The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000-2010

Outpatient Prescriptions for Insomnia Medications During the First Year Following Combat-Related Amputations

INTRODUCTION

Sleep-related disorders are associated with pain, fatigue, and deficits in cognitive performance, which may interfere with successful rehabilitation. The study objectives were to (1) quantify outpatient prescriptions for insomnia medications during the first year following combat-related amputations, (2) examine longitudinal changes in prescriptions for insomnia medications, and (3) analyze patient characteristics associated with prescriptions for insomnia medications.

MATERIAL AND METHODS

This was a retrospective study of DoD casualty records from the Expeditionary Medical Encounter Dataset and prescriptions for outpatient medications from the Pharmacy Data Transaction Service. Patients were a total of 1,651 U.S. service members who sustained major limb amputations in Operations Iraqi and Enduring Freedom from 2001 through 2017 and had outpatient prescriptions for any medication during the first year postinjury. Prescriptions for medications recommended for insomnia were low-dose antidepressants, anxiolytic sedatives, benzodiazepines, melatonin receptor agonist, and low-dose quetiapine. These prescription medications were analyzed by medication type, postinjury time, and patient characteristics during the first year postinjury.

RESULTS

During the first year postinjury, 78% of patients (1,291 of 1,651) had outpatient prescriptions for insomnia medications, primarily anxiolytic sedative drugs (e.g., zolpidem), averaging a total of 86 prescription days (median = 66). The prevalence of these prescriptions declined substantially during the first year, from 57% of patients during the first quarter to 28% during the fourth quarter postinjury. In univariate analyses, multiple patient characteristics, including high Injury Severity Score, continued opioid and non-opioid analgesic prescriptions, and diagnoses of chronic pain, mood disorder, and posttraumatic stress disorder, were significantly associated with higher prevalence and duration of outpatient prescriptions for insomnia medications.

CONCLUSIONS

The present results indicate a high prevalence of outpatient prescriptions for insomnia medications following combat-related amputations, a prevalence that is substantially higher than previously reported among active duty personnel. These findings can inform DVA/DoD guidelines for amputation care and insomnia among military subpopulations. The results highlight the need for more research on the treatment of insomnia during early postinjury rehabilitation among patients who sustained serious combat injuries.

Prevalence of Obstructive Sleep Apnea Among Veterans and Nonveterans

PURPOSE

Understanding disease prevalence can inform treatment and resource needs across populations. This study aimed to identify the prevalence of sleep apnea (OSA) among veterans and nonveterans.

DESIGN

The national Comparative Health Assessment Interview Study, cross-sectional survey using probability-based sampling frames.

SETTING

Surveys completed by Internet or phone.

SUBJECTS

15,166 veterans (40% response rate) and 4,654 nonveterans (57% response rate).

MEASURES

Self-report of healthcare provider-based diagnosis of OSA.

ANALYSIS

Calculation of prevalence of OSA using statistical weighting to allow for direct comparison between veterans and nonveterans. Secondary analyses evaluated OSA by deployment status among veterans and compared average age of OSA diagnosis and differences in OSA prevalence among veterans and nonveterans stratified by gender, marital status, race/ethnicity, and posttraumatic stress disorder diagnosis.

RESULTS

OSA diagnosis was more than twice as prevalent among veterans (21%, 95% CI 20%-22%) than nonveterans (9%, 95% CI 8%-10%; aOR: 2.56, 95% CI 2.22-2.95, P < .001). Deployment was associated with higher odds of OSA among veterans (aOR: 1.64, 95% CI 1.43-18.7, P < 001.) Veterans were diagnosed with OSA on average 5 years earlier than nonveterans.

CONCLUSION

Veterans have a high prevalence rate of OSA, highlighting the importance of veterans' access to treatment. OSA is likely underdiagnosed in nonveterans, particularly among racial/ethnic minoritized groups. Future research should investigate disparities in access to diagnostic testing for racial/ethnic minority nonveterans and/or risk factors for OSA among racial/ethnic minority veterans. The increased odds of OSA among those with PTSD highlights in the importance of early referral for OSA testing by providers as well as development of trauma-informed strategies to promote OSA treatment adherence. Limitations include a bias toward underestimation of true disease prevalence due to self-report of diagnosis.

Objectively Measured Sleep Duration and Health-Related Quality of Life in Older Adults with Metabolic Syndrome: A One-Year Longitudinal Analysis of the PREDIMED-Plus Cohort

The aim of our cross-sectional and longitudinal study is to assess the relationship between daytime and night-time sleep duration and health-related quality of life (HRQoL) in adults with metabolic syndrome after a 1-year healthy lifestyle intervention. Analysis of the data from 2119 Spanish adults aged 55-75 years from the PREDIMED-Plus study was performed. Sleep duration was assessed using a wrist-worn accelerometer. HRQoL was measured using the SF-36 questionnaire. Linear regression models adjusted for socioeconomic and lifestyle factors and morbidity were developed. In cross-sectional analyses, participants with extreme night-time sleep duration categories showed lower physical component summary scores in Models 1 and 2 [β-coefficient (95% confidence interval) <6 h vs. 7-9 h: -2, 3 (-3.8 to -0.8); p = 0.002. >9 h vs. 7-9 h: -1.1 (-2.0 to -0.3); p = 0.01]. Participants who sleep less than 7 h a night and take a nap are associated with higher mental component summary scores [β-coefficient (95% confidence interval) 6.3 (1.3 to 11.3); p = 0.01]. No differences between night-time sleep categories and 12-month changes in HRQoL were observed. In conclusion, in cross-sectional analyses, extremes in nocturnal sleep duration are related to lower physical component summary scores and napping is associated with higher mental component summary scores in older adults who sleep less than 7 h a night.

Identifying predictors of the amount of veteran participation in cognitive behavioral therapy for insomnia in the Veterans Affairs health care system

Insomnia is a prevalent and negatively impactful disorder among veterans. The Department of Veterans Affairs (VA) has committed significant resources to the development and dissemination of training related to cognitive behavioral therapy for insomnia (CBT-I), the recommended first-line intervention for chronic insomnia disorder. It has been established that VA clinicians can be effectively trained to deliver high fidelity CBT-I and that treatment results in significant improvements in insomnia. However, there is a paucity of research examining rates and predictors of veterans' participation in CBT-I in routine VA clinical care. In this study, we conducted a secondary analysis of data from VA electronic health records (EHR) to determine individual predisposing, enabling, and need factors associated with CBT-I participation. The sample included veterans who had at least one CBT-I templated note from the VA mid-Atlantic region of the United States (VISN4) between 2015 and 2019 in their chart (N = 2,801). CBT-I participation was defined by number of CBT-I templated notes occurring within a 6-month period from the initial note. Findings indicated that veterans most often completed only one session of CBT-I and, on average, completed approximately three sessions. Results from multinomial logistic regression identified significant associations of race, the presence of comorbid mental health disorders, rurality, presence of insomnia diagnosis, and insomnia medication with CBT-I participation; associations varied depending on how CBT-I participation was defined. More work is needed to better understand factors contributing to participation and reasons for completion and noncompletion of CBT-I. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Effectiveness of Imagery Rescripting Interventions for Military Veterans With Nightmares and Sleep Disturbances: A Systematic Review and Meta-Analysis

Imagery rescripting (ImRs) interventions have been found effective in improving sleep outcomes, although research has mostly focused on civilian, rather than military, samples. The aim of this review was to estimate the overall effectiveness of ImRs interventions for military veterans on primary outcomes of nightmare frequency and sleep quality. A systematic search was conducted in CINAHL, MEDLINE, PsycArticles, PsycINFO, Psychology and Behavioural Sciences Collection and the PTSDpubs database and was completed on 1 November 2021. Randomised controlled trials, nonrandomised trials and pre-post studies of ImRs interventions in veterans with sleep disturbances or nightmares were included. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool, and meta-analysis was performed using Stata. Nineteen articles from 15 empirical studies were included in the review, and data from the 15 studies (involving 658 participants) were included in the meta-analysis. Meta-analysis findings indicated that ImRs interventions are associated with significant positive changes from pretreatment to posttreatment for nightmare and sleep quality. Significantly greater improvements were found in ImRs interventions compared to control groups for sleep quality (Hedges' g = -0.65, 95% CI [-1.20, -0.10]) but not for nightmare frequency (Hedges' g = -0.10, 95% CI [-0.34, 0.14]). Overall, the meta-analysis included a relatively small number of studies with poor methodological quality and considerable heterogeneity; therefore, findings should be cautiously interpreted. Further research should focus on veteran participants with larger samples and from a broader range of sources to determine effectiveness more confidently.

