Combat Vets With Insomnia Benefit From CBT Variation

Brief behavioral treatment can relieve insomnia in combat-exposed military veterans, said Anne Germain, Ph.D., an associate professor of psychiatry at the University of Pittsburgh School of Medicine.

As many as 70 percent of U.S. military veterans who served in Afghanistan or Iraq report having insomnia, she said at the annual meeting of the Associated Professional Sleep Societies in Boston in June.

To help them, she and colleagues adapted and evaluated a two-session cognitive-behavioral treatment for insomnia (CBTI) they had devised for older adults in primary care settings (see Several Strategies Fight Insomnia in Mood-Disorder Patients; also see The Virtual Doctor Will See You Now below).

After being interviewed in person, 40 veterans completed questionnaires, kept sleep diaries, and wore wrist activity monitors to keep track of their schedules for 10 days. They then were randomized to a four-week active or control treatment.

Veterans in the active group met individually with a therapist for about an hour in week 1. They learned why sleeping in bursts or at irregular times as occurs in deployment disturbs sleep and how aligning the body’s sleep drive and biological clock promotes restful sleep and optimal alertness.

The therapist prescribed a bedtime and wake time, based on the veterans’ sleep diaries. The therapist helped them plan evening activities consistent with the prescribed bedtime and explained how getting up at the same time every day benefits sleep.

Veterans in the control group met individually with a therapist for about 10 minutes in week 1. They were given informational brochures on sleep and insomnia, but no suggestions for behavioral change.

Both groups received short face-to-face booster sessions in week 3, phone calls from the therapist in weeks 2 and 4, and monthly follow-up calls for six months.

Sleep improved in three-quarters of the active-treatment group. To the researchers’ surprise, it also improved in half of the information-only group. Those veterans modified behavior on their own. Members of the military are used to following orders, Germain said. They interpreted the informational brochures as directives.

This cost-effective approach may prove sufficient to reduce stress and improve sleep in some military veterans, she said. Research continues to determine whether restoring good sleep also helps prevent mood, anxiety, and addictive disorders in returning veterans.

A single weekend of sleep therapy can jump-start durable relief from chronic insomnia, according to Leon Lack, Ph.D., a professor of psychology at Flinders University in Adelaide, South Australia.

People undergoing intensive sleep retraining (ISR) agree to sleep no more than five hours on a Friday night, inducing mild sleep deprivation. Treatment in the sleep laboratory starts at 10:30 p.m. on Saturday, and continues until 10 p.m. on Sunday. Participants have an opportunity to sleep every 30 minutes—50 opportunities in all. If they fall asleep, they are awakened after three minutes to maintain their sleep-deprived state.

“People who usually don’t feel sleep pressure find sleepiness novel and not aversive,” Lack said. “Some think they have forgotten how to sleep. In one weekend, we show them they can fall asleep rapidly.”

Lack’s group recently studied 23 men and 56 women whose insomnia had a mean length of 16 years. They randomly assigned participants to one of four treatment conditions: ISR, stimulus control therapy (SCT—the most widely studied and supported behavioral insomnia treatment) for five weekly sessions, ISR and SCT combined, or, as a control, basic information on how caffeine, alcohol, and other factors affect sleep.

The combined ISR/SCT group had fewer treatment dropouts and more treatment responders. Some 61 percent of these participants reached “good sleeper” status and continued to sleep well at six-month follow-up, Jodie Harris, Ph.D. (also of Flinders University), Lack, and colleagues reported in the January 2012 issue of Sleep.

More information about research on insomnia in military veterans is posted at www.veteranssleep.pitt.edu/. An abstract of “A Randomized Controlled Trial of Intensive Sleep Retraining (ISR): A Brief Conditioning Treatment for Chronic Insomnia” is posted at www.journalsleep.org/ViewAbstract.aspx?pid=28395.

The Virtual Doctor Will See You Now

Internet-based cognitive-behavioral therapy for insomnia (CBTI) could vastly increase availability of this effective therapy, according to speakers at the annual meeting of the Associated Professional Sleep Societies in Boston in June.

While sleep specialists deem CBTI the treatment of choice for chronic difficulty falling and staying asleep, early awakening, or nonrestorative sleep, its use has been limited by a lack of trained practitioners. An estimated 10 percent to 15 percent of adults report chronic insomnia. Only about 200 clinicians in the United States have been certified in behavioral sleep medicine, however. They usually provide CBTI in six to eight weekly individual or group sessions.

Lee Ritterband, Ph.D., an associate professor of psychiatry and neurobehavioral sciences at the University of Virginia School of Medicine in Charlottesville, demonstrated an online program, Sleep Healthy Using the Internet (SHUTi). It was developed at the University of Virginia with funding from the National Institutes of Health.

A guided six-unit CBTI program, SHUTi uses text, graphics, animations, audio, and video to provide tutorials on sleep management tailored to each user, with feedback, homework, and follow-up.

A study of 28 people with cancer and insomnia found SHUTi use significantly improved sleep, Ritterband and colleagues reported in the July Psychooncology.

In a four-year study now in progress, funded by the National Institute of Mental Health and University of Virginia, participants are being asked to use SHUTi for one to two hours a week for nine weeks and to complete daily electronic sleep diaries.

Researchers will compare SHUTi’s efficacy with that of a static sleep-education Web site. They have recruited about 150 of the planned 300 subjects.

Colin Espie, Ph.D., a professor of clinical psychology and director of the University of Glasgow Sleep Center in Glasgow, Scotland, described Sleepio, also a six-unit CBTI program.

Sleepio’s animated virtual therapist, a cartoon character, “The Prof,” addresses each user by name. At the start of each session, The Prof reviews weekly progress based on sleep diary data users enter each morning.

He discusses cognitive, behavioral, and relaxation techniques and personalizes advice with tactics that users select from a menu of options.

Users may interact with other participants or graduates in a forum. Online programs, Espie noted, can offer 24/7 support, provided by the community. “It’s exciting,” he said, “to see the partnership between therapy and technology.”

In a study of 164 adults with chronic insomnia, Espie and colleagues compared Sleepio’s CBTI program with a Web-based placebo intervention, also delivered by The Prof, and a waitlist treatment-as-usual control.

CBTI participants fell asleep faster, slept more soundly and longer, and felt better in the daytime. These outcomes are comparable to those of face-to-face therapist-delivered CBTI, the researchers reported in the June Sleep.

More information about the SHUTi study is posted at http://clinicaltrials.gov/ct2/show/NCT01438697 . The SHUTi Web site is www.shuti.org . An abstract of “Initial Evaluation of an Internet Intervention to Improve the Sleep of Cancer Survivors With Insomnia” is posted at www.ncbi.nlm.nih.gov/pubmed/21538678 . An abstract of “A Randomized, Placebo-Controlled Trial of Online Cognitive-Behavioral Therapy for Chronic Insomnia Disorder Delivered Via an Automated Media-Rich Web Application” is posted at www.journalsleep.org/ViewAbstract.aspx?pid=28534 .