Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury.

OBJECTIVE: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD: Semi-structured interviews (n = 49) with 29 clinical stakeholders and 20 Veterans were conducted. Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders. Veterans included those with a clinician-confirmed mTBI with a recent history of insomnia disorder and/or OSA treatment. Themes were identified using a Descriptive and Interpretive approach. RESULTS: Barriers to sleep disorder treatment adherence included factors associated with the patient (e.g., negative appraisal of treatment benefit), intervention (e.g., side effects), health conditions (e.g., cognitive challenges), health care system (e.g., limited availability of care), and socioeconomic status (e.g., economic instability). Similarly, facilitators of adherence included patient- (e.g., positive appraisal of treatment benefit), intervention- (e.g., flexible delivery format), condition- (e.g., accommodating cognitive impairments), health care system- (e.g., access to adherence support), and socioeconomic-related factors (e.g., social support). CONCLUSIONS: Interviews revealed the multi-faceted nature of factors influencing adherence to sleep disorder treatment among Veterans with mTBI. Findings can inform the development of novel interventions and care delivery models that meet the complex needs of this population.

Mindful Night-to-Day: A Pilot Feasibility Trial of a Mindfulness-Based Insomnia and Symptom Management Intervention for Patients with Hematologic Cancer.

OBJECTIVES: Patients with hematologic cancer experience severe symptoms (i.e. insomnia, fatigue, pain, distress). Few interventions addressing insomnia and other symptoms exist for this population. Mindfulness-Based Therapy for Insomnia (MBTI) may be appropriate but has only been tested in healthy outpatients. This study aimed to develop and test an adapted MBTI protocol for hematologic cancer patients. METHODS: Patient (n = 3) and clinician (n = 1) focus groups, and user-testing (N = 5) informed adaptation of Mindful Night-to-Day (MBTI+). A single-arm pilot trial (N = 32) evaluated feasibility (accrual, attrition, adherence), acceptability (intervention satisfaction), and changes to insomnia symptom severity (Insomnia Severity Index; primary outcome) and secondary outcomes (fatigue, pain, distress, pre-sleep arousal, mindfulness, symptom management self-efficacy) at baseline, post-intervention, and 1-month post-intervention. Descriptive statistics and paired sample t-tests were conducted. RESULTS: Qualitative feedback informed MBTI+ content, format, and delivery. Mindfulness was used to increase symptom awareness (sleepiness vs. fatigue). Meditations and behavioral skills were applied to inpatient treatment. MBTI+ met feasibility (N = 32/12 months; 8.1% attrition; 83.8% adherence) and acceptability (M = 3.52/4.00) benchmarks. Insomnia symptom severity decreased (d = 1.20) from baseline to post-intervention, as did most secondary outcomes. CONCLUSIONS: MBTI+ was feasible, acceptable, and showed promise for benefits throughout inpatient and outpatient treatment. Findings warrant further evaluation in a randomized trial.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines.

Description: In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. Methods: In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Roles of Guilt Cognitions in Trauma-Related Sleep Disturbance in Military Veterans With Posttraumatic Stress Disorder.

Objective/Background: Despite a well-established role of guilt cognitions in the maintenance and treatment of posttraumatic stress disorder (PTSD), relationships of guilt cognitions to nightmares are not well understood. This study investigated the ways in which guilt cognitions, related to traumatic events, influenced the relationship between combat exposure and trauma-related sleep disturbance in military Veterans with PTSD. Participants: We recruited a sample of 50 Veterans with PTSD who completed study measures at a screening session. Methods: Participants completed self-report measures of exposure to potentially traumatic events, trauma-related guilt (hindsight bias, wrongdoing, and lack of justification) and trauma-related sleep disturbance as measured by a self-report scale and clinician ratings of nightmare severity. Results: Bivariate regression analyses established a relationship of combat exposure to wrongdoing (ß = .31, p = .031), and a relationship of wrongdoing with self-reported trauma-related sleep disturbance (ß = .27, p = .049) and clinician-rated nightmare severity (ß = .36, p = .009). Bootstrapping analysis that included years of education as a covariate found a significant overall indirect effect of combat exposure on clinician-rated nightmare severity exerted through wrongdoing (ß = .10, 95% CI [.004, .246]). Conclusions: Results suggest the association of combat exposure with trauma-related sleep disturbance is significantly influenced by perceived wrongdoing related to a traumatic event. Targeting cognitions related to wrongdoing and moral injury during a traumatic event in PTSD treatment may help ameliorate trauma-related sleep disturbance.

