Sleep disturbance is one of the most common complaints among recently deployed Veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn (hereinafter RD Veterans). Research suggests that up to sixty percent return from deployment with insomnia; further complicating the difficult process of re-integration into civilian society. Sleep disturbance is associated with a range of health conditions, including obesity, metabolic syndrome, Type 2 diabetes mellitus, and all-cause mortality. Insomnia is also associated with a range of mental health conditions, including those which are prevalent in RD veterans; such as PTSD and depression. Cognitive-Behavioral Therapy for Insomnia has demonstrated efficacy for improving sleep in those with both primary insomnia, and insomnia that is comorbid with both medical and mental health conditions. Healthcare costs associated with insomnia, which are estimated to be in the billions of US dollars annually, are largely associated with the increased risk of various psychiatric and medical conditions. In spite of the prevalence of sleep disturbance in RD Veterans, VA behavioral resources for addressing insomnia are very limited. Efforts are underway to increase access to behavioral treatment of insomnia by training mental health providers to provide Cognitive-Behavioral Therapy for Insomnia (CBTI). However, when considering the combined needs of RD Veterans and those serving in earlier services eras, treatment resources will remain limited. Thus, innovative treatment approaches are imminently needed to address these concerns and impede the adverse health consequences of untreated sleep disturbance. A stepped model of care may be a cost-effective method for achieving these objectives. By first addressing the needs of those who are receptive and responsive to entry level self-management approaches, higher level, clinic-based resources can be reserved for those whose symptoms require the attention of an individual health care provider. The proposed research involves designing a stepped care model for insomnia treatment in RD Veterans that can be readily integrated with existing VA clinical services. The model involves an entry level self-management intervention, a secondary group intervention, and individual therapy as the tertiary level. Projects are proposed to accomplish three primary objectives: 1) Obtain patient and provider perspectives and preferences for insomnia treatment; 2) Evaluate the feasibility of implementing a stepped care model for insomnia treatment; and 3) Write, submit, and revise an IIR grant application to assess the effectiveness of a stepped care model for insomnia treatment in recently deployed Veterans. In preliminary projects, survey research will be used to examine VA provider perspectives nationwide, and focus groups will be used to explore emerging themes in greater depth. Patient focus groups will be used to obtain treatment preferences and perspectives on the proposed model of care. Preliminary project findings will be used to inform the design of a study evaluating the feasibility and acceptability of a stepped care model. Feasibility study findings will be used to prepare a Merit Review application to evaluate the effectiveness of the treatment model. With our increasing knowledge of the role of sleep disturbance in the development of mental health and chronic disease conditions, we have an opportunity with our younger Veteran population to impede the development of many conditions which have plagued our older Veterans. Although the VA is training mental health providers in CBTI, health care resources to address insomnia will continue to be limited. With limited clinical services readily available to address these concerns, self-management interventions could be an important element of treatment that may also hasten the reduction of long-term risks of insomnia. A stepped care approach which includes an entry level self-management intervention will maximize our limited VA sleep specialty resources.

Public Health Relevance

Sleep disturbance is one of the most common complaints among recently deployed Veterans. Research suggests that as much as sixty percent of Veterans of recent conflicts return from deployment with insomnia, further complicating the difficult process of re-integration into civilia society. Insomnia is associated with a range of mental and physical health conditions that are common among recently deployed Veterans. However, VA resources for addressing insomnia using empirically supported non-pharmacological therapies are limited. Thus, innovative treatment approaches are needed to increase access to behavioral sleep medicine among recently deployed Veterans. The proposed research projects and training activities will result in an empirically- derived stepped care model for insomnia treatment in recently deployed Veterans, and will prepare me to conduct independent research on insomnia in Veterans, with specific foci on increasing access to cognitive- behavioral treatment and examining health-related correlates.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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HSR&D Career Development Award (CDA0)
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Durham VA Medical Center
United States
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Hughes, Jaime M; Ulmer, Christi S; Gierisch, Jennifer M et al. (2018) Insomnia in United States military veterans: An integrated theoretical model. Clin Psychol Rev 59:118-125
Rissling, Michelle B; Dennis, Paul A; Watkins, Lana L et al. (2016) Circadian Contrasts in Heart Rate Variability Associated With Posttraumatic Stress Disorder Symptoms in a Young Adult Cohort. J Trauma Stress 29:415-421
Ulmer, Christi S; Bosworth, Hayden B; Germain, Anne et al. (2015) Associations between sleep difficulties and risk factors for cardiovascular disease in veterans and active duty military personnel of the Iraq and Afghanistan conflicts. J Behav Med 38:544-55