Pain in your day? Get sleep treatment anyway! The role of pain in insomnia treatment efficacy in women veterans.

Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder treatment benefit. Prior research has not addressed how pain impacts the effects of behavioural insomnia treatment in United States women veterans. Using data from a comparative effectiveness clinical trial of two insomnia behavioural treatments (both including sleep restriction, stimulus control, and sleep hygiene education), we examined the impact of pain severity and pain interference on sleep improvements from baseline to post-treatment and 3-month follow-up. We found no significant moderation effects of pain severity or interference in the relationship between treatment phase and sleep outcomes. Findings highlight opportunities for using behavioural sleep interventions in patients, particularly women veterans, with comorbid pain and insomnia, and highlight areas for future research.

Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans.

PURPOSE: Sleep-disordered breathing (SDB) is a common sleep disorder in veterans; however, limited research exists in women veterans. We sought to estimate patterns of care in terms of evaluation, diagnosis, and treatment among women veterans with factors associated with elevated SDB risk. METHODS: Within one VA healthcare system, women identified through electronic health record data as having one or more factors (e.g., age >50 years, hypertension) associated with SDB, completed telephone screening in preparation for an SDB treatment study and answered questions about prior care related to SDB diagnosis and treatment. RESULTS: Of 319 women, 111 (35%) reported having completed a diagnostic sleep study in the past, of whom 48 (43%) were diagnosed with SDB. Women who completed a diagnostic study were more likely to have hypertension or obesity. Those who were diagnosed with SDB based on the sleep study were more likely to have hypertension, diabetes, or be ≥50 years old. Of the 40 women who received treatment, 37 (93%) received positive airway pressure therapy. Only 9 (24%) had used positive airway pressure therapy in the prior week. Few women received other treatments such as oral appliances or surgery. CONCLUSIONS: Findings support the need for increased attention to identification and management of SDB in women veterans, especially those with conditions associated with elevated SDB risk.

Values Expressed by Women Veterans Receiving Treatment for Chronic Insomnia Disorder.

OBJECTIVES: Insomnia may contribute to fewer value-consistent choices and less engagement in meaningful life activities. We sought to identify values commonly expressed by women veterans engaged in a trial testing psychological treatment of insomnia disorder. METHODS: Seventy-four women veterans (mean age = 48.3 [±13] years), meeting DSM-5 diagnostic criteria for insomnia disorder received an acceptance-based behavioral treatment for insomnia. In the first session, participants responded to questions regarding personal values and the impact of insomnia on those values. Responses were categorized into values domains informed by the Bull's Eye Values survey (level 1 categories) and the Valued Living Questionnaire (level 2 categories). RESULTS: Raters reached 100% agreement after independent coding and adjudication. Level 1 value categories in frequency order were: relationships (n = 68), personal care/health (n = 51), work/education (n = 46), pets (n = 12), and leisure (n = 5). The most frequently reported level 2 value categories were: family (other than marriage/parenting; n = 50), parenting (n = 31), work (n = 31), physical health (n = 30), and spirituality (n = 19). The level 1 value categories impacted by insomnia in frequency order were: personal care/health (n = 65), relationships (n = 58), work/education (n = 46), pets (n = 12), and leisure (n = 5). CONCLUSIONS: Women veterans undergoing insomnia treatment highly value relationships and personal care/health, which should be considered patient-centered outcomes of insomnia treatments. CLINICAL TRIALS REGISTRATION: NCT02076165.

Sleep Disruption Due to Stress in Women Veterans: A Comparison between Caregivers and Noncaregivers.

Objective/Background: Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role. Participants: Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age = 51.7 ± 15.9 years). Two hundred forty three (17%) respondents (mean age 53.8 ± 12.7 years) were caregivers for an adult, predominantly for a parent, providing transportation. Methods: The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information. Results: In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, p = .001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (ß = 3.9, p = .031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors. Conclusions: Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.

Insomnia Precipitating Events among Women Veterans: The Impact of Traumatic and Nontraumatic Events on Sleep and Mental Health Symptoms.