Sleep Apnea Among Gulf War Veterans: An Examination of VA Utilization Rates, Treatment Initiation, and Health Outcomes

OBJECTIVES

Obstructive sleep apnea (OSA) among veterans is frequently underdiagnosed and undertreated. The present study sought to: 1) characterize the prevalence and rate of treatment of OSA among VA users and non-users and 2) examine the associations between diagnosed or probable OSA and key physical and mental health outcomes.

METHODS

Gulf-War I-era Veterans were recruited as part of a national survey assessing mental and physical health concerns, healthcare needs, and healthcare utilization. OSA diagnoses were self-reported while sleep apnea risk was assessed via the STOP-Bang. Veterans also completed questionnaires assessing overall health, pain, depression, PTSD, and psychosocial functioning.

RESULTS

1,153 veterans were included in the present analyses (Mean age = 58.81; 21.84% female). Compared to non-VA healthcare users, veterans receiving care at the VA were more likely to have been diagnosed with OSA (p < .001) and report receiving treatment for OSA (p = .005). Compared to veterans at low risk for OSA, veterans at elevated risk reported higher levels of pain (p = .001), depression (p = .02), and poorer psychosocial functioning (p < .001).

CONCLUSIONS

OSA diagnoses appear to be more common among VA healthcare users. Findings suggest that OSA remains underdiagnosed and associated with important physical and mental health consequences. Additional screening for OSA, especially among non-VA clinics, is warranted.

Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

Multidisciplinary providers' perceptions of care delivery for sleep disorders: A qualitative case study

OBJECTIVES

Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders.

METHODS

A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care.

RESULTS

We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers.

CONCLUSIONS

A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.

Insomnia and risk of mortality in older adults

Existing evidence linking insomnia to all-cause mortality in older individuals remains inconclusive. We conducted a retrospective study of a large cohort of veterans aged 65-80 years old identified from the Corporate Data Warehouse, a large data repository derived from the Veterans Health Administration integrated medical records. Veterans' enrollees with and without International Classification of Diseases, Ninth and Tenth Revision, codes corresponding to insomnia diagnosis between 1 January 2010 and 30 March 2019 were assessed for eligibility. The primary outcome was all-cause mortality. A total of 36,269 veterans, 9584 with insomnia and 26,685 without insomnia, were included in the analysis. Baseline mean (SD) age was 72.6 (4.2) years. During a mean follow-up of 6.0 (2.9) years of the propensity score matched sample, the mortality rate was 34.8 [95% confidence interval: 33.2-36.6] deaths per 1000 person-years among patients with insomnia compared with 27.8 [95% confidence interval: 26.6-29.1] among patients without insomnia. In a Cox proportional hazards model, insomnia was significantly associated with higher mortality (hazard ratio: 1.39; [95% confidence interval: 1.27-1.52]). Patients with insomnia also had a higher risk of non-fatal cardiovascular events (hazard ratio: 1.21; [95% confidence interval: 1.06-1.37]). Secondary stratified analyses by sex, race, ethnicity and hypertension showed no evidence of effect modification. A higher risk of mortality (hazard ratio: 1.51; [95% confidence interval: 1.33-1.71]) was observed when depression was present compared with absent (hazard ratio: 1.26; [95% confidence interval: 1.12-1.44]; p = 0.02). In this cohort study, insomnia was associated with increased risk-adjusted mortality and non-fatal cardiovascular events in older individuals.

Investigating a clinically informed sleep disturbance threshold for physical and mental health among Gulf War Illness veterans

Study Objectives

This study (1) assessed sleep quality and health in Gulf War veterans (GWV) meeting the Gulf War Illness (GWI) criteria and (2) compared health associations for both those meeting a "clinically disturbed sleep" threshold, and those below, as determined by the Pittsburgh Sleep Quality Index (PSQI) cutoff for military populations (≥10) on measures of physical, mental, and cognitive health.

Methods

Participant data consisted of questionnaires and assessments completed prior to group assignment in a clinical trial. The sample consisted of 147 GWV, where 81.0% were males, and the median age was 53.4 years.

Results

The mean (SD) PSQI global score was 12.34 (4.00) with 61% of the sample qualifying as clinically disturbed sleepers according to the cutoff (global PSQI ≥ 10). GWI veterans with PSQI scores ≥10 did not differ from others in age (p = 0.20), sex (p = 0.19), or years of education (p = 0.87), but showed worse GW-related symptomology on the Gulf War Kansas questionnaire (p < 0.01), and poorer mental health on the Veterans Rand-36 (p < 0.01).

Conclusions

Disturbed sleep was associated with measures of pain, fatigue, and cognitive health. Our results suggest that a previously determined clinical threshold for clinically disturbed sleep is useful when examining the health status of the study population. Given that GWI is associated with elevated PSQI scores and a high frequency of disturbed sleep, cutoffs determining sleep health should be sensitive to population exposures and health history to improve interpretability.

Sleep disorders and cancer incidence: examining duration and severity of diagnosis among veterans

Introduction

Sleep disruption affects biological processes that facilitate carcinogenesis. This retrospective cohort study used de-identified data from the Veterans Administration (VA) electronic medical record system to test the hypothesis that patients with diagnosed sleep disorders had an increased risk of prostate, breast, colorectal, or other cancers (1999-2010, N=663,869). This study builds upon existing evidence by examining whether patients with more severe or longer-duration diagnoses were at a greater risk of these cancers relative to those with a less severe or shorter duration sleep disorder.

Methods

Incident cancer cases were identified in the VA Tumor Registry and sleep disorders were defined by International Classification of Sleep Disorder codes. Analyses were performed using extended Cox regression with sleep disorder diagnosis as a time-varying covariate.

Results

Sleep disorders were present among 56,055 eligible patients (8% of the study population); sleep apnea (46%) and insomnia (40%) were the most common diagnoses. There were 18,181 cancer diagnoses (41% prostate, 12% colorectal, 1% female breast, 46% other). The hazard ratio (HR) for a cancer diagnosis was 1.45 (95% confidence interval [CI]: 1.37, 1.54) among those with any sleep disorder, after adjustment for age, sex, state of residence, and marital status. Risks increased with increasing sleep disorder duration (short [<1-2 years] HR: 1.04 [CI: 1.03-1.06], medium [>2-5 years] 1.23 [1.16-1.32]; long [>5-12 years] 1.52 [1.34-1.73]). Risks also increased with increasing sleep disorder severity using cumulative sleep disorder treatments as a surrogate exposure; African Americans with more severe disorders had greater risks relative to those with fewer treatments and other race groups. Results among patients with only sleep apnea, insomnia, or another sleep disorder were similar to those for all sleep disorders combined.

Discussion

The findings are consistent with other studies indicating that sleep disruption is a cancer risk factor. Optimal sleep and appropriate sleep disorder management are modifiable risk factors that may facilitate cancer prevention.

Improving adherence to PAP therapy: A brief PAP coaching intervention for health care providers

Objectives

To evaluate a training program for non-specialist health care providers in a brief coaching intervention to improve positive airway pressure (PAP) usage in Veterans with sleep apnea.

Methods

We conducted a national webinar training designed for non-specialist providers to implement a brief telephone coaching intervention to improve PAP adherence. The curriculum was crafted by experts in sleep medicine and behavioral sleep medicine based on principles of PAP desensitization. Providers who participated in this training were asked to complete evaluations at 30 days and 1 year.

Results

Provider surveys indicated that most respondents had incorporated the intervention into their clinical practice and felt comfortable counseling patients about sleep apnea and adherence to PAP. Provider feedback suggested that future training programs should include refresher trainings, more training on PAP equipment specifics, and facilitated collaboration with local sleep medicine staff.

Conclusions

This pilot training program demonstrated that a webinar format was a feasible method to increase training in PAP adherence among non-specialist health care providers.

Innovation

Non-specialists can be trained as PAP coaches in webinar format, improving patients' access to effective strategies and support to be successful with PAP therapy.