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review.

The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, patients are rarely referred to this treatment, especially in primary care where most insomnia treatment is provided. We reviewed the evidence about barriers to CBT-I referrals and efforts to increase the use of CBT-I services. PubMed, PsycINFO, and Embase were searched on January 11, 2018; additional titles were added based on a review of bibliographies and expert opinion and 51 articles were included in the results of this narrative review. Implementation research testing specific interventions to increase routine and sustained use of CBT-I was lacking. Most research focused on pre-implementation work that revealed the complexity of delivering CBT-I in routine healthcare settings due to three distinct categories of barriers. First, system barriers result in limited access to CBT-I and behavioral sleep medicine (BSM) providers. Second, primary care providers are not adequately screening for sleep issues and referring appropriately due to a lack of knowledge, treatment beliefs, and a lack of motivation to assess and treat insomnia. Finally, patient barriers, including a lack of knowledge, treatment beliefs, and limited access, prevent patients from engaging in CBT-I. These findings are organized using a conceptual model to represent the many challenges inherent in providing guideline-concordant insomnia care. We conclude with an agenda for future implementation research to systematically address these challenges.

Single-Item Measures for Detecting Sleep Problems in United States Military Veterans.

BACKGROUND: As many as two-thirds of post-9/11 military veterans complain of sleep problems, including insomnia-like symptoms. Left untreated, chronic sleep problems increase the risk for a range of negative outcomes, including incident mental health disorders. However, sleep problems remain overlooked in primary care settings. To date, no brief sleep screeners have been developed or validated. Items assessing insomnia and poor sleep are often embedded into commonly used psychological assessments, and may serve as a viable first step in screening. OBJECTIVE: The objective of this study was to examine the utility of three single items (i.e., trouble falling asleep, awakening in the early morning, and sleep that is restless or disturbed) embedded into the Symptom Checklist-90-Revised (SCL) for identifying two outcomes of interest, poor sleep and probable insomnia. DESIGN: Data were drawn from the cross-sectional Post-Deployment Mental Health Study, hosted by the Mid-Atlantic VA Mental Illness Research, Education, and Clinical Center. Item performance was evaluated using sensitivity, specificity, and predictive value calculations, along with receiver operating characteristic (ROC) curves. PARTICIPANTS: Post-9/11 U.S. military veterans with one or more overseas deployments and with no current DSM Axis I mental health disorder (N = 1118). MAIN MEASURES: An in-person health and sleep questionnaire, including the Pittsburgh Sleep Quality Index (PSQI) and the Symptom  Checklist (SCL). KEY RESULTS: Using an item response of 1, all three items demonstrated moderate sensitivity (0.70-0.78) and acceptable rates of false positives and false negatives (0.23-0.48 and 0.11-0.42, respectively) in predicting both outcomes, poor sleep and probable insomnia. CONCLUSIONS: Our initial findings suggest that existing items in the SCL may serve as a first step in screening for sleep problems. Early detection and treatment of sleep problems might prevent or ameliorate several negative outcomes, including incident mental health disorders.

Work stressors, depressive symptoms and sleep quality among US Navy members: a parallel process latent growth modelling approach across deployment.