OBJECTIVE/BACKGROUND: The current study describes insomnia precipitating events reported by women Veterans and examines differences in sleep and psychological distress variables in those who endorsed traumatic, nontraumatic, or no insomnia precipitating events. PARTICIPANTS: Baseline data were collected from 347 women Veterans enrolled in a behavioral sleep intervention study (NCT02076165). METHODS: Participants completed self-report measures of insomnia symptoms, sleep quality, sleep efficiency (SE), nightmare frequency, and depression and posttraumatic stress disorder (PTSD) symptoms; SE was also assessed by wrist actigraphy. Participants responded to 2 open-ended questions assessing stressful life events and health changes that coincided with insomnia symptom onset. Responses were coded as traumatic, nontraumatic, and no events. Analyses of covariance examined the effect of insomnia precipitating event type on sleep and psychological symptom variables after controlling for sociodemographic factors. RESULTS: Overall, 25.80% of participants endorsed traumatic events, 65.80% endorsed only nontraumatic events, and 8.41% endorsed no events. Participants who endorsed traumatic events reported more severe insomnia (p = .003), PTSD (p = .001), and depression symptoms (p = .012), and poorer quality of sleep (p = .042) than participants who endorsed no events. Participants who endorsed traumatic events reported more severe PTSD symptoms (p = .004), a longer duration of sleep problems (p = .001), and poorer quality of sleep (p = .039) than participants who endorsed nontraumatic events. Participants who endorsed nontraumatic events reported more severe insomnia (p = .029) and PTSD (p = .049) symptoms than participants who endorsed no events. CONCLUSIONS: Trauma as a precipitant for insomnia may be related to higher symptom severity in women Veterans. Implications for treatment engagement and effectiveness remain unstudied.

The Development of Video Messages to Reduce Binge Drinking: Focus Group Results.

AIMS: The current study examined college students' perceptions of loss framed and gain framed messages aimed at reducing binge drinking. METHODS: Using focus groups (n = 3) consisting of undergraduates (n = 131), an iterative process was undertaken to ensure the acceptability and construct validity of loss framed and gain framed video messages. Both quantitative and qualitative data were collected. RESULTS: Results across all focus groups demonstrated that each message condition possessed strong construct validity. Participants in focus Group 3 rated messages as moderately to highly acceptable and acceptability ratings across loss framed messages and gain framed messages were comparable. CONCLUSIONS: These findings demonstrate the importance of focus group testing in the development of brief alcohol interventions among college students. Messages used in the currents study will be included in a video intervention aimed at reducing binge drinking among college students.

The effectiveness of cognitive behavioral therapy for insomnia on sleep outcomes in the context of pain among older adult veterans.

BACKGROUND: Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard treatment for insomnia disorder in adults. Compared to young adults, older adults have increased risk for the development of conditions associated with chronic pain, which may impact the efficacy of CBT-I in improving insomnia symptoms in older adults. This study evaluated the effect of participant-rated pain on sleep-related outcomes of a supervised, non-clinician administered CBT-I program in older adult patients with chronic insomnia disorder. METHODS: Secondary analysis was conducted using data from a randomized controlled trial among 106 community-dwelling older adult veterans (N = 106; mean age 72.1 years, 96% male, 78.3% White, 6.6% Hispanic, 5.7% African American) with chronic (≥3 months) insomnia disorder. Participants engaged in five sessions of manual-based CBT-I in individual or group format within one Department of Veterans Affairs healthcare system, provided by non-clinician "sleep coaches" who had weekly telephone supervision by behavioral sleep medicine specialists. Insomnia symptoms (Insomnia Severity Index), perceived sleep quality (Pittsburgh Sleep Quality Index), fatigue (Flinder's Fatigue Scale), daytime sleepiness (Epworth Sleepiness Scale), and perceived pain severity (items from the Geriatric Pain Measure) were assessed at 4 time points: baseline, one-week posttreatment, 6-month follow-up, and 12-month follow-up. Mixed effects models with time invariant and time varying predictors were employed for analyses. RESULTS: CBT-I improved insomnia symptoms, perceived sleep quality, fatigue, and daytime sleepiness among older veterans with chronic insomnia. Participant-reported pain was associated with greater improvements in insomnia symptoms following CBT-I. Pain did not affect improvements in other sleep-related outcomes (-0.38 ≤ b ≤ 0.07, p > 0.05). Between-subjects differences in pain, but not within-subject changes in pain over time, appeared to play a central role in insomnia symptom improvement at posttreatment, with individuals with higher-than-average pain showing greater insomnia symptom improvement (ISI score reduction; -0.32 ≤ b ≤ -0.28, p ≤ 0.005). CONCLUSIONS: Pain did not meaningfully hinder the effects of CBT-I on sleep outcomes. Among older veterans with chronic insomnia disorder, individuals with higher pain exhibited slightly greater improvement in insomnia than those with lower levels of pain. These findings suggest that experiencing pain does not impair treatment response and should not preclude older adults with insomnia from being offered CBT-I.