Poor sleep quality and associated determinants among textile and garment manufacturing workers in Addis Ababa, Ethiopia

Background

Sleep is a physiological process that is essential to human physical, emotional, and mental health. Sleep difficulties affect an estimated 150 million individuals globally, with roughly 17% of the population in developing countries. As a result, the purpose of this study was to determine the prevalence and associated factors of poor sleep quality among textile and garment manufacturing workers in Addis Ababa, Ethiopia, in 2022.

Methods

A facility-based cross-sectional study was done from July 15th to August 15th, 2022, using a simple random sample technique. The degree of self-reported poor sleep quality was quantified using a validated, interviewer-administered, standardized Pittsburgh Sleep Quality Index. To determine the relationship between independent variables and poor sleep quality, multivariable logistic regression analysis was carried out with a p-value of less than 0.05 and a 95% confidence interval (CI).

Results

The prevalence of poor sleep quality was 75.4% (95% CI: 70.8, 80). Working more than 8 h per day (AOR = 2.83, 95% CI: 1.01, 7.94), work dissatisfaction (AOR = 3.27, 95% CI: 1.52-7.05), and using electronic materials before sleeping (AOR = 2.08, 95% CI: 1.01-4.30) were all associated with poor sleep quality.

Conclusion

Poor sleep quality was common among garment and textile industrial workers. Work dissatisfaction, working hours, and the utilization of electronic materials before bedtime were all substantially related to poor sleep quality, which should be taken into account and addressed early to reduce poor sleep quality.

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration

OBJECTIVE

To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients.

METHODS

Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021.

RESULTS

Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients.

CONCLUSIONS

Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.

Sleep-wake disorders in veterans with opioid use disorder: Prevalence and comorbidities

OBJECTIVE

To determine the prevalence of sleep-wake disorders among veterans with opioid use disorder (OUD) and the demographic characteristics, medical comorbidities, and outpatient medications in this group.

METHODS

US veterans seeking care in the VA Connecticut Healthcare System between January 1, 2000, and December 31, 2021 with a diagnosis of OUD (N = 5937) were analyzed retrospectively for sleep-wake disorders (N = 1447). That group was analyzed for demographic characteristics, comorbidities, and medications.

RESULTS

Of those with OUD, 24.4% had a diagnosis of any sleep-wake disorder. The most common was obstructive sleep apnea (73.7%). Major depressive disorder (68.6%) and hypertension (67.1%) were the most common comorbid conditions. Commonly prescribed medications included antidepressants (91%) and benzodiazepines (62%).

CONCLUSIONS

Veterans with OUD frequently suffer from sleep-wake disorders. Comorbid medical and psychiatric conditions and the detrimental effects of specific medication classes should be considered in this patient population to create more effective prevention and treatment strategies.

Insomnia in the Veteran Population: A Sleep Health and Wellness Intervention

The purpose of this evidence-based project (EBP) was to determine if an evidence-based sleep health and wellness intervention improved sleep in veterans self-reporting a history of insomnia. Insomnia can negatively affect an individual's physical and psychological well-being, as well as increase health-care costs and decrease the overall quality of life. The intervention utilized a combination of insomnia treatments, delivered to two American Legion veteran participant groups: an Alabama American Legion Retreat and individuals at an American Legion Post site. The holistic-focused modalities used in this intervention included Cognitive Behavioral Therapy for Insomnia (CBT-I) techniques, sleep hygiene principles, and Complementary and Alternative Medicine (CAM) methods. The measurement tool, the Insomnia Severity Index (ISI), indicated statistically significant changes in the severity of participants' self-reported insomnia. Based upon the research evidence and results of the pre- and post-test ISI, a more permanent, ongoing sleep health and wellness intervention is feasible and would have numerous beneficial effects for the veteran's management of insomnia symptoms. Future efforts include implementing sleep hygiene, CAM interventions, and holistic nursing-supported education interventions at other sites and venues within the Alabama American Legion, as well as maintaining long-term community partnerships with veteran groups such as the Alabama American Legion.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial

BACKGROUND

Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans.

OBJECTIVE

The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans.

METHODS

We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters.

RESULTS

Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported.

CONCLUSIONS

Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

Association Between Family Context and Sleep Trajectory in Middle-Aged and Elderly Chinese Adults

Objective

The study aims to reveal the association between family context and sleep trajectories in middle-aged and elderly Chinese adults.

Methods

Subjects (n=7777) aged between 40 and 65 years were selected from the China Family Panel Studies (CFPS). Latent class analysis and the multi-trajectory method were used to identify the family context and sleep trajectories from 2010 to 2018. Multinomial (polytomous) logistic regression was performed to explore the relationship between family context and sleep trajectories.

Results

Five family context classes were identified according to family demographic characteristics. Simultaneously, four sleep trajectories were determined based on three sleep-related indexes. Subjects from family that had only sons or multiple-child are liable to shorten or prolong sleep duration and increase midday nap ratios compare with subjects who from family that had one or more daughters, and in future public health prevention and control, more attention could be paid to such families.

Conclusion

The study found that family context is associated with sleep trajectories among middle and old Chinese adults. Subjects from families with only girls seemed to have more stable sleep trajectories, while those with one or more boys' families had unstable sleep trajectories. Further interventions would be carried out for sleep disorders, it is necessary to pay more attention to the family context, especially the number and gender of children.

Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia

Purpose

Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia.

Methods

We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics.

Results

Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11).

Conclusion

Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist.

OBJECTIVES

This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes.

METHODS

We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed.

RESULTS

Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers.

DISCUSSION

Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Associations between sleep difficulties and health outcomes in treatment-seeking veterans

BACKGROUND

Sleep disturbance in UK Armed Forces personnel appears to be frequent due to factors such as hostile sleeping environments and can persist even once they have transitioned into civilian life. Despite this, there is currently very limited literature surrounding the prevalence and associated factors of insomnia disorder among UK veterans.

AIMS

This study aimed to expand knowledge of the prevalence and associated demographic, military, health and functional outcomes with probable insomnia disorder within a clinical sample of veterans.

METHODS

Treatment-seeking veterans from a national UK mental health charity were invited to complete a questionnaire including socio-demographic, military, health and well-being questions.

RESULTS

Of the sample, 489 (43%) completed the questionnaire. Seventy per cent of the sample reported having probable insomnia disorder. Having probable insomnia disorder was significantly associated with being younger and having physical health problems. Moreover, unadjusted models found associations between probable insomnia disorder and common mental health difficulties, obsessive-compulsive disorder and complex post-traumatic stress disorder.

CONCLUSIONS

The results suggest that many UK veterans with physical and mental health difficulties experience co-morbid insomnia disorder. Therefore, it is important that clinical services are aware of this prevalence and use targeted interventions to reduce the frequency of insomnia disorder in this population.

The relationship between alcohol- and sleep-related traits: Results from polygenic risk score and Mendelian randomization analyses

STUDY OBJECTIVES

We investigated whether genetic risk for insomnia and sleep duration abnormalities are associated with AUD and alcohol consumption. We also evaluated the causal relationships between sleep- and alcohol-related traits.

METHODS

Individual-level phenotype and genotype data from the Million Veteran Program were used. Polygenic risk scores (PRS) were computed using summary statistics from two recent discovery GWAS of insomnia (N= 453,379 European-ancestry (EA) individuals) and sleep duration (N= 446,118 EAs) and tested for association with lifetime AUD diagnosis (N= 34,658 EA cases) and past-year Alcohol Use Disorders Identification Test-Consumption scale scores (AUDIT-C, N= 200,680 EAs). Bi-directional two-sample Mendelian Randomization (MR) analyses assessed causal associations between the two sleep traits and the two alcohol-related traits.

RESULTS

The insomnia PRS was positively associated with AUD at 2/9 PRS thresholds, with p<0.01 being the most significant (OR = 1.02, p = 3.48 × 10-5). Conversely, insomnia PRS was negatively associated with AUDIT-C at 6/9 PRS thresholds (most significant threshold being p = 0.001 (β = -0.02, p = 5.6 × 10-8). Sleep duration PRS was positively associated with AUDIT-C at 2/9 PRS thresholds, with the most significant threshold being p = 1 × 10-6 (β = 0.01, p = 0.0009). MR analyses supported a significant positive causal effect of insomnia on AUD (14 SNPs; β = 104.14; SE = 16.19; p = 2.22 × 10-5), although with significant heterogeneity. MR analyses also showed that shorter sleep duration had a causal effect on the risk of AUD (27 SNPs; β = -63.05; SE = 3.54; p = 4.55 × 10-16), which was robust to sensitivity analyses.