The present study examined whether work stressors contribute to sleep problems and depressive symptoms over the course of deployment (i.e. pre-deployment, post-deployment and 6-month reintegration) among US Navy members. Specifically, we examined whether depressive symptoms or sleep quality mediate the relationships between work stressors and these outcomes. Participants were 101 US Navy members who experienced an 8-month deployment after Operational Enduring Freedom/Operation Iraqi Freedom. Using piecewise latent growth models, we found that increased work stressors were linked to increased depressive symptoms and decreased sleep quality across all three deployment stages. Further, increases in work stressors from pre- to post-deployment contributed to poorer sleep quality post-deployment via increasing depressive symptoms. Moreover, sleep quality mediated the association between increases in work stressors and increases in depressive symptoms from pre- to post-deployment. These effects were maintained from post-deployment through the 6-month reintegration. Although preliminary, our results suggest that changes in work stressors may have small, but significant implications for both depressive symptoms and quality of sleep over time, and a bi-directional relationship persists between sleep quality and depression across deployment. Strategies that target both stress and sleep could address both precipitating and perpetuating factors that affect sleep and depressive symptoms.

Prevalence of and characteristics associated with insomnia and obstructive sleep apnea among veterans with knee and hip osteoarthritis.

BACKGROUND: Few studies have examined patterns of specific sleep problems among individuals with osteoarthritis (OA). The primary objective of this study was to examine prevalence of symptoms of insomnia and obstructive sleep apnea (OSA) among Veterans with OA. Secondary objectives were to assess proportions of individuals with insomnia and OSA symptoms who may have been undiagnosed and to examine Veterans' characteristics associated with insomnia and OSA symptoms. METHODS: Veterans (n = 300) enrolled in a clinical trial completed the Insomnia Severity Index (ISI) and the Berlin Questionnaire (BQ) at baseline; proportions of participants with symptoms consistent with insomnia and OSA were calculated, using standard cut-offs for ISI and BQ. For Veterans with insomnia and OSA symptoms, electronic medical records were searched to identify whether there was a diagnosis code for these conditions. Multivariable linear (ISI) and logistic (BQ) regression models examined associations of the following characteristics with symptoms of insomnia and OSA: age, gender, race, self-reported general health, body mass index (BMI), diagnosis of post-traumatic stress disorder (PTSD), pain severity, depressive symptoms, number of joints with arthritis symptoms and opioid use. RESULTS: Symptoms consistent with insomnia and OSA were found in 53 and 66% of this sample, respectively. Among participants screening positive for insomnia and OSA, diagnosis codes for these disorders were present in the electronic medical record for 22 and 51%, respectively. Characteristics associated with insomnia were lower age (ß (SE) = - 0.09 (0.04), 95% confidence interval [CI] = - 0.16, - 0.02), having a PTSD diagnosis (ß (SE) = 1.68 (0.73), CI = 0.25, 3.11), greater pain severity (ß (SE) = 0.36 (0.09), CI = 0.17, 0.55), and greater depressive symptoms (ß (SE) = 0.84 (0.07), CI = 0.70, 0.98). Characteristics associated with OSA were higher BMI (odds ratio [OR] = 1.13, CI = 1.06, 1.21), greater depressive symptoms (OR = 1.12, CI = 1.05, 1.20), and opioid use (OR = 0.51, CI = 0.26, 0.99). CONCLUSIONS: Insomnia and OSA symptoms were very common in Veterans with OA, and a substantial proportion of individuals with symptoms may have been undiagnosed. Characteristics associated with insomnia and OSA symptoms were consistent with prior studies. TRIAL REGISTRATION: NCT01130740 .

Circadian Contrasts in Heart Rate Variability Associated With Posttraumatic Stress Disorder Symptoms in a Young Adult Cohort.