Contribution of post-trauma insomnia to depression and posttraumatic stress disorder in women service members: findings from the Millennium Cohort Study.

STUDY OBJECTIVES: We examined whether women service members and veterans who reported recent combat and/or sexual trauma experiences had a greater risk of insomnia compared with women who did not report these recent experiences, and whether insomnia would be associated with a greater risk of mental health outcomes. METHODS: We analyzed two waves of survey data (2011-2013, Time 1 [T1] and 2014-2016, Time 2 [T2]) from 26 443 current and former women service members from the Millennium Cohort Study. We assessed recent traumas in the past 3 years, and probable insomnia at T1 and probable post-traumatic stress disorder (PTSD) and depression at T2. A longitudinal mediation model was used to quantify separate indirect effects of recent traumas on mental health outcomes through probable insomnia. RESULTS: Women who had experienced recent sexual assault (odds ratio [OR] = 1.68; 95% CI = 1.24-2.10), sexual harassment (OR = 1.22; 95% CI = 1.05-1.41), and combat (OR = 1.34; 95% CI = 1.20-1.49) at T1 had a greater risk of probable insomnia at T1 compared with women who had not recently experienced these events. Probable insomnia at T1, in turn, was associated with probable depression (OR = 2.66; 95% CI = 2.31-3.06) and PTSD (OR = 2.57; 95% CI = 2.27-2.90) at T2. Recent combat experience did not moderate the associations of recent sexual trauma with insomnia or mental health outcomes. CONCLUSIONS: Insomnia contributes to the risk of subsequent mental health conditions following trauma. The diagnosis and treatment of post-trauma insomnia should be prioritized to mitigate the development of posttraumatic mental health conditions.

A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes.

OBJECTIVE: Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBTI) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined. METHODS: Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up. RESULTS: At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen's d = 0.41-0.67) and pain interference (p < .001, Cohen's d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen's d = 0.59). CONCLUSION: CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.

Novel treatment based on acceptance and commitment therapy versus cognitive behavioral therapy for insomnia: A randomized comparative effectiveness trial in women veterans.

OBJECTIVE: This randomized comparative effectiveness trial evaluated a novel insomnia treatment using acceptance and commitment therapy (ACT) among women veterans. Participants received either the acceptance and the behavioral changes to treat insomnia (ABC-I) or cognitive behavioral therapy for insomnia (CBT-I). The primary objectives were to determine whether ABC-I was noninferior to CBT-I in improving sleep and to test whether ABC-I resulted in higher treatment completion and adherence versus CBT-I. METHOD: One hundred forty-nine women veterans with insomnia disorder (Mage = 48.0 years) received ABC-I or CBT-I. The main sleep outcomes were Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and sleep efficiency (SE) by actigraphy (objective) and sleep diary (subjective). Measures were collected at baseline, immediate posttreatment, and 3-month posttreatment follow-up. Treatment completion and adherence were assessed during the interventions. RESULTS: Both interventions improved all sleep outcomes from baseline to immediate posttreatment and 3-month posttreatment follow-up. At immediate posttreatment, ABC-I was statically noninferior for sleep diary SE and objective SE, but noninferiority was not statistically confirmed for ISI or PSQI total scores. At 3-month posttreatment follow-up, ABC-I was noninferior for all four of the key outcome variables. There was not a statistically significant difference between the number of participants who discontinued CBT-I (11%) versus ABC-I (18%; p = .248) before completing treatment. ABC-I was superior to CBT-I for some adherence metrics. CONCLUSIONS: Overall, ABC-I was similar in effectiveness compared to CBT-I for the treatment of insomnia and may improve adherence to some behavioral elements of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Benefits of Cognitive Behavioral Therapy for Insomnia for Women Veterans with and without Probable Post-Traumatic Stress Disorder.

