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CDA 13-260 – HSR&D Study

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CDA 13-260
Implementation of Brief Treatments for Insomnia in Primary Care
Adam D. Bramoweth PhD
VA Pittsburgh Healthcare System University Drive Division, Pittsburgh, PA
Pittsburgh, PA
Funding Period: April 2016 - March 2021

BACKGROUND/RATIONALE:
Chronic insomnia is among the most reported complaints of Veterans and military personnel, especially those referred for mental health services. Insomnia is highly comorbid with medical and psychiatric disorders, and is associated with significantly increased healthcare utilization and costs. Despite this impact, insomnia remains under-treated. When identified, insomnia is typically treated in primary care with pharmacotherapy, rather than evidence-based psychotherapies (EBPs), like Cognitive Behavioral Therapy for Insomnia (CBTI) and Brief Behavioral Treatment for Insomnia (BBTI). However, a number of system-, provider-, patient-, and treatment-level barriers contribute to the under-treatment and inadequate access to EBPs. To increase access to care, key advantages of BBTI versus CBTI is that it is briefer and offers a flexible treatment delivery (in-person + phone) if BBTI could be successfully implemented and integrated into primary care settings. Although efficacious, it is not yet known if BBTI achieves the same clinical outcomes as CBTI, the standard of care in the VA. Furthermore, it is necessary to identify patient, provider, and system level factors that will impact successful implementation. To increase the viability of EBPs for insomnia in the VA, it is critical to determine which treatments are most effective, and which implementation factors impact the uptake and integration into practice.

OBJECTIVE(S):
The aims are (1) to directly compare two EBPs for insomnia, CBTI vs. BBTI, and (2) to conduct a qualitative needs assessment in order to identify the barriers and facilitators that will impact efforts to implement and integrate brief treatments for insomnia.

METHODS:
This is a Hybrid Type 1 trial. Aim 1 is a randomized clinical trial of CBTI vs. BBTI. The recruitment target is 56 Veterans with chronic insomnia (n=28/treatment arm; anticipate 25% attrition). Non-inferiority analysis will compare mean change score on the Insomnia Severity Index (ISI) from baseline to post-treatment between treatments. Non-inferiority will be estimated if the 95% confidence interval of the BBTI ISI change score is less than the non-inferiority margin of CBTI, as determined by the Reliable Change Index. For Aim 2, qualitative interviews will be conducted with Veterans from Aim 1 as well as primary care providers and nurses (n=8-12 per group; n=32-48 total). The Consolidated Framework for Implementation Research (CFIR) informed the development of the interviews and an open iterative coding approach will identify CFIR factors, themes, and additional implementation elements that arise through the coding process.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
This project may help to increase access to evidence-based, brief behavioral insomnia care. By improving access, the risks and burdens associated with chronic insomnia, including comorbid psychiatric symptoms, prescription sleep medication use, and healthcare utilization may be decreased.

PUBLICATIONS:

Journal Articles

  1. Soreca I, Tighe CA, Bramoweth AD. The Intersection of Sleep Apnea and Severe Mental Illness in Veterans. Psychosomatics. 2019 Jan 22.
  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. Bramoweth AD, Germain A, Youk AO, Rodriguez KL, Chinman MJ. A hybrid type I trial to increase Veterans' access to insomnia care: study protocol for a randomized controlled trial. Trials. 2018 Jan 26; 19(1):73.
  4. Bramoweth AD, Luther J, Hanusa BH, Walker JD, Atwood CW, Germain A. Clinical Characterization of Insomnia among Veterans with PTSD: Identifying Risk Factors for Diagnosis and Treatment with Sedative-Hypnotics. Defence and Peace Economics. 2017 Jul 12; http://dx.doi.org/10.1080/10242694.2017.1349633.
  5. Bramoweth AD, Renqvist JG, Hanusa BH, Walker JD, Germain A, Atwood CW. Identifying the Demographic and Mental Health Factors That Influence Insomnia Treatment Recommendations Within a Veteran Population. Behavioral sleep medicine. 2017 May 2; 1-12.
  6. Parthasarathy S, Carskadon MA, Jean-Louis G, Owens J, Bramoweth A, Combs D, Hale L, Harrison E, Hart CN, Hasler BP, Honaker SM, Hertenstein E, Kuna S, Kushida C, Levenson JC, Murray C, Pack AI, Pillai V, Pruiksma K, Seixas A, Strollo P, Thosar SS, Williams N, Buysse D. Implementation of Sleep and Circadian Science: Recommendations from the Sleep Research Society and National Institutes of Health Workshop. Sleep. 2016 Dec 1; 39(12):2061-2075.
  7. Dietch JR, Taylor DJ, Sethi K, Kelly K, Bramoweth AD, Roane BM. Psychometric Evaluation of the PSQI in U.S. College Students. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2016 Aug 15; 12(8):1121-9.
  8. DiNapoli EA, Bramoweth AD, Cinna C, Kasckow J. Sedative hypnotic use among veterans with a newly reported mental health disorder. International psychogeriatrics. 2016 Aug 1; 28(8):1391-8.
  9. Bramoweth AD, Renqvist JG, Germain A, Buysse DJ, Gentili A, Kochersberger G, Rodriguez E, Rossi MI, Weiner DK. Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part VII: Insomnia. Pain medicine (Malden, Mass.). 2016 May 1; 17(5):851-63.
  10. DiNapoli EA, Bramoweth AD, Whiteman KL, Hanusa BH, Kasckow J. Mood Disorders in Middle-Aged and Older Veterans With Multimorbidity. Journal of aging and health. 2017 Jun 1; 29(4):657-668.
Journal Other

  1. Bramoweth AD. A Step in the Right Direction: Moving Toward Increased Access to Insomnia Care. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2017 Feb 15; 13(2):161-162.
  2. Bramoweth AD, Klima G, Appelt C, Chinman MJ. Implementing Behavioral Insomnia Treatments: A Qualitative Study with Veterans. [Abstract]. Sleep. 2016 Jun 30; 30:A396-A397.
Center Products

  1. Bramoweth AD. Understanding and Treating Sleep Disturbance: Lessons Learned from Treating Veterans [Kentucky Psychological Association Webinar]. 2016 Jun 22. Available from: http://www.kpa.org/events/EventDetails.aspx?id=752497&hhSearchTerms=%22Lessons+and+Learned+and+Treating+and+Veterans%22.
Conference Presentations

  1. Bramoweth AD, Klima G, Appelt C, Chinman M. Implementing Behavioral Insomnia Treatments: A Qualitative Study with Veterans. Presented at: American Academy of Sleep Medicine / Sleep Research Society Annual Meeting of the Associated Professional Sleep Societies; 2016 Jun 5; Denver, CO.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Guideline Development and Implementation
MeSH Terms: none