CONCLUSION

The genetic risk for insomnia shows pleiotropy with AUD, and sleep continuity abnormalities have a causal influence on the development of AUD.

The risk of major adverse cardiovascular events associated with the use of hypnotics in patients with insomnia

OBJECTIVES

To examine whether hypnotic use in patients with insomnia reduces major adverse cardiovascular events, including all-cause mortality and nonfatal major adverse cardiovascular events.

METHODS

Using the Veterans Affairs Corporate Data Warehouse, we conducted a retrospective cohort study of 16,064 patients who were newly diagnosed with insomnia between January 1, 2010, and December 31, 2019. A pair of 3912 hypnotic users and nonusers were selected based on a 1:1 propensity score methodology. The primary outcome was extended major adverse cardiovascular events, a composite of the first occurrence of all-cause mortality or nonfatal major adverse cardiovascular events.

RESULTS

During the median follow-up of 4.8 years, a total of 2791 composite events occurred, including 2033 deaths and 762 nonfatal major adverse cardiovascular events. Although the incidence rates of major adverse cardiovascular events were comparable between hypnotic users and nonusers in the propensity-matched cohort, users of benzodiazepines and Z-drugs had a higher risk of all-cause mortality (hazard ratio 1.47 [95% CI, 1.17-1.88] and 1.20 [95% CI, 1.03-1.39], respectively), while serotonin antagonist and reuptake inhibitors users had a survival advantage (hazard ratio 0.79 [95% CI, 0.69-0.91]) compared with nonusers. There were no differences in the risk of nonfatal major adverse cardiovascular events between all classes of hypnotics. Male patients and those aged 60 years or younger who were using benzodiazepines or Z-drugs experienced higher major adverse cardiovascular events than their counterparts.

CONCLUSIONS

In patients with newly diagnosed insomnia, treatment with hypnotics resulted in higher extended major adverse cardiovascular events but not nonfatal major adverse cardiovascular events with benzodiazepine and Z-drug users compared with nonusers. The use of serotonin antagonist and reuptake inhibitors agents had a protective effect against major adverse cardiovascular events warranting further investigation.

Obesity paradox or hypoxia preconditioning: How obstructive sleep apnea modifies the Obesity-MI relationship

OBJECTIVES

The objective of this study was to evaluate the interaction between obesity and obstructive sleep apnea on acute MI in hospital mortality.

METHODS

This retrospective cohort study utilized Veterans Health Administration data from years 1999-2020. Participants were categorized according to their body mass index (BMI) to non-obese (BMI <30) and obese (BMI ≥30) groups. Clinical obstructive sleep apnea (SA) diagnosis was confirmed using ICD9/10 codes and the study subgroups included non-obese with no obstructive sleep apnea (nOB-nSA), non-Obese with obstructive sleep apnea (nOB-SA), obese with no obstructive sleep apnea (OB-nSA), and obese with obstructive sleep apnea (OB-SA). The primary outcome was odds ratio of in-hospital mortality during the hospitalization with acute MI as the principal diagnosis adjusted for age, gender, race, ethnicity, and Charlson comorbidity index (CCI) with the nOB-nSA group as the comparison group.

RESULTS

Among 72,036 veterans with acute-MI hospitalization, individuals with obesity and obstructive sleep apnea (OB-SA) had the lowest in-hospital mortality rate (1.0%) compared to those without obesity and obstructive sleep apnea (nOB-nSA, 2.8%), with obesity but without obstructive sleep apnea (OB-nSA, 2.4%), and with obesity and obstructive sleep apnea (nOB-SA, 1.4%). The adjusted odds ratio for mortality, compared to nOB-nSA, was 9% higher but not significant in OB-nSA (aOR, 1.09, 95%CI: 0.95, 1.25), 46% lower in OB-nSA (aOR, 0.54, 95%CI: 0.45, 0.66), and 52% lower in OB-SA (aOR, 0.48: 95%CI: 0.41, 0.57).

CONCLUSION

Our data suggest that the association between obesity and improved survival in acute MI is largely driven by the presence of sleep apnea.

Association between patterns of nutrient intake and circulating vitamin D with sleep status among Iranian adults

Nutrient pattern analysis is an easy way to compare nutrient intakes across different nations due to the universality of nutrients nature. The purpose of this study was to examine the relationship between dietary nutrient patterns (NPs) and circulating 25(OH)D concentrations with sleep duration and sleep quality among Iranian adults. We used a multistage cluster random sampling method to enroll 535 adults in this cross-sectional investigation. A validated food frequency questionnaire was applied to evaluate typical dietary intakes. Fasting blood samples were obtained to determine levels of circulating 25(OH)D. Sleep characteristics were assessed using the Pittsburgh Sleep Quality Index (PSQI). Participants had a mean age of 42.57 years and 51.2% of them had insufficient or deficient levels of serum vitamin D. Three NPs were identified: "high animal protein", "high vegetable" and "high carbohydrate". After adjustments for potential confounders, no significant associations were observed between "high animal protein" pattern and short sleeping or sleep quality. Greater adherence to "high vegetable" NP was associated with lower odds of short sleeping (OR 0.24; 95% CI 0.10, 0.54) and poor sleep quality (OR 0.45; 95% CI 0.20, 1.05). Stratified analysis revealed that these associations were stronger in normal-weight participants. Greater adherence to "high carbohydrate" NP, on the other hand, was connected to higher odds of short sleeping (OR 2.83; 95% CI 1.20, 6.72). Low adherence to "high vegetable" pattern and vitamin D insufficiency/deficiency were jointly associated with increased odds of short sleeping (OR 3.42, 95% CI 1.42, 6.64). High adherence to pattern comprising mainly of vegetable nutrients was associated with a reduced likelihood of being short sleepers and having poor sleep quality in Iranian adults, especially among those with a normal weight. Lower adherence to vegetable NP and insufficient/deficient vitamin D levels were synergistically associated with greater likelihood of being short sleepers. Greater adherence to carbohydrate NP was associated with an increased likelihood of short sleeping.

Impact of PTSD and Obstructive Sleep Apnea on Cognition in Older Adult Veterans

Background: Posttraumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are highly prevalent and comorbid among older adult male veterans. Both PTSD and OSA are independently associated with cognitive deficits in older adults, but little research regarding the impact of comorbid PTSD and OSA among older adults exists. Purpose: The current study aimed to examine the independent and interactive effects of PTSD and OSA on cognitive functioning in older adult veterans. Study Sample: Older adult male veterans with (n = 106) and without PTSD (n = 69), ranging in age from 55 to 89 (M = 63.35). Data Collection: Participants underwent polysomnography evaluation to assess severity of OSA symptoms and comprehensive neuropsychological evaluation to assess cognitive functioning in 3 domains: attention and processing speed, learning and memory, and executive functioning. Results: Multiple regression analyses showed that the interaction between PTSD and OSA did not predict cognitive performance. However, PTSD significantly predicted poorer attention and processing speed, and increased OSA severity predicted poorer learning and memory. Conclusions: While PTSD and OSA did not have a synergistic detrimental impact on cognition, each independently predicted poorer cognitive functioning within certain domains, suggesting that older adults with these comorbid conditions may experience a wider array of cognitive difficulties.

Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data

STUDY OBJECTIVES

This study aimed to estimate the 12-month prevalence of diagnosed sleep disorders among veterans with and without serious mental illnesses (SMI) in Veterans Affairs health record data in 2019. We also examined diagnosed sleep disorders across a 9-year period and explored associations with demographic and health factors.

METHODS

This study used health record data from VISN 4 of the Veterans Health Administration from 2011 to 2019. SMI diagnoses included schizophrenia and bipolar spectrum diagnoses as well as major depression with psychosis. Sleep diagnoses included insomnias, hypersomnias, sleep-related breathing disorders, circadian rhythm sleep-wake disorders, and sleep-related movement disorders. Demographic and health-related factors were also collected from the record.