Prior research has demonstrated that individuals exposed to trauma have shown impaired autonomic function. We sought to determine if heart rate variability (HRV), a marker of impaired autonomic function, differed across periods of wake, rest, and sleep as a function of the level of symptoms of posttraumatic stress disorder (PTSD). A sample of young adults (N = 209), 95 of whom met full criteria for current PTSD based on the Clinician Administered PTSD Scale (CAPS; Blake et al., 1995), were evaluated for ≈ 24 hr using actigraphy and electrocardiogram. Actigraphy data were categorized as active, rest, or sleep. Multilevel modeling analyses showed that individuals with high PTSD symptom severity had lower high-frequency HRV than individuals with low PTSD symptom severity during periods of sleep, t(1083) = 2.20, p = .028, Cohen's d = 0.12. No differences were found during periods of activity, t(1083) = 1.34, p = .499, d = 0.05, or rest, t(1083) = 1.34, p = .180, d = 0.09. Our findings extended the import of prior studies to suggest that those with elevated PTSD symptoms may have decreased parasympathetic control during sleep. Moreover, relative to periods of wake and rest, sleep may represent a state of increased vulnerability for decreased parasympathetic cardiac control. Individuals with elevated PTSD symptoms may benefit from early screening for detection of cardiovascular disease.

Impact of combat deployment and posttraumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces.

BACKGROUND: The recent conflicts in Iraq and Afghanistan have exposed thousands of service members to intense stress, and as a result, many have developed posttraumatic stress disorder (PTSD). The role of military deployment experiences and PTSD in coronary heart disease (CHD) is not well defined, especially in young US service members with recent combat exposure. METHODS AND RESULTS: We conducted a prospective cohort study to investigate the relationships between wartime experiences, PTSD, and CHD. Current and former US military personnel from all service branches participating in the Millennium Cohort Study during 2001 to 2008 (n=60 025) were evaluated for newly self-reported CHD. Electronic medical record review for International Classification of Diseases, Ninth Revision, Clinical Modification codes for CHD was conducted among a subpopulation of active duty members (n=23 794). Logistic regression models examined the associations between combat experiences and PTSD with CHD with adjustment for established CHD risk factors. A total of 627 participants (1.0%) newly reported CHD over an average of 5.6 years of follow-up. Deployers with combat experiences had an increased odds of newly reporting CHD (odds ratio, 1.63; 95% confidence interval, 1.11-2.40) and having a diagnosis code for new-onset CHD (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) compared with noncombat deployers. Screening positive for PTSD symptoms was associated with self-reported CHD before but not after adjustment for depression and anxiety and was not associated with a new diagnosis code for CHD. CONCLUSIONS: Combat deployments are associated with new-onset CHD among young US service members and veterans. Experiences of intense stress may increase the risk for CHD over a relatively short period among young adults.

Associations between sleep difficulties and risk factors for cardiovascular disease in veterans and active duty military personnel of the Iraq and Afghanistan conflicts.

Recent evidence suggests that sleep disturbance may play an important role in the development of cardiovascular disease (CVD). Despite the prevalence of sleep complaints among service members of recent military conflicts, few studies have examined associations between sleep and risk factors for CVD in this population. Symptom checklist items regarding distress about "trouble falling asleep" and "restless/disturbed sleep" were used as proxies for sleep onset and maintenance difficulties to examine these associations in US military service members of recent conflicts. Veterans having both sleep onset and maintenance difficulties had greater odds of being a current smoker and having psychiatric symptoms and diagnoses. Increased odds of a self-reported hypertension diagnosis and elevated systolic blood pressure were also found in certain subsets of this sample. Findings highlight the need for greater recognition of sleep difficulties as a CVD risk factor in a population known to be at increased risk for this condition.

Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury.

STUDY OBJECTIVES: We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM. METHODS: Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans. RESULTS: Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively. CONCLUSIONS: Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes. CITATION: Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med. 2024;20(5):801-812.

Nocturnal blood pressure non-dipping, posttraumatic stress disorder, and sleep quality in women.

