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

ABSTRACT

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.

In this secondary data analysis, we examined improvements in insomnia severity, suicidal ideation (SI), and suicide risk correlates in veterans with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) examining an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I). Veterans in the iCBT-I group experienced greater improvements in insomnia severity and hopelessness than veterans in the Insomnia Education Website control. Although between-group differences in SI and other suicide risk correlates were not statistically significant, effect sizes suggest that SI and symptoms of depression, irritability, concentration, post-traumatic stress disorder, and hostility may improve following iCBT-I intervention. These results suggest that digital and iCBT-I interventions may be especially powerful tools for use in suicide prevention among veterans but highlight the critical need for additional large-scale studies to examine suicide-specific mechanisms and outcomes to guide implementation efforts.