RESULTS

In 2019, 21.8% of veterans with SMI were diagnosed with a sleep disorder. This is a significantly higher proportion than for veterans without SMI, 15.1% of whom were diagnosed with a sleep disorder. Sleep disorder rates were highest in veterans with a chart diagnosis of major depression with psychosis. From 2011 to 2019, the overall prevalence of sleep disorders in veterans with SMI more than doubled (10.2%-21.8%), suggesting improvements in the detection and diagnosis of sleep concerns for this group.

CONCLUSIONS

Our findings suggest that identification and diagnosis of sleep disorders for veterans with SMI has improved over the past decade, though diagnoses still likely underrepresent actual prevalence of clinically relevant sleep concerns. Sleep concerns may be at particularly high risk of going untreated in veterans with schizophrenia-spectrum disorders.

CITATION

Bonfils KA, Longenecker JM, Soreca I, et al. Sleep disorders in veterans with serious mental illnesses: prevalence in Veterans Affairs health record data. J Clin Sleep Med. 2023;19(9):1651-1660.

Association between smoking status and subjective quality of sleep in the South Korean population: a cross-sectional study

PURPOSE

This study aimed to investigate the relationship between smoking and subjective sleep quality in the Korean adult population.

METHODS

We designed a cross-sectional survey using data from the 2018 Korean Community Health Service Conditions Survey and selected smoking status as our variable of interest. We divided the participants into people who currently, never, and formerly smoked, those who smoked < 20 cigarettes/day, and those who smoked > 20 cigarettes/day. Subjective sleep quality was analyzed using the Pittsburgh Sleep Quality Index. Multiple logistic regression analysis was performed for statistical analysis.

RESULTS

A total of 174,665 participants were enrolled. People who formerly and currently smoked were found to have poorer subjective sleep quality than those who never smoked. The odds of poor subjective sleep quality in people who smoked > 20 cigarettes/day were 1.15 times (95% confidence interval: 1.09-1.21) for men and 1.51 times (95% confidence interval: 1.22-1.86) for women, compared with men and women who never smoked.

CONCLUSIONS

Smoking was negatively associated with subjective sleep quality. Smoking cessation programs and lifestyle improvement education may be justifiable to improve the quality of sleep in Korean adults.

In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for insomnia disorder. The goal of this study was to evaluate clinical benefits of CBT-I to veterans with insomnia disorder during the early months of the COVID-19 pandemic using an uncontrolled observational design.

METHODS

A cohort of 63 Veterans Affairs (VA) mental health providers delivered CBT-I to 180 veterans as part of an evidence-based psychotherapy training program and captured de-identified treatment outcome data through a data portal. The main patient outcomes were change in the Insomnia Severity Index (ISI) total score from the initial clinical assessment session to the last treatment session, response rate (% with ISI change > 7 from assessment to last session), and remission rate (% with ISI < 8 at the last session). We tested the noninferiority of telehealth only compared with at least 1 in-person session.

RESULTS

Fifty-six percent of veterans seen for an evaluation completed CBT-I treatment during the structured training program phase and completed an initial and final ISI. Among these veterans, ISI scores decreased by an average of 9.9 points from before to after treatment (P < .001), 66% experienced a clinically meaningful treatment response, and 43% experienced insomnia symptom remission. Benefits were similar whether the veteran received some in-person care or received CBT-I entirely via telehealth.

CONCLUSIONS

Findings suggest, regardless of treatment modality, CBT-I remained highly effective during the early months of the pandemic, which was a challenging time for both clinical providers and veterans in need of insomnia treatment.

CITATION

Martin JL, DeViva J, McCarthy E, et al. In-person and telehealth treatment of veterans with insomnia disorder using cognitive behavioral therapy for insomnia during the COVID-19 pandemic. J Clin Sleep Med. 2023;19(7):1211-1217.

The association between long-term exposure to outdoor artificial light at night and poor sleep quality among Chinese veterans: A multi-city study

BACKGROUND

A handful of previous studies have reported the association between exposure to outdoor artificial light at night (ALAN) and sleep problems. However, evidence for such association is limited in low- and middle-income countries. This study aimed to examine the association between outdoor ALAN exposure and sleep quality in veterans across different regions of China.

METHODS

Within the network of the Chinese Veteran Clinical Research Platform, we selected 7258 participants from 277 veteran communities in 18 cities across China during December 2009 and December 2011, using a multi-stage stratified cluster sampling strategy. Face-to-face interviews with the participants were conducted by trained investigators. We used the Pittsburgh Sleep Quality Index (PSQI) to assess participants' sleep quality. We defined poor sleep quality as a PSQI global score >7. The 3-year average exposure to outdoor ALAN prior to the baseline interview was calculated using satellite imagery data, according to participants' geolocation information. The association of ALAN exposure with sleep quality was examined using the mixed-effects logistic regression models with natural cubic splines.

RESULTS

The exposure-response curve for sleep quality associated with ALAN exposure was nonlinear, with a threshold value of 49.20 nW/cm2/sr for the 3-year average exposure to outdoor ALAN prior to the baseline interview. Higher ALAN exposure above the threshold was associated with increased risk of poor sleep quality. After adjusting for potential confounders, the odds ratios (and 95%CI, 95% confidence intervals) were 1.15 (0.97, 1.36) and 1.45 (1.17, 1.78) at the 75th and 95th percentiles of ALAN against the threshold. The association of ALAN exposure with poor sleep quality was more pronounced in veterans with depression than those without. Higher OR of poor sleep quality at the 75th percentile of ALAN against the threshold was observed in veterans with depression than those without [2.09 (1.16, 3.76) vs. 1.09 (0.92, 1.30)].

CONCLUSIONS

Long-term exposure to outdoor ALAN was associated with higher risk of poor sleep quality in Chinese veterans. Effective outdoor ALAN management may help to reduce the burden of sleep disorders in Chinese veterans.

Travel Burden as a Measure of Healthcare Access and the Impact of Telehealth within the Veterans Health Administration

BACKGROUND

Travel is a major barrier to healthcare access for Veteran Affairs (VA) patients, and disproportionately affects rural Veterans (approximately one quarter of Veterans). The CHOICE/MISSION acts' intent is to increase timeliness of care and decrease travel, although not clearly demonstrated. The impact on outcomes remains unclear. Increased community care increases VA costs and increases care fragmentation. Retaining Veterans within the VA is a high priority, and reduction of travel burdens will help achieve this goal. Sleep medicine is presented as a use case to quantify travel related barriers.

OBJECTIVE

The Observed and Excess Travel Distances are proposed as two measures of healthcare access, allowing for quantification of healthcare delivery related to travel burden. A telehealth initiative that reduced travel burden is presented.

DESIGN

Retrospective, observational, utilizing administrative data.

SUBJECTS

VA patients with sleep related care between 2017 and 2021. In-person encounters: Office visits and polysomnograms; telehealth encounters: virtual visits and home sleep apnea tests (HSAT).

MAIN MEASURES

Observed distance: distance between Veteran's home and treating VA facility. Excess distance: difference between where Veteran received care and nearest VA facility offering the service of interest. Avoided distance: distance between Veteran's home and nearest VA facility offering in-person equivalent of telehealth service.

KEY RESULTS

In-person encounters peaked between 2018 and 2019, and have down trended since, while telehealth encounters have increased. During the 5-year period, Veterans traveled an excess 14.1 million miles, while 10.9 million miles of travel were avoided due to telehealth encounters, and 48.4 million miles were avoided due to HSAT devices.

CONCLUSIONS

Veterans often experience a substantial travel burden when seeking medical care. Observed and excess travel distances are valuable measures to quantify this major healthcare access barrier. These measures allow for assessment of novel healthcare approaches to improve Veteran healthcare access and identify specific regions that may benefit from additional resources.

Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea

STUDY OBJECTIVES

Chronic noncancer pain (CP) commonly co-occurs with obstructive sleep apnea (OSA) and may contribute to greater symptom burden. The study aims were to (1) characterize CP among veterans with OSA and (2) examine differences in sleepiness (Epworth Sleepiness Scale), insomnia symptoms (Insomnia Severity Index), and quality of life (Short Form Health Survey-20) in veterans with OSA with or without pre-existing CP.

