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MIRECC/CoE Mental Health Innovations Newsletter - December 2013

Research topic on PTSD and Sleep Education topic on provider education Clinical topic on tele-health

Helping Veterans Find Their Way to Better Zzz’s: Getting a Good Night’s Sleep


The Impact of PTSD Treatment on Sleep Disturbance: A Mixed Picture

Veterans with Posttraumatic Stress Disorder (PTSD) frequently report insomnia and distressing dreams. However, a question that has remained unanswered is whether successfully completing an evidence-based treatment for PTSD might also reduce sleep problems. Led by Drs. Sean P.A. Drummond and Carla M. Nappi, researchers at the VISN 22 Center for Excellence in Stress and Mental Health (CESAMH) examined this question. Forty-one Veterans who had served in Operations Iraqi Freedom and Enduring Freedom were enrolled in a course of Prolonged Exposure Therapy (PE), a time-limited, evidence-based treatment for PTSD. As expected, the 23 Veterans who completed treatment showed significant improvement in It’s clear that sleep problems are a core component of PTSD and need to be specifically and independently treated.overall PTSD symptoms. They also reported subjectively improved overall sleep, reduced time to falling asleep at night, and reduced nightmare frequency. Despite these positive changes, Veterans continued to report significant sleep problems and saw no change in perceived total sleep time or in objective measures of sleep. Taken together, these results present a mixed picture. PE did appear to have some positive impact on sleep problems even though the treatment did not directly focus on sleep disturbance. However, residual insomnia symptoms continued to be present. This suggests that some Veterans who receive PE would also benefit from engaging in psychopharmacological or behavioral treatments that specifically target sleep problems. As Dr. Drummond states, “It’s clear that sleep problems are a core component of PTSD and need to be specifically and independently treated.” Dr. Drummond’s group plans to explore this area in the future to determine the best way to deliver both types of treatment to Veterans with PTSD and sleep disorder comorbidity.


Developing Tools to Educate Treatment Providers about Sleep Problems in Veterans with Serious Mental Illness

The education program will increase treatment providers’ knowledge and ability to address sleep problems in Veterans with serious mental illness.

Researchers and clinicians at the VISN 5 MIRECC are helping Veterans with serious mental illness (SMI) gain access to needed treatment for sleep problems. More than 75% of individuals with SMI report sleep disturbance. However, Veterans with SMI have indicated that they have limited knowledge about treatment for sleep problems or how to access such treatment within VA. This gap in care is being addressed by a team of investigators led by Dr. Elizabeth Klingaman. Their goal is to increase treatment providers’ knowledge and ability to effectively address sleep concerns when working with Veterans with SMI. The research team is currently collecting data from Veterans with SMI and VA mental health providers and will develop education materials based on the findings of their study. This will ensure that the program’s content reflects the actual experiences and perspectives of both Veterans and treatment providers. The program will also address behavioral health issues that are often related to sleep problems and which are commonly experienced by Veterans with SMI, such as weight management, diet, and cigarette smoking. Ultimately, the program will improve communication about sleep problems between Veterans and their providers and increase access to treatment for insomnia. It will also educate providers and Veterans with SMI about how improvements in sleep can impact their recovery. Dr. Klingaman expressed, “I see this program as being an essential piece of offering better insomnia interventions to the many Veterans with SMI who consistently don’t get a good night’s rest. Better sleep will support other aspects of their recovery.” The training program will be available to mental health providers at VA Medical Centers nationwide.


More Veterans are Sleeping Better Thanks to Telehealth

Telehealth increases access to CBT-I, an evidence-based treatment for sleep disturbance.

Chronic sleep difficulties are often reported among Veterans seeking care at VA Medical Centers. These difficulties can be effectively treated using an evidence-based psychotherapy, Cognitive-Behavioral Treatment for Insomnia (CBT-I). CBT-I is considered a first-line treatment because it provides greater long-term improvements in sleep than medication. CBT-I is brief, usually requiring 8 or fewer sessions. It is effective when delivered in either an individual or group treatment format. CBT-I retrains one’s body to sleep well again and usually delivers quick results. Ideally more Veterans would receive CBT-I and experience relief from chronic, often debilitating, sleep disturbance. Dr. Philip Gehrman and colleagues at the VISN 4 MIRECC are using Telemedicine to increase the number of Veterans accessing CBT-I. Dr. Gehrman’s Tele-Insomnia program delivers CBT-I to groups of Veterans over the course of 6 weeks using Clinical Video Telehealth technology. This technology expands access to sites where there is not a provider trained or available to deliver CBT-I. The Tele-Insomnia program has also been used to train staff at other sites so they can offer CBT-I to Veterans in their area. To date, groups have been held at VA facilities in 10 states and delivered services to over 200 Veterans. Veterans who completed the program no longer experienced clinically significant insomnia and reported high satisfaction with the treatment. Dr. Gehrman reports that “they were thrilled to have an option other than medication to deal with sleep.” The Tele-Insomnia program is a significant step forward in increasing Veterans’ access to effective treatment for insomnia.

There are 15 VA specialized mental health centers of excellence which include 10 Mental Illness Research, Education and Clinical Centers (MIRECCs), 4 Mental Health Centers of Excellence, and the National Center for PTSD. The centers share a mission to improve the health and well being of Veterans through cutting-edge science, education, and clinical initiatives. Mental health problems are often multiple complex conditions. Each center addresses a particular mental health disorder, environmental situation or Veteran cohort. To learn more about these centers, go to www.mirecc.va.gov.

Noosha Niv, PhD (Editor), Shannon McCaslin, PhD and MIRECC Communications Workgroup (Contributors)