Women with posttraumatic stress disorder (PTSD) have poor sleep quality and increased risk of cardiovascular disease (CVD). Non-dipping of nocturnal blood pressure may be an explanatory factor for the relationship between sleep and CVD found in previous research. The current study was designed to determine if non-dipping nocturnal blood pressure was associated with trauma exposure, PTSD diagnosis, PTSD symptoms, and sleep quality in a sample of women. Participants completed 24 hours of ABPM and self-report questionnaires. Non-dipping was defined as less than 10% reduction in blood pressure during sleep. The frequency of non-dippers did not differ by diagnostic status (d = .15). However, non-dippers endorsed more traumatic event categories (d = .53), more PTSD hyperarousal symptoms (d = .53), poorer overall sleep quality (d = .59), more frequent use of sleep medication (d = .62), greater sleep-related daytime dysfunction (d = .58), and longer sleep onset latencies (d = .55) than dippers. Increased attention to nocturnal blood pressure variation may be needed to improve blood pressure control in trauma-exposed women.

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study.

BACKGROUND: Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans Health Administration has successfully implemented a large dissemination effort to train providers in CBT-I, the limited number of trained CBT-I providers continues to restrict the number of individuals who can receive CBT-I. Digital mental health intervention adaptations of CBT-I have been found to have similar efficacy as traditional CBT-I. To help address the unmet need for insomnia disorder treatment, the VA commissioned the creation of a freely available, internet-delivered digital mental health intervention adaptation of CBT-I known as Path to Better Sleep (PTBS). OBJECTIVE: We aimed to describe the use of evaluation panels composed of veterans and spouses of veterans during the development of PTBS. Specifically, we report on the methods used to conduct the panels, the feedback they provided on elements of the course relevant to user engagement, and how their feedback influenced the design and content of PTBS. METHODS: A communications firm was contracted to recruit 3 veteran (n=27) and 2 spouse of veteran (n=18) panels and convene them for three 1-hour meetings. Members of the VA team identified key questions for the panels, and the communications firm prepared facilitator guides to elicit feedback on these key questions. The guides provided a script for facilitators to follow while convening the panels. The panels were telephonically conducted, with visual content displayed via remote presentation software. The communications firm prepared reports summarizing the panelists' feedback during each panel meeting. The qualitative feedback described in these reports served as the raw material for this study. RESULTS: The panel members provided markedly consistent feedback on several elements of PTBS, including recommendations to emphasize the efficacy of CBT-I techniques; clarify and simplify written content as much as possible; and ensure that content is consistent with the lived experiences of veterans. Their feedback was congruent with previous studies on the factors influencing user engagement with digital mental health interventions. Panelist feedback influenced multiple course design decisions, including reducing the effort required to use the course's sleep diary function, making written content more concise, and selecting veteran testimonial videos that emphasized the benefits of treating chronic insomnia symptoms. CONCLUSIONS: The veteran and spouse evaluation panels provided useful feedback during the design of PTBS. This feedback was used to make concrete revisions and design decisions consistent with existing research on improving user engagement with digital mental health interventions. We believe that many of the key feedback messages provided by these evaluation panels could prove useful to other digital mental health intervention designers.

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.

Probable trauma associated sleep disorder in post-9/11 US Veterans.

Study Objectives: The purpose of this study was to (1) estimate trauma associated sleep disorder (TASD) prevalence among post-9/11 era veterans and to describe differences in service and comorbid mental health clinical characteristics among individuals with and without probable TASD, and (2) estimate TASD prevalence and characteristics of reported traumatic experiences stratified by sex. Methods: We used cross-sectional data from the post-deployment mental health study of post-9/11 veterans, which enrolled and collected baseline data from 2005 to 2018. We classified veterans as having probable TASD using self-reported measures: traumatic experiences from the traumatic life events questionnaire (TLEQ) and items from the Pittsburgh sleep quality index with Addendum for posttraumatic stress disorder (PTSD) mapped to TASD diagnostic criteria and ascertained mental health diagnoses (PTSD, major depressive disorder [MDD]) via Structured Clinical Interview for DSM-IV. We calculated effect sizes as prevalence ratios (PR) for categorical variables and Hedges' g for continuous variables. Results: Our final sample included 3618 veterans (22.7% female). TASD prevalence was 12.1% (95% CI: 11.1% to 13.2%) and sex-stratified prevalence was similar for female and male veterans. Veterans with TASD had a much higher comorbid prevalence of PTSD (PR: 3.72, 95% CI: 3.41 to 4.06) and MDD (PR: 3.93, 95% CI: 3.48 to 4.43). Combat was the highest reported most distressing traumatic experience among veterans with TASD (62.6%). When stratifying by sex, female veterans with TASD had a wider variety of traumatic experiences. Conclusions: Our results support the need for improved screening and evaluation for TASD in veterans, which is currently not performed in routine clinical practice.