METHODS

An observational, cross-sectional, study of 111 veterans with newly diagnosed, untreated OSA was conducted. Descriptive statistics characterized the sample and comorbid CP outcomes. Regression analyses were performed to investigate associations between self-reported CP and sleep-related symptoms or quality of life while controlling for potential confounders.

RESULTS

CP was reported by 69.5% (95% confidence interval: 61.8%, 76.2%) of participants. Having CP was associated with increased Epworth Sleepiness Scale (12.7 ± 5.5 vs 10.2 ± 5.2; P = .021) and Insomnia Severity Index scores (18.1 ± 6.2 vs 13.7 ± 7.4; P = .002), and worse quality of life across all Short Form Health Survey-20 domains.

CONCLUSIONS

There is a high prevalence of CP among veterans with OSA and symptom burden is higher in patients with OSA and CP. Future investigations should address symptom response and burden to OSA treatment in comorbid OSA and CP to guide outcome expectancies and residual OSA symptom treatment plans.

CITATION

Saconi B, Kuna ST, Polomano RC, Compton PA, Keenan BT, Sawyer AM. Chronic pain is common and worsens daytime sleepiness, insomnia, and quality of life in veterans with obstructive sleep apnea. J Clin Sleep Med. 2023;19(6):1121-1132.

Race and Socioeconomic Status: Interlinked Drivers of Sleep Health Disparities

The effect of race and socioeconomic status on sleep disorders has significant effects on the availability of healthcare and health outcomes. This paper examines how race and SES contribute to sleep health disparities, emphasizing the importance of understanding their impact on sleep disorders and treatment particularly in minority populations and veterans.

Obstructive sleep apnea modulates clinical outcomes post-acute myocardial infarction: A large longitudinal veterans' dataset report

BACKGROUND

While the longer-term Obstructive Sleep apnea (OSA)-related intermittent hypoxia (IH) leads to various comorbidities, it has become increasingly evident that OSA confers protective advantages during and after acute myocardial infarction (AMI). We hypothesized in patients who were admitted with acute MI, the presence of OSA is associated with lower in-hospital mortality compared to those without a prior diagnosis of OSA.

METHODS

In this nationwide retrospective study utilizing Veterans Health Administration records, we included patients hospitalized for MI with a history of sleep disorders from 1999 to 2020. We divided patients into two cohorts: those with OSA and those without OSA. The primary outcome was in-hospital mortality during AMI hospitalization. We analyzed the data using logistic regression and calculated the odds ratio of in-hospital mortality.

RESULTS

Out of more than four million veterans with any sleep diagnosis, 76,359 patients were hospitalized with a diagnosis of AMI. We observed 30,116 with OSA (age, 64 ± 10 years; BMI, 33 ± 7 kg/m2) and 43,480 without OSA (age, 68 ± 12 years; BMI, 29 ± 6 kg/m2). The aOR of in-patient mortality (n = 333 (1.1%)) was lower in those with OSA (aOR, 0.43; 95% CI, 0.38 to 0.49) compared to without-OSA (n = 1,102, 2.5%). However, the OSA cohort had a higher proportion of the prolonged length of stay (28.1%).

CONCLUSIONS

Presence of OSA is associated with lower in-hospital mortality among patients admitted for AMI, after adjusting for various demographic and co-morbidity factors. This study highlights the complex relationship between OSA and cardiovascular health and highlights the need for further research in this area.

Genome-wide association study of obstructive sleep apnoea in the Million Veteran Program uncovers genetic heterogeneity by sex

BACKGROUND

Genome-wide association studies (GWAS) for obstructive sleep apnoea (OSA) are limited due to the underdiagnosis of OSA, leading to misclassification of OSA, which consequently reduces statistical power. We performed a GWAS of OSA in the Million Veteran Program (MVP) of the U.S. Department of Veterans Affairs (VA) healthcare system, where OSA prevalence is close to its true population prevalence.

METHODS

We performed GWAS of 568,576 MVP participants, stratified by biological sex and by harmonized race/ethnicity and genetic ancestry (HARE) groups of White, Black, Hispanic, and Asian individuals. We considered both BMI adjusted (BMI-adj) and unadjusted (BMI-unadj) models. We replicated associations in independent datasets, and analysed the heterogeneity of OSA genetic associations across HARE and sex groups. We finally performed a larger meta-analysis GWAS of MVP, FinnGen, and the MGB Biobank, totalling 916,696 individuals.

FINDINGS

MVP participants are 91% male. OSA prevalence is 21%. In MVP there were 18 and 6 genome-wide significant loci in BMI-unadj and BMI-adj analyses, respectively, corresponding to 21 association regions. Of these, 17 were not previously reported in association with OSA, and 13 replicated in FinnGen (False Discovery Rate p-value < 0.05). There were widespread significant differences in genetic effects between men and women, but less so across HARE groups. Meta-analysis of MVP, FinnGen, and MGB biobank revealed 17 additional, previously unreported, genome-wide significant regions.

INTERPRETATION

Sex differences in genetic associations with OSA are widespread, likely associated with multiple OSA risk factors. OSA shares genetic underpinnings with several sleep phenotypes, suggesting shared aetiology and causal pathways.

FUNDING

Described in acknowledgements.

Exposure to war and conflict: The individual and inherited epigenetic effects on health, with a focus on post-traumatic stress disorder

War and conflict are global phenomena, identified as stress-inducing triggers for epigenetic modifications. In this state-of-the-science narrative review based on systematic principles, we summarise existing data to explore the outcomes of these exposures especially in veterans and show that they may result in an increased likelihood of developing gastrointestinal, auditory, metabolic and circadian issues, as well as post-traumatic stress disorder (PTSD). We also note that, despite a potential "healthy soldier effect", both veterans and civilians with PTSD exhibit the altered DNA methylation status in hypothalamic-pituitary-adrenal (HPA) axis regulatory genes such as NR3C1. Genes associated with sleep (PAX8; LHX1) are seen to be differentially methylated in veterans. A limited number of studies also revealed hereditary effects of war exposure across groups: decreased cortisol levels and a heightened (sex-linked) mortality risk in offspring. Future large-scale studies further identifying the heritable risks of war, as well as any potential differences between military and civilian populations, would be valuable to inform future healthcare directives.

Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service

STUDY OBJECTIVES

In young adults performing compulsory military service, fatigue and somnolence are common and presumably associated with objective or self-reported sleep deprivation. We aimed to find out whether objective sleep parameters from ambulatory polysomnography could explain their self-reported tiredness and sleepiness and whether habits were associated with sleep parameters or tiredness.

METHODS

Seventy (67 male, age 18-24 years) participants had their sleep assessed with polysomnography. Their self-reported symptoms and demographic data were obtained from online survey including Epworth Sleepiness Scale, Beck's Depression Inventory, items from Basic Nordic Sleep Questionnaire, Internet Addiction Scale, and lifestyle questions.

RESULTS

Snoring (audio recording, percentage of total sleep time) was associated with self-reported sleepiness (P = .010) and tiredness (P = .030) and snoring seemed to, partially, explain sleepiness (P = .029). Twenty-six percent of the conscripts had self-reported sleep deprivation (mismatch between reported need for sleep and reported sleep). Self-reported sleep deprivation was significantly associated with somnolence (P = .016) and fatigue (P = .026). Smartphone usage, both average time (P = .022) and frequency of usage (P = .0093) before bedtime, was associated with shorter total sleep time. On average, objective sleep time was rather short (7 hours, 6 minutes), sleep efficiency high (94.9%), proportion of N3 sleep high (27.7%), and sleep latency brief (9 minutes)-suggesting that many of the conscripts might have chronic partial sleep deprivation.

CONCLUSIONS

Snoring might predispose to tiredness in presumably healthy young adults. Conscripts may have partial sleep deprivation.

CITATION

Orjatsalo M, Toppila J, Heimola M, et al. Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service. J Clin Sleep Med. 2023;19(2):243-251.

