A pilot study to evaluate the effect of a single shot CBT-I invention on veteran students’ insomnia symptoms.
Introduction
Between 2002-2012, the number of military veterans attending college nearly doubled, however, it has been found that only 60-70% of veterans complete the academic requirements to graduate (McGuffin et al., 2019). Several factors contribute to these statistics. Student military veterans experience significant social and emotional difficulties during their military to college student transition, a greater history of trauma exposure, and more work and family obligations than traditional college students (Smith et al., 2017; Barry et al. 2014; Barry et al., 2015, National Survey of Student Engagement, 2010). In addition, many student veterans are learning to cope with the physical and psychological consequences of their military service and the stress of transitioning from military to civilian life which further contributes to greater psychological distress and disrupted sleep (Klaw et al, 2021). According to prevalence estimates, insomnia symptoms affect 27% and 47% of military service members and veterans, respectively (Hughes et. al, 2018). Military service members with co-morbid major depression have the highest prevalence of insomnia disorder (85.0%), followed by those with generalized anxiety disorder (82.6%) and posttraumatic stress disorder (69.7%) (Brownlow et al., 2017). In addition, there are significant interaction effects between insomnia and these psychiatric disorders demonstrating how their comorbidity influences the relationship between insomnia and memory/concentration problems. Similarly, this relationship was validated by Okano and colleagues (2019) in their study of insomnia in college students which found sleep duration, quality, and consistency were all strongly associated with better academic performance.
Sleep is both a biologic necessity and a vital component of learning and memory consolidation, both of which are critical components of academic performance.
Insomnia, which can be acute or chronic (lasting >3 months), is characterized by persistent trouble falling asleep, staying asleep, and/or early waking that leads to clinical symptoms and functional impairment (McGuffin et al., 2019). Findings suggest that changes in sleep architecture that occur when a person transitions from experiencing acute insomnia symptoms to chronic insomnia elevates their risk of developing first-time depression (Ellis et al., 2014). Chronic insomnia has been linked to a wide range of physical and psychological issues that are common in the veteran population, including chronic pain, cardiometabolic and neurologic disorders, substance abuse, depression, and posttraumatic stress (Byrne et al., 2021). In addition to the physical and mental effects of poor sleep, human performance studies of military personnel also confirm that lack of sleep is significantly associated with decreased motivation, attention, alertness, short-term memory recall, and task and physical performance (Itani et al., 2017; Main et al., 2023; Satterfield et al., 2019; Bonnett et al., 2019).
Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line therapy for insomnia (Ho et al., 2016; Kelly et al., 2021). It’s been found to reduce the severity of insomnia symptoms across subjective and objective sleep measures, reduce reported nightmares and sleep-related fear, and improve general health functioning in military and veteran populations, including those with co-morbid mental health issues like post-traumatic stress disorder and depression (Van Straten et al., 2018; Kannady et al., 2018; Ho et al., 2016; Lee et al., 2021; Kelly et al., 2021). In response to the growing body of evidence demonstrating the high prevalence of insomnia among military and veterans and the negative short and long-term health effects when it is not addressed, in 2019 the Department of Veterans Affairs and Department of Defense (VA/DoD) published clinical practice guidelines recommending CBT-i as the first-line treatment for insomnia over medication management (Ulmer et al., 2021). Subsequently, over one thousand VA/DoD providers were trained to deliver CBT-i and a self-help CBT-I Coach smartphone application was launched to expand treatment availability.
In its traditional form, CBT-I is delivered by a trained provider over 6-8 sessions and is comprised of psychoeducation about normal and abnormal sleep patterns, the etiology of insomnia, and sleep health education (Kelly et al., 2019). It introduces behavioral interventions, like sleep restriction, stimulus control, and relaxation strategies which are practiced, and their effectiveness assessed, over the course of treatment. Cognitive therapy, the foundation of CBT-I, is used to address a person’s core beliefs, dysfunctional assumptions, and automatic negative thoughts that contribute to the insomnia symptoms (Kelly et al., 2019). Because of the effectiveness of CBT-I as a first-line treatment, efforts have been made to expand access by exploring alternative delivery systems and content format. In doing so, CBT-I has been found to reduce insomnia symptoms whether delivered individually or in group formats (Yamadera et al., 2005), via online or telehealth (Taylor et al., 2017; Arnedt et al., 2021), through online applications that are not clinician-directed (Erten et al., 2021), and in briefer formats of 2-4 sessions (Bramoweth et al., 2020; Germaine & Buysse, 2011) and one session (Ellis et al., 2015).
Despite efforts to reduce systematic barriers that prevent military and veteran populations from accessing CBT-I to treat insomnia symptoms, there are also individual beliefs about mental health treatment that could prevent them from accessing services. Veterans who are younger, diagnosed with a mental health condition, and identify as a racial/ethnic minority are less likely to seek traditional mental health care for their symptoms (Pietrzak, 2009). Therefore, connecting student veterans experiencing insomnia with CBT-I resources in non-mental health settings may be a means of reducing stigma, promoting health engagement, and fostering academic success.
Aim
The primary aim of this pilot study is to evaluate changes in subjective sleep outcomes after a brief “one shot” education intervention on insomnia symptom self-management using the mobile application CBT-i Coach as an intervention for student veterans with insomnia.
Methods
This is prospective single arm interventional pilot study will use a pre-post study design.
Sample and Setting
A convenience sample of 15 military and veteran students enrolled at Metropolitan State University of Denver will be recruited for study participation. Study inclusion and exclusion criteria for participation include 1) prior history of serving in the U.S. Armed Services; 2) Scoring >7 on the Insomnia Severity Index-3 (ISI-3) screening tool for insomnia; 3) currently enrolled as a student in college; 4) no current or prior CBT-I treatment; 5) access to a Smartphone.
Study Procedures
After obtaining Institutional Review Board approval from the university, advertisements outlining the purpose of the study and study point of contact will be hung at the MSU Military and Veteran Students Center and on approved bulletin boards throughout campus and targeted recruitment will occur at campus events geared towards military and veteran students. After screening and consent, participants will be asked to complete the following baseline study instruments: Demographic Questionnaire, Insomnia Severity Index (ISI); Patient Health Questionnaire-9 (PHQ-9); and Generalized Anxiety Disorder-7 (GAD-7). They will be asked to download the free Sleepzy sleep tracking app and CBT-I Coach app onto their personal cellphones. They will use the Sleepzy app to track their sleep quality, time asleep, and sleep debt for one week prior to receiving the intervention. Participants will attend a 60 minute “single shot” group educational intervention during which they will receive instruction on insomnia symptom management and layout and use of the CBT-I Coach app. The education on self-management of insomnia was created by Ellis et al. (2015) in the framework of the 3D’s (Detect – how to record a sleep diary; Detach – stimulus control instructions; and Distract – cognitive control and imagery distraction instructions). Participants will be asked to track their nightly use of the CBT-I Coach app for four weeks after the educational intervention, During week four, they will be asked to measure their objective sleep quality once again using the Sleepzy app. Afterwards, the group will be asked to complete the post-intervention ISI, PHQ-9, and GAD-7 assessments and turn in their CBT-I Coach app usage logs for the four weeks
Data Analysis
Collected data will be analyzed using descriptive statistics to describe the study sample and key variables and correlational analysis to highlight the strength and direction of the relationships between study variables. Pair-wise t-Tests will be used to determine the effectiveness of the single shot CBT-I intervention in reducing insomnia symptoms in student veterans.
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