Nightmares: an independent risk factor for cardiovascular disease?

STUDY OBJECTIVES: Prior work has established associations between post-traumatic stress disorder (PTSD), disrupted sleep, and cardiovascular disease (CVD), but few studies have examined health correlates of nightmares beyond risks conferred by PTSD. This study examined associations between nightmares and CVD in military veterans. METHODS: Participants were veterans (N = 3468; 77% male) serving since September 11, 2001, aged 38 years (SD = 10.4); approximately 30% were diagnosed with PTSD. Nightmare frequency and severity were assessed using the Davidson Trauma Scale (DTS). Self-reported medical issues were assessed using the National Vietnam Veterans Readjustment Study Self-report Medical Questionnaire. Mental health disorders were established using the Structured Clinical Interview for DSM-IV. The sample was stratified by the presence or absence of PTSD. Within-group associations between nightmare frequency and severity and self-reported CVD conditions, adjusting for age, sex, race, current smoking, depression, and sleep duration. RESULTS: Frequent and severe nightmares during the past week were endorsed by 32% and 35% of participants, respectively. Those endorsing nightmares that were frequent, severe, and the combination thereof were more likely to also evidence high blood pressure (ORs 1.42, OR 1.56, and OR 1.47, respectively) and heart problems (OR 1.43, OR 1.48, and OR 1.59, respectively) after adjusting for PTSD diagnosis and other covariates. CONCLUSIONS: Nightmare frequency and severity among veterans are associated with cardiovascular conditions, even after controlling for PTSD diagnosis. Study findings suggest that nightmares may be an independent risk factor for CVD. Additional research is needed to validate these findings using confirmed diagnoses and explore potential mechanisms.

Provider-supported self-management cognitive behavioral therapy for insomnia (Tele-Self CBTi): Protocol for a randomized controlled trial.

BACKGROUND: Cognitive Behavioral Therapy for Insomnia (CBTi) is recommended as first-line treatment for insomnia, yet patient access to CBTi is limited. Self-help CBTi could increase patient access. Self-help CBTI with provider sup]port is more effective and is preferred by patients. Self-help CBTi has not been evaluated in veterans; a population with greater medical and mental health morbidity and more severe sleep difficulties than non-veterans. Moreover, those with mental health conditions have been largely excluded from prior CBTi self-help trials. Stablishing the efficacy of provider-supported Self-help CBTi is an important first step for expanding veteran access to CBTi. METHODS: In a 2-armed randomized controlled trial, a provider-supported self-help CBTi (Tele-Self CBTi) is compared to Health Education for improving insomnia severity (primary outcome) among treatment-seeking veterans with insomnia disorder. Tele-Self CBTi is comprised of two treatment components: self-help CBTi via a professionally designed manual developed using an iterative process of expert review and patient input; and 6 telephone-based support sessions lasting >20 min. Outcomes are assessed at baseline, 8 weeks, and 6 months after baseline. The primary outcome, insomnia severity, is measured using the Insomnia Severity Index. Secondary outcomes include self-reported and actigraphy-assessed sleep, fatigue, depression symptoms, and sleep-related quality of life. CONCLUSION: Innovative approaches are essential to improving overall health among veterans; a population with highly prevalent insomnia disorder. If effective, Tele-Self CBTi may bridge the gap between unavailable resources and high demand for CBTi and serve as the entry level intervention in a stepped model of care. GOV IDENTIFIER: NCT03727438.

Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients.