Adapting Group CBT-I for Telehealth-to-Home With Military Veterans in Primary Care

Utilization of telehealth modalities to provide cognitive and behavioral therapies is rapidly increasing. Limitations to access to care can prohibit individuals from getting the care they need, especially evidence-based treatments. In the U.S., Veterans are a population in great need of accessible and high-quality evidence-based psychotherapy for insomnia, as it often co-occurs with other common syndromes such as depression and PTSD. Cognitive Behavioral Therapy for Insomnia (CBT-I) offers effective treatment for insomnia and can be delivered via telehealth and in a group format to greatly increase availability and accessibility. To date, however, few programs exist offering telehealth-to-home CBT-I, fewer still are offered in a primary care setting, and none to our knowledge are offered in group format. We examine the feasibility and efficacy of a fully telehealth-to-home (TTH) group CBT-I pilot program in primary care and compare primary outcomes to those seen in a face-to-face (F2F) format as well as meta-analytic studies of group CBT-I. Primary endpoints, as typically defined such as sleep efficiency (SE) and scores on the insomnia severity index (ISI) appear comparable to those seen in F2F groups in our clinic, and to outcomes seen in the literature. We discuss challenges and strategies for successful implementation of such a program in integrated primary care to increase access and availability of this evidence-based treatment.

Veteran Acceptance of Sleep Health Information Technology: a Mixed-Method Study

Sleep disturbances, including chronic insomnia and sleep apnea, are major concerns for US veterans, with rising rates and detrimental effects on physical, mental, and social well-being. Sleep disturbances in veterans are also underdiagnosed and undertreated for reasons that include limited sleep clinician availability, long wait times, and the time commitment for treatment. Greater use of sleep health information technologies could improve access to assessment and treatment of sleep disturbances. However, the assessment of acceptance of these technologies among veterans is still ongoing. This mixed-method study combines data from two separate but similar randomized controlled trials to assess acceptance of sleep health information technologies for veterans with chronic insomnia. Sleep health information technologies included in these trials were the following: (1) a WatchPAT sleep monitor for home-based sleep assessment, including detection of sleep apnea, and (2) the VA mobile app Cognitive Behavioral Therapy for Insomnia (CBT-i Coach), which supports self-management of insomnia. The combined sample of 37 veterans receiving care within one New England VA medical center completed a six-week trial using both health information technology tools. Participants completed a survey and interview at the end of the 6 weeks. Overall, participants found the tools acceptable, easy to use, and useful and reported they would use them in the future. Thus, these sleep health information technologies appear to provide an acceptable remote option for assessing and managing sleep issues for veterans. ClinicalTrials.gov NCT02392000; http://clinicaltrials.gov/ct2/show/NCT02392000 and ClinicalTrials.gov NCT03305354; https://clinicaltrials.gov/ct2/show/NCT03305354.

A comprehensive evaluation of insomnia, obstructive sleep apnea and comorbid insomnia and obstructive sleep apnea in US military personnel

STUDY OBJECTIVES

The aim of this study was to characterize the sleep disorders of insomnia, obstructive sleep apnea (OSA), and comorbid insomnia and OSA (COMISA) in active duty military personnel.

METHODS

Prospective observational study of 309 military personnel with a mean age of 37.17 years (SD = 7.27). Participants served in four branches of the U.S. military (47.9% Air Force, 38.8% Army, 11.3% Navy, and 1.9% Marines). Sleep diagnoses were rendered after video-polysomnography and a clinical evaluation. Validated self-report measures assessed insomnia severity, excessive daytime sleepiness, sleep quality, disruptive nocturnal behaviors, nightmare disorder, shift work disorder (SWD), sleep impairment, fatigue, posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, and traumatic brain injury (TBI). General linear models and Pearson chi-square tests were used for between-group differences in data analyses.

RESULTS

Insomnia was diagnosed in 32.7%, OSA in 30.4% and COMISA in 36.9%. Compared to military personnel with OSA alone, those with insomnia only and COMISA had significantly greater insomnia severity, disruptive nocturnal behaviors, sleep-related impairment, rates of nightmare disorder, and poorer sleep quality (all Ps < .05). They also reported greater symptoms of fatigue, PTSD, anxiety, and depression (all Ps < .05). There were no significant differences among the three sleep disorder diagnostic groups on sleepiness, SWD, or TBI.

CONCLUSIONS

Military personnel with insomnia only and COMISA overall report worsened symptoms of sleep disorders, sleep-related impairment, fatigue, and psychiatric disorders than those with OSA. Results highlight the importance of a comprehensive assessment for sleep-related impairment, sleep, and comorbid disorders in military personnel with clinically significant sleep disturbances.

Posttraumatic stress disorder (PTSD), sleep, and cardiovascular disease risk: A mechanism-focused narrative review

OBJECTIVE

Growing longitudinal research has demonstrated that posttraumatic stress disorder (PTSD) precedes and predicts the onset of cardiovascular disease (CVD), and a number of physiological (e.g., dysregulation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system, chronic systemic inflammation) and behavioral (e.g., physical inactivity, smoking, poor diet) factors might underlie this association. In this narrative review, we focus on sleep as a modifiable risk factor linking PTSD with CVD.

METHOD

We summarize the evidence for sleep disturbance after trauma exposure and the potential cardiotoxic effects of poor sleep, with an emphasis on mechanisms. In addition, we review the literature that has examined sleep in the context of the PTSD-CVD risk relation.

RESULTS

Although sleep disturbance is a hallmark symptom of PTSD and a well-established risk factor for the development of CVD, the role of sleep in the association between PTSD and CVD has been largely unexamined in the extant literature. However, such work has the potential to improve our understanding of mechanisms of risk and inform intervention efforts to offset elevated CVD risk after trauma.

CONCLUSIONS

We outline several recommendations for future research and behavioral medicine models in order to help define and address the role of sleep behavior in the development of CVD among trauma-exposed individuals with PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018

STUDY OBJECTIVES

Recent initiatives to discourage overprescription of sleep medications have increased awareness of their potential adverse effects; however, it is unknown whether these efforts translated into a decline in use of these medications in the United States. We assessed recent national trends in the use of medications used for sleep disturbance.

METHODS

We used data from n = 29,400 participants in the 2013-2018 National Health and Nutrition Examination Survey. At each of three waves of in-person assessments, participants presented prescription bottles for all medications used in the prior month. Interviewers recorded each medication and participants self-reported duration and reasons for use. We identified all medications used for sleep disturbance and categorized medications into two categories: Food and Drug Administration-approved sleep medications and those used off-label for sleep disturbance. We examined changes in the prevalence in use of these medications across the study period.

RESULTS

The odds of using medications for sleep disturbance decreased 31% between 2013 and 2018 (odds ratio = 0.69, 95% confidence interval = 0.51-0.93, P = .015). This trend was driven by declines in use of Food and Drug Administration-approved medications for sleep disturbance, especially for medium- and long-term duration of use. Notably, among those age 80+ years, we observed an 86% decline (odds ratio = 0.14, 95% confidence interval = 0.05-0.36, P < .001) in use of Food and Drug Administration-approved sleep medications over the study period.

CONCLUSIONS

Use of prescription medications for sleep disturbance declined nationally, suggesting a possible effect of efforts to curb overprescription and encourage judicious use of these agents. Future research needs to examine whether these changes have coincided with improved population sleep health.

CITATION

Kaufmann CN, Spira AP, Wickwire EM, et al. Declining trend in use of medications for sleep disturbance in the United States from 2013 to 2018. J Clin Sleep Med. 2022;18(10):2459-2465.

Nightmare disorder and low back pain in veterans: cross-sectional association and effect over time

Low back pain (LBP) disproportionately impacts US military veterans compared with nonveterans. Although the effect of psychological conditions on LBP is regularly studied, there is little published to date investigating nightmare disorder (NMD) and LBP. The purpose of this study was to (1) investigate whether an association exists between NMD and LBP and (2) estimate the effect of NMD diagnosis on time to LBP. We used a retrospective cohort design with oversampling of those with NMD from the Veterans Health Administration (n = 15 983). We used logistic regression to assess for a cross-sectional association between NMD and LBP and survival analysis to estimate the effect of NMD on time to LBP, up to 60-month follow-up, conditioning on age, sex, race, index year, Charlson Comorbidity Index, depression, anxiety, insomnia, combat exposure, and prisoner of war history to address confounding. Odds ratios (with 95% confidence intervals [CIs]) indicated a cross-sectional association of 1.35 (1.13 to 1.60) and 1.21 (1.02 to 1.42) for NMD and LBP within 6 months and 12 months pre- or post-NMD diagnosis, respectively. Hazard ratios (HRs) indicated the effect of NMD on time to LBP that was time-dependent-HR (with 95% CIs) 1.27 (1.02 to 1.59), 1.23 (1.03 to 1.48), 1.19 (1.01 to 1.40), and 1.10 (0.94 to 1.29) in the first 3, 6, 9, and 12 months post-diagnosis, respectively-approximating the null (1.00) at >12 months. The estimated effect of NMD on LBP suggests that improved screening for NMD among veterans may help clinicians and researchers predict (or intervene to reduce) risk of future back pain.

Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT

OBJECTIVE

The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health.

REVIEW METHODS

A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR.

SUMMARY

Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.

What's sleep got to do with it? Longitudinal associations between insomnia, PTSD, and alcohol use among U.S. Veterans

U.S. veterans are at risk for insomnia, which often co-occurs with symptoms of posttraumatic stress disorder (PTSD) and alcohol use. Much of the research on veterans and these three constructs is cross-sectional and focused on unidirectional pathways. Recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, PTSD, and alcohol use, yet few longitudinal studies exist. A clearer understanding of these pathways is needed to help inform integrated treatments. Using a sample of 1,230 post-9/11 veterans assessed over four time points across 12 months, we used a latent difference score modeling approach to examine proportional and dynamic change between insomnia, PTSD, and alcohol. Results revealed a complex interplay between all three constructs. Higher prior levels of both PTSD and alcohol use were associated with greater subsequent changes in insomnia symptoms (i.e., worse sleep). Moreover, although veterans drank less frequently as their insomnia symptoms worsened over time, greater changes in insomnia symptoms (i.e., worse symptoms) was a mechanism linking PTSD and more frequent drinking. As the research on interventions addressing insomnia, PTSD, and alcohol is limited, there are opportunities for researchers and clinicians to develop programs that effectively target all three in integrated treatments.

The association of polysomnographic sleep on posttraumatic stress disorder symptom clusters in trauma-exposed civilians and veterans

Study Objectives

Self-reported sleep disturbance has been established as a risk factor and predictor for posttraumatic stress disorder (PTSD); however, less is known about the relationship between objective sleep and PTSD symptom clusters, and the specific role of hyperarousal. The present study examined the relationships between sleep continuity and architecture on PTSD symptom clusters.

Methods

Participants underwent two in-laboratory sleep studies to assess sleep continuity and architecture. They also completed the Clinician-Administered PTSD-IV scale and the Structured Clinical Interview for the DSM-IV to assess for PTSD diagnosis and other psychiatric disorders.

Results

Sleep continuity (i.e. total sleep time, sleep efficiency percent, wake after sleep onset, sleep latency) was significantly related to PTSD Cluster B (reexperiencing) symptom severity (R ² = .27, p < .001). Sleep architecture, specifically Stage N1 sleep, was significantly associated with PTSD Cluster B (t = 2.98, p = .004), C (Avoidance; t = 3.11, p = .003), and D (Hyperarosual; t = 3.79, p < .001) symptom severity independently of Stages N2, N3, and REM sleep. REM sleep variables (i.e. REM latency, number of REM periods) significantly predicted Cluster D symptoms (R ² = .17, p = .002).

Conclusions

These data provide evidence for a relationship between objective sleep and PTSD clusters, showing that processes active during Stage N1 sleep may contribute to PTSD symptomatology in civilians and veterans. Further, these data suggest that arousal mechanisms active during REM sleep may also contribute to PTSD hyperarousal symptoms.This paper is part of the War, Trauma, and Sleep Across the Lifespan Collection. This collection is sponsored by the Sleep Research Society.

Barriers to positive airway pressure adherence among veterans with sleep apnea: a mixed methods study

Rates of adherence to positive airway pressure (PAP) for sleep apnea are suboptimal. Though previous studies have identified individual factors associated with PAP nonadherence, few projects have investigated a wide range of possible barriers directly from the patient perspective. We examined the range of factors that patients identify as barriers to optimal use of PAP as well as the solutions most commonly offered by providers. We employed a mixed methods design including semistructured interviews and medical record review at a US Department of Veterans Affairs Medical Center. Thirty patients identified as nonadherent to PAP participated. Patients were asked to report on current sleep problems, reasons for nonadherence, and solutions proposed by providers. Chart review was used to identify untreated apnea severity, Epworth Sleepiness Scale score, therapy hours, and residual apnea severity. Patients described physical and psychological barriers to adherent use at approximately equal rates: Mask leaks and dry throat/nose were common physical barriers, and anxiety/claustrophobia and worsening insomnia were common psychological barriers. Untreated apnea severity, residual apnea severity, and daytime sleepiness were not associated with therapy hours. Solutions offered by providers most frequently addressed physical barriers, and solutions to psychological barriers were rarely proposed. The most common solution offered by providers was trying different masks. We recommend individualized assessment of each patient's barriers to use as well as increased involvement of behavioral health providers in sleep medicine clinics.

Translational Approaches to Influence Sleep and Arousal

Sleep disorders are widespread in society and are prevalent in military personnel and in Veterans. Disturbances of sleep and arousal mechanisms are common in neuropsychiatric disorders such as schizophrenia, post-traumatic stress disorder, anxiety and affective disorders, traumatic brain injury, dementia, and substance use disorders. Sleep disturbances exacerbate suicidal ideation, a major concern for Veterans and in the general population. These disturbances impair quality of life, affect interpersonal relationships, reduce work productivity, exacerbate clinical features of other disorders, and impair recovery. Thus, approaches to improve sleep and modulate arousal are needed. Basic science research on the brain circuitry controlling sleep and arousal led to the recent approval of new drugs targeting the orexin/hypocretin and histamine systems, complementing existing drugs which affect GABA_A receptors and monoaminergic systems. Non-invasive brain stimulation techniques to modulate sleep and arousal are safe and show potential but require further development to be widely applicable. Invasive viral vector and deep brain stimulation approaches are also in their infancy but may be used to modulate sleep and arousal in severe neurological and psychiatric conditions. Behavioral, pharmacological, non-invasive brain stimulation and cell-specific invasive approaches covered here suggest the potential to selectively influence arousal, sleep initiation, sleep maintenance or sleep-stage specific phenomena such as sleep spindles or slow wave activity. These manipulations can positively impact the treatment of a wide range of neurological and psychiatric disorders by promoting the restorative effects of sleep on memory consolidation, clearance of toxic metabolites, metabolism, and immune function and by decreasing hyperarousal.

A Pilot Randomized Controlled Trial of the Insomnia Coach Mobile App to Assess Its Feasibility, Acceptability, and Potential Efficacy

Insomnia is highly prevalent among military veterans but access to cognitive-behavioral therapy for insomnia (CBT-I) is limited. Thus, this study examined the feasibility, acceptability, and potential efficacy of Insomnia Coach, a CBT-I-based, free, self-management mobile app. Fifty U.S. veterans, who were mostly male (58%) and mean age 44.5 (range = 28-55) years with moderate insomnia symptoms were randomized to Insomnia Coach (n = 25) or a wait-list control condition (n = 25) for 6 weeks. Participants completed self-report measures and sleep diaries at baseline, posttreatment, and follow-up (12 weeks postrandomization), and app participants (n = 15) completed a qualitative interview at posttreatment. Findings suggest that Insomnia Coach is feasible to use, with three quarters of participants using the app through 6 weeks and engaging with active elements. For acceptability, perceptions of Insomnia Coach were very favorable based on both self-report and qualitative interview responses. Finally, for potential efficacy, at posttreatment, a larger proportion of Insomnia Coach (28%) than wait-list control participants (4%) achieved clinically significant improvement (p = .049) and there was a significant treatment effect on daytime sleep-related impairment (d = -0.6, p = .044). Additional treatment effects emerged at follow-up for insomnia severity (d = -1.1, p = .001), sleep onset latency (d = -0.6, p = .021), global sleep quality (d = -0.9, p = .002), and depression symptoms (d = -0.8, p = .012). These findings provide preliminary evidence that among veterans with moderate insomnia symptoms, a CBT-I-based self-management app is feasible, acceptable, and promising for improving insomnia severity and other sleep-related outcomes. Given the vast unmet need for insomnia treatment in the population, Insomnia Coach may provide an easily accessible, convenient public health intervention for individuals not receiving care.