calhoun PS. The Association of Sleep Duration, Mental Health, and Health Risk Behaviors among U.S. Afghanistan/Iraq Era Veterans. Sleep. 2013 Jul 1; 36(7):1019-1025.
  20. Edinger JD, Ulmer CS, Means MK. Sensitivity and specificity of polysomnographic criteria for defining insomnia. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013 May 15; 9(5):481-91.
  21. Ulmer CS, Calhoun PS, Bosworth HB, Dennis MF, Beckham JC. Nocturnal blood pressure non-dipping, posttraumatic stress disorder, and sleep quality in women. Behavioral Medicine (Washington, D.C.). 2013 Jan 1; 39(4):111-21.
  22. Ong JC, Ulmer CS, Manber R. Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia. Behaviour Research and Therapy. 2012 Nov 1; 50(11):651-60.
  23. Olsen MK, Stechuchak KM, Edinger JD, Ulmer CS, Woolson RF. Move over LOCF: principled methods for handling missing data in sleep disorder trials. Sleep Medicine. 2012 Feb 1; 13(2):123-32.
  24. Ulmer CS, Sutherland M, Edinger JD, Davidson J, Connor KM, Zhang W, Krystal A. REM Sleep Bout Duration and Frequency in PTSD. Journal of aggression, maltreatment & trauma. 2012 Jan 18; 21(1):67-76.
  25. Ulmer CS, Edinger JD, Calhoun PS. A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2011 Feb 15; 7(1):57-68.
  26. Means MK, Ulmer CS, Edinger JD. Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders. Behavioral sleep medicine. 2010 Oct 1; 8(4):260-73.
  27. Ulmer CS, Stetson BA, Salmon PG. Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers. Behaviour Research and Therapy. 2010 Aug 1; 48(8):805-9.
  28. Ulmer CS, Calhoun PS, Edinger JD, Wagner HR, Beckham JC. Sleep disturbance and baroreceptor sensitivity in women with posttraumatic stress disorder. Journal of traumatic stress. 2009 Dec 1; 22(6):643-7.
Journal Other

  1. Leggett M, Ulmer CS. Implementation of a Group Intervention for CPAP Adherence in a VA Behavioral Sleep Medicine Clinic. [Abstract]. Sleep. 2016 Jul 11; 39:1-421.
  2. Ulmer CS, Jeffreys AL, Olsen MK, Burgess HJ, Beckham JC. Associations between Nocturnal Sleep Episode Patterns and Mental Health Diagnoses in Veterans of the Iraq and Afghanistan Conflicts. [Abstract]. Sleep. 2016 Jul 11; 39:1-421.
  3. Ulmer CS, Leggett M. Group-based Cognitive-behavioral Therapy For Insomnia In a VA Healthcare Setting: Treatment Protocol Development and Evaluation. [Abstract]. Sleep. 2016 Jul 11; 39:1-421.
  4. Ulmer CS, Bosworth HB, MIRREC Registry WG, Germain A, Beckham JC. Sleep Disturbance in Veterans of the Iraq and Afghanistan Conflicts: A Cardiovascular Disease Risk Factor? [Editorial]. Sleep. 2011 Nov 1; 34(Suppl):A242,0703.
  5. 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.
  6. Edinger JD, Ulmer CS, Grubber J, Zervakis JB, Olsen MK. Effects of a One-Time Sleep Specialty Consultation on Sleep Problem Management in Primary Care. [Abstract]. Sleep. 2011 Oct 20; 34(Suppl):A337,0984.
  7. Means MK, Ulmer CS, Edinger JD, Meyers J, Crowley M, Young M, Husain A. CPAP Adherence in Military Veterans with and without Psychiatric Disorders. [Abstract]. Sleep. 2010 Apr 1; 33(Suppl):A152,0445.
  8. Zervakis JB, Ulmer CS, Edinger JD. Can a One-Time Sleep Specialty Consultation Enhance Providers' Attention to Sleep Problems in Primary Care? [Abstract]. Sleep. 2010 Mar 1; 33(Suppl):A365,1092.
  9. Ulmer CS, Sutherland M, Edinger JD, Krystal A. REM Sleep Bout Duration and Frequency in those with PTSD. [Abstract]. Sleep. 2010 Feb 1; 32(Suppl):A362.
VA Cyberseminars