OBJECTIVE: This study compared the benefits of cognitive-behavioral therapy for insomnia for sleep, mental health symptoms, and quality of life (QoL) in a sample of women veterans with and without probable post-traumatic stress disorder (PTSD) comorbid with insomnia disorder. METHODS: Seventy-three women veterans (30 with probable PTSD) received a manual-based 5-week cognitive-behavioral therapy for insomnia treatment as part of a behavioral sleep intervention study. Measures were completed at baseline, post-treatment, and 3-month follow-up. Sleep measures included the Insomnia Severity Index, Pittsburgh Sleep Quality Index, sleep efficiency measured by actigraphy, and sleep efficiency and total sleep time measured by sleep diary. Mental health measures included the PTSD Checklist-5, nightmares per week, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 scale. QoL was measured with the Short Form-12. Linear mixed models compared changes over time across groups. Independent t tests examined PTSD symptom changes in women veterans with probable PTSD. RESULTS: Both groups demonstrated improvements across sleep (ps < .001-.040), mental health symptoms (ps < .001), and QoL measures (ps < .001). The probable PTSD group reported greater improvements in diary sleep efficiency (p = .046) and nightmares per week (p = .001) at post-treatment and in total sleep time (p = .029) and nightmares per week (p = .006) at follow-up. Most participants with probable PTSD experienced clinically significant reductions in PTSD symptoms at post-treatment (66.7%) and follow-up (60.0%). Significant reductions in intrusive and arousal/reactivity symptoms were maintained at follow-up. CONCLUSIONS: Cognitive-behavioral therapy for insomnia improves insomnia, mental health symptoms, and QoL among women veterans, with greater improvement in those with probable PTSD.

What Drives Women Veterans' Trust in VA Healthcare Providers?

INTRODUCTION: Little is known about women veterans' trust in Veterans Affairs (VA) health care and what factors promote trust in VA providers. We examined provider behaviors and characteristics of women veterans associated with trust in their VA providers. METHODS: We used a 2015 survey of women veterans who were routine users of primary care at 12 VA medical centers (n = 1,395). Patient trust in their VA provider was measured on a seven-item scale. We used multiple logistic regression to examine associations of patient-provider communication and gender appropriateness with complete trust in VA provider (100 [complete trust] vs. <100 [less than complete trust]), controlling for patient characteristics. RESULTS: On average, 39.7% of women veterans reported complete trust in their VA providers. Those with complete trust reported greater patient-provider communication and gender appropriateness of VA services than those with less-than-complete trust (all ps ≤ .001). In multiple logistic regression models, higher ratings of provider communication (adjusted odds ratio, 2.37), gender-appropriate care (adjusted odds ratio, 1.93), and trauma-sensitive communication (adjusted odds ratios, 1.79-6.08) were associated with a higher likelihood of reporting complete trust in their VA provider. CONCLUSIONS: Women veterans reported high levels of trust in their VA providers. Provider communication, gender-appropriate care, and trauma-sensitive communication were associated with greater patient trust. Although it is important to highlight the steps already taken by VA to increase the quality of care for women veterans, current findings suggest that women veterans' trust may be further increased by interventions to improve trauma-informed care by VA providers.

Sexual Victimization and Benefit Expectations of Risky Behavior Among Female College Students.

Sexual victimization has been shown to positively relate to both engagement in risky behavior and subsequent sexual victimization. Research has focused on the degree to which women consider the risks or costs of engaging in risky behaviors. The purpose of the current study was to examine the degree to which women weigh the costs and benefits of engaging in risky behaviors. Using self-report data from 113 female undergraduates, two separate hierarchical regression analyses were performed to examine the contributions of number of sexual victimization experiences, emotion dysregulation, cost expectations of risky behavior, and benefit expectations of risky behavior to latency to exit a risk perception vignette involving a stranger and frequency of engagement in risky behavior. Regression analyses revealed that the full set of predictors accounted for 13% of the variance in latency to exit the risk perception vignette involving a stranger, with emotion dysregulation and benefit expectations making significant and independent contributions. Regression analyses revealed that the same set of predictors accounted for 34% of the variance in frequency of engagement in risky behavior, with number of sexual victimization experiences and benefit expectations making significant and independent contributions. The current findings suggest that sexual victimization risk may be influenced by perceived benefits of risky behavior. Implications of the current findings will be discussed in the context of sexual victimization risk reduction.