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.

Treatment utilization and modality preference among veterans receiving outpatient substance use disorder treatment during a pandemic

BACKGROUND AND OBJECTIVES

This study examines substance use disorder (SUD) treatment utilization patterns in response to a pandemic.

METHOD

Retrospective electronic medical record data were collected during three time periods (N = 390): "Pre-COVID-19" (12/02/2019-03/14/2020), "COVID-19" (03/15/2020-06/30/2020), and COVID-19 "Re-entry" (7/01/2020-10/01/2020). Number of visits in each time period, SUD diagnosis, treatment modality (video, telephone, none), demographic, and clinical variables were examined. One-way analyses of variance (ANOVA) and chi-square analyses tested the relationships between treatment modality, demographics, clinical variables, and psychiatric emergency room (PER) visits. Binary logistic regressions examined the effect of treatment modality on PER use during COVID-19 and Re-entry, controlling for alcohol, opioid, and cocaine use disorders, age, and past-year (pre-COVID-19) PER use.

RESULTS

Treatment modality was associated with SUD (alcohol, cocaine, opioids), age, and PER visits. Veterans who primarily attended telephone appointments were more likely to require PER services compared to those attending video appointments. In the full model, alcohol use disorder (AUD), past-year PER visits, and treatment modality (telephone visits) continued to be significantly associated with COVID-19 PER use, while past-year PER visits correlated with Re-entry PER use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

During COVID-19, veterans whose main treatment modality was telephone were more likely to require PER services than veterans who were seen by video, even after controlling for age, AUD, opioid use disorder, and past-year PER visits. This study is the first to have examined SUD treatment modality utilization patterns in response to COVID-19. Findings suggest that treatment modality during the initial phase of COVID-19 correlated with PER presentation.

0471 Identifying Trauma-Informed Adaptations to Cognitive Behavioral Therapy for Insomnia among Women Veterans: Results of an Expert Panel

Introduction

Trauma-informed care is an emerging area of health services research. While trauma-focused care specifically targets symptoms of posttraumatic stress disorder (PTSD), trauma-informed care involves tailoring interventions to meet the unique needs of patients who have experienced trauma. Insomnia and PTSD are common comorbid disorders, but no known previous studies have identified trauma-informed adaptations to cognitive behavioral therapy for insomnia (CBT-I).

Methods

We identified PTSD clinical presentations that may interfere with the delivery of effective CBT-I and possible adaptations to standard CBT-I that may address these clinical presentations based on a literature review. We then incorporated trauma-informed adaptations into a 5-session CBT-I protocol. Four Veterans Affairs (VA) Expert Trainers in CBT-I were sent the trauma-informed CBT-I materials and rating forms. They were asked to rate the extent to which PTSD clinical presentations serve as barriers to CBT-I (1=low barrier; 5=high barrier), the feasibility of possible adaptations (1=low feasibility; 5=high feasibility), and to provide qualitative feedback. A 60-minute panel meeting was convened and aggregated data from rating forms were presented and discussed. We then revised the trauma-informed CBT-I materials. Panelists reviewed the revised trauma-informed CBT-I materials and completed post-panel rating forms.

Results

The highest-ranked clinical presentations based on rating forms and panel consensus included: sleep avoidance/nighttime arousal, sleep-related self-efficacy, substance/medication use to induce sleep, and safety behaviors intended to reduce nighttime arousal. Panel meeting consensus identified the following trauma-informed adaptations to CBT-I: PTSD-related nighttime hyperarousal psychoeducation, identification of alternatives to PTSD-related safety behaviors, nightmare psychoeducation, psychoeducation about PTSD avoidance in the context of substance/medication use, cognitive techniques, and behavioral tracking to challenge beliefs and avoidant behaviors. Panelists agreed the revised trauma-informed CBT-I materials adequately addressed the PTSD clinical presentations that may limit the effectiveness of standard CBT-I for patients with comorbid PTSD.

Conclusion

This was the first study to use an expert panel to identify trauma-informed adaptations to CBT-I. Trauma-informed adaptations, including supplemental materials, may improve CBT-I outcomes for patients with comorbid PTSD. Future studies should incorporate feedback from patients with insomnia and PTSD to refine trauma-informed adaptations to CBT-I further.

Support (If Any)

VA HSR&D (RCS-20-191, Martin), NHLBI (K23HL143055, Martin)

Veteran interest in family involvement in PTSD treatment

[Correction Notice: An erratum for this article was reported in Vol 7(3) of Psychological Services (see record 2010-17074-004). The copyright for the article was listed incorrectly. This article is in the Public Domain. The online version has been corrected.] The present study examined interest in family involvement in treatment and preferences concerning the focus of family oriented treatment for veterans (N = 114) participating in an outpatient Veterans Affairs outpatient posttraumatic stress disorder (PTSD) program. Most veterans viewed PTSD as a source of family stress (86%) and expressed interest in greater family involvement in their treatment (79%). These results suggest the need to consider increasing family participation in the clinical care of individuals with PTSD and to develop specialized family educational and support services for this population. (PsycINFO Database Record (c) 2016 APA, all rights reserved)