  1. Ulmer CS, Voils CI. Management of Insomnia in the Primary Care Setting. HSR&D Career Development Award Enhancement Initiative [Cyberseminar]. HSR&D. 2016 Oct 11.
Conference Presentations

  1. Leggett M, Ulmer CS. Implementation of a Group Intervention for CPAP Adherence in a VA Behavioral Sleep Medicine Clinic. Poster session presented at: American Academy of Sleep Medicine/Sleep Research Society Conference; 2016 Jun 11; Denver, CO.
  2. Ulmer CS, Jeffreys AL, Olsen MK, Burgess HJ, Beckham JC, Germain A. Associations between Nocturnal Sleep Episode Patterns and Mental Health Diagnoses in Veterans of the Iraq and Afghanistan Conflicts. Poster session presented at: American Academy of Sleep Medicine/Sleep Research Society Conference; 2016 Jun 11; Denver, CO.
  3. Ulmer CS, Leggett M. Therapy For Insomnia In a VA Healthcare Setting: Treatment Protocol Development and Evaluation. Poster session presented at: American Academy of Sleep Medicine/Sleep Research Society Conference; 2016 Jun 11; Denver, CO.
  4. Swinkels C, Beckham JC, Mid-Atlantic MIRECC WG, Ulmer CS. The Relationship Between Sleep Quality and Resilience in Veterans and Active Duty Personnel of the Iraq and Afghanistan Conflicts. Poster session presented at: American Academy of Sleep Medicine / Sleep Research Society Annual SLEEP Meeting; 2015 Jun 7; Seattle, WA.
  5. Ulmer CS, Swinkles CM, Rissling MB, Hughes J, O'Brien JL, Beckham J. An Exploratory Factor Analysis of Symptoms in Veterans and Military Personnel with PTSD and Poor Sleep Quality. Poster session presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2014 Jun 2; Minneapolis, MN.
  6. Kirby AC, Ulmer CS, Dennis PM, Roberts ST. Effectiveness of a group Acceptance and Commitment Therapy (ACT) intervention in the treatment of PTSD in Veterans. Presented at: International Society for Traumatic Stress Studies Annual Symposium; 2013 Nov 7; Philadelphia, PA.
  7. Allen KD, Bosworth HB, Coffman CJ, Jeffreys AL, Oddone EZ, Yancy WS, Ulmer CS. Patient Characteristics Associated With Insomnia and Sleep Apnea in Knee and Hip OA. Presented at: Association of Rheumatology Health Professionals Annual Meeting; 2013 Oct 25; San Diego, CA.
  8. Edinger JD, Grubber J, Ulmer CS, Zervakis JB, Olsen MK. Collaborative Care Model for Improving Sleep Disorders Management in Primary Care. Presented at: World Association of Sleep Medicine International Annual Congress; 2013 Oct 2; Valencia, Spain.
  9. Allen R, Green K, Calhoun PS, Beckham JC, Dennis MF, Ulmer CS, Hall J. Association of physical activity, sleep, veteran status and posttraumatic stress disorder symptom cluster severity in a sample of younger individuals with and without posttraumatic stress disorder (PTSD). Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 16; Los Angeles, CA.
  10. Swinkles C, Ulmer C, Beckham JC, Calhoun PS. The association of sleep duration and mental health and health risk behaviors among OEF/OIF/OND Veterans. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 16; Los Angeles, CA.
  11. Harris S, Germain A, Ulmer CS. Imagery Rehearsal Therapy for Nightmares. Paper presented at: Association for Behavioral and Cognitive Therapies Annual Convention; 2012 Nov 15; National Harbor, MD.
  12. Ulmer CS. Sleep disturbance in Veterans with Subclinical Mental Health Symptoms. Paper presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 3; Los Angeles, CA.
  13. Gehrman P, Seelig A, Jacobson I, Boyko E, Hooper T, Gackstetter G, Ulmer CS, Smith T. Health Effects of Poor Sleep: An Investigation of New Onset Mental Illness in Relation to Sleep Patterns in the Millennium Cohort Study. Paper presented at: Military Health Research Forum; 2012 Aug 13; Ft. Lauderdale, FL.