BACKGROUND: The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Implementation through Dynamic Adaptations (MIDAS) Quality Enhancement Research Initiative (QUERI) program was funded as a series of trials to test multi-component implementation strategies to sustain optimal use of three EBPs: (1) a deprescribing approach intended to reduce potentially inappropriate polypharmacy; (2) appropriate dosing and drug selection of direct oral anticoagulants (DOACs); and (3) use of cognitive behavioral therapy as first-line treatment for insomnia before pharmacologic treatment. We describe the design and methods for a harmonized series of cluster-randomized control trials comparing two implementation strategies. METHODS: For each trial, we will recruit 8-12 clinics (24-36 total). All will have access to relevant clinical data to identify patients who may benefit from the target EBP at that clinic and provider. For each trial, clinics will be randomized to one of two implementation strategies to improve the use of the EBPs: (1) individual-level academic detailing (AD) or (2) AD plus the team-based Learn. Engage. Act. PROCESS: (LEAP) quality improvement (QI) learning program. The primary outcomes will be operationalized across the three trials as a patient-level dichotomous response (yes/no) indicating patients with potentially inappropriate medications (PIMs) among those who may benefit from the EBP. This outcome will be computed using month-by-month administrative data. Primary comparison between the two implementation strategies will be analyzed using generalized estimating equations (GEE) with clinic-level monthly (13 to 36 months) percent of PIMs as the dependent variable. Primary comparative endpoint will be at 18 months post-baseline. Each trial will also be analyzed independently. DISCUSSION: MIDAS QUERI trials will focus on fostering sustained use of EBPs that previously had targeted but incomplete implementation. Our implementation approaches are designed to engage frontline clinicians in a dynamic optimization process that integrates the use of actional clinical data and making incremental changes, designed to be feasible within busy clinical settings. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05065502 . Registered October 4, 2021-retrospectively registered.

Prevalence of insomnia disorder and sleep apnea in a sample of veterans at risk for cardiovascular disease.

STUDY OBJECTIVES: The objectives of this study were to examine the proportion of study participants screening positive for insomnia disorder and/or sleep apnea in veterans engaged in routine health care and known to be at risk for cardiovascular disease and to compare these proportions with those previously documented in medical records. METHODS: This was a cross-sectional analysis of baseline data from a randomized clinical intervention trial for patients at risk of cardiovascular disease and a review of study participants' medical records. Participants were veterans ≥ 40 years of age, enrolled in Veterans Affairs primary care, and diagnosed with hypertension and/or hypercholesterolemia. Self-report outcomes were the proportion of patients screening positive for an insomnia disorder and sleep apnea, self-reporting a sleep apnea diagnosis, and endorsing undertreated sleep apnea. Medical record outcomes were the proportion of patients diagnosed with insomnia and sleep apnea. RESULTS: Participants (n = 420) were veterans (84.8% male) with a mean age of 61.1 years. More than half of the sample (52.1%) screened positive for sleep apnea without prior self-reported diagnosis. More than one-third of the sample (39%) screened positive for an insomnia disorder. Medical records revealed considerably lower rates, with 3.8% diagnosed with insomnia, 20.5% diagnosed with sleep apnea, and about 1% diagnosed with both conditions. CONCLUSIONS: Undiagnosed and undertreated sleep disorders are common among veterans at risk for cardiovascular disease. Most of the sample (82%) screened positive for, or met, study criteria for sleep apnea or an insomnia disorder. Limitations include the use of self-reported sleep apnea treatment adherence, an insomnia disorder diagnosis based on questionnaire score, and a sample comprised primarily of male veterans. Routine sleep disorders screening in veterans at risk for cardiovascular disease could help to identify those at even greater risk because of the adverse effects of undiagnosed or undertreated sleep disorders. CLINICAL TRIAL REGISTRATION: Registry; ClinicalTrials.gov; Name: Cardiovascular Intervention Improvement Telemedicine Study; URL: https://clinicaltrials.gov/ct2/show/NCT01142908; Identifier: NCT01142908.