  14. Seelig AD, Boyko EJ, Gehrman P, Jacobson IG, Hooper T, Smith B, Ulmer CS, Gackstetter GD, Crum-Cianflone N, Smith TC. Health Effects of Poor Sleep among US Military Personnel: A look at new onset diabetes and mental illness in relation to sleep patterns in the Millennium Cohort Study. Paper presented at: Armed Forces Public Health Conference; 2012 Jun 16; San Diego, CA.
  15. Ong J, Ulmer CS, Fiorentino L, Smith K. Mindfulness and Acceptance Based Approaches to Treating Sleep Disturbance. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2012 Jun 15; Boston, MA.
  16. Gehrman P, Seelig A, Jacobson I, Boyko E, Hooper T, Ulmer CS, Gackstetter G, Smith T. Health effects of poor Sleep: An investigation of new onset mental illness in relation to sleep patterns in the Millennium Cohort Study. Presented at: Epidemiology Research Exchange Annual Conference; 2012 Apr 27; San Diego, CA.
  17. Ulmer CS. Sleep Disturbances in Veterans: Cognitive-Behavioral Treatment and Implications for Cardiovascular Health. Paper presented at: University of Pittsburgh Behavioral Health Grand Rounds; 2012 Jan 12; Pittsburgh, PA.
  18. Ulmer CS. A Multi-Component Cognitive-Behavioral Intervention for Sleep Disturbance in Veterans with PTSD. Paper presented at: VA National Mental Health Conference; 2011 Aug 5; Baltimore, MD.
  19. Edinger JD, Grubber J, Ulmer CS, Zervakis JB, Olsen MK. Effects of a one-time sleep specialty consultation on sleep problem management in primary care. Poster session presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2011 Jun 15; Minneapolis, MN.
  20. 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.
  21. Ulmer CS, Bosworth HB, Germain A, Beckham JC. Sleep Disturbance in Veterans of the Iraq and Afghanistan Conflicts: A Cardiovascular Disease Risk Factor? Paper presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2011 Jun 11; Minneapolis, MN.
  22. Ulmer CS, Bosworth HB, Beckham JC. Sleep disturbance in Veterans with PTSD: A cardiovascular disease risk factor reduced with behavioral sleep interventions. Poster session presented at: VA HSR&D Career Development Annual Meeting; 2011 Feb 16; National Harbor, MD.
  23. Bagnell ME, Granado NS, Boyko EJ, Smith B, Ulmer CS, Smith TC. Posttraumatic stress disorder and cardiovascular disease: a prospective US military cohort study. Paper presented at: Force Health Protection Annual Conference; 2010 Aug 15; Phoenix, AZ.
  24. Bagnell M, Granado N, Boyko E, Smith B, Ulmer CS, Smith T. Posttraumatic Stress Disorder and Cardiovascular Disease: A Prospective US military cohort study. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2010 Aug 7; Phoenix, AZ.
  25. Oser ML, Sears K, Ulmer C, Gregg J, Westrup D, Walser R. Gender differences among Veterans completing PTSD residential treatment: Relations among change processes and outcomes for female Veterans. Poster session presented at: VA HSR&D Field-Based Women's Health Meeting; 2010 Jul 15; Washington, DC.
  26. Means MK, Ulmer CS, Edinger JD. CPAP Adherence in Military Veterans with and without Psychiatric Disorders. Paper presented at: American Academy of Sleep Medicine Annual Meeting; 2010 Jun 15; Minneapolis, MN.
  27. Ulmer CS, Edinger JD, Calhoun PS, Almirall D, Bosworth HB. A Brief Intervention for Sleep Disturbance in PTSD: Pilot Study Findings. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  28. Ulmer CS, Edinger JD, Calhoun PS, Almirall D, Bosworth HB. A Multi-Component Cognitive-Behavioral Intervention for Sleep Disturbance in Veterans with PTSD: A Pilot Study. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 12; Minneapolis, MN.


DRA: Military and Environmental Exposures, Mental, Cognitive and Behavioral Disorders, Cardiovascular Disease
DRE: Epidemiology, Prevention, Technology Development and Assessment
Keywords: Cardiovasc’r disease, PTSD, Sleep disorders
MeSH Terms: none

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