Insomnia is a critical obstacle to the rehabilitation and recovery of Veterans with psychotic disorders. The VHA has made treatment of insomnia a high priority and has initiated a nationwide dissemination of Cognitive Behavioral Therapy for Insomnia (CBT-I) - an evidence-based practice and the first-line standard of care for insomnia - across the VHA system, but it is largely not provided to Veterans with psychosis and insomnia. This study involves developing empirically-derived guidelines for the clinical tailoring of CBT-I for Veterans with psychosis and insomnia, and testing the acceptability, feasibility, and preliminary efficacy of CBT-I for improving sleep-related functional outcomes. This work will yield a well- specified behavioral intervention that has the potential to improve not only sleep but also physical health functioning more broadly. Insomnia is highly prevalent among individuals with psychotic disorders and confers significant long-term negative impacts on their physical, emotional, psychosocial, and cognitive recovery. Many behaviors that contribute to insomnia (e.g., poor diet, exercise, substance use, and smoking) are associated with harmful medical conditions that are highly prevalent among Veterans with psychosis (e.g., obesity, cardiovascular disease, obstructive sleep apnea). Improving sleep may improve these medical conditions, yet Veterans with psychosis are largely not provided with CBT-I, the current gold standard treatment for insomnia. The proposed research will develop guidelines for the clinical tailoring of CBT-I for Veterans with psychotic disorders and study the preliminary feasibility, acceptability, and utility of the resulting progra in improving sleep and associated functional outcomes. The first step of this research will involve an iterative process of review of the extant literature, analysis and integration of information on sleep problems gathered through pilot work, and input from Veteran clients, expert consultants, mentors, and VA treatment providers to develop guidelines and materials for the clinical tailoring of CBT-I for Veterans with psychotic disorders. Using qualitative procedures we will complete an initial acceptability trial of CBT-I with six Veterans with psychosis and insomnia for further refinements of the guidelines. Finally, the proposed study will use a small randomized controlled feasibility and preliminary efficacy trial comparing CBT-I (n=30) to a Health and Wellness control intervention (n=30) to assess rates of recruitment, initial intervention engagement, attendance at intervention sessions, and therapist fidelity. Outcomes include insomnia symptoms and functioning (e.g., health-related quality of life, physical functioning, role limitations, life activities, social interactions, participation in society, and cognitive functioning). We will explore whether baseline clinical and sleep characteristics, physical comorbidities, and other health behaviors (e.g., smoking, caffeine use, physical activity) moderate the impact of CBT-I on insomnia and functional outcomes, improve as a result of participation in CBT-I, or mediate the effect of CBT-I on functioning. In addition, we will assess the durability of effects of CBT-I on insomnia symptoms and functioning at a 3 month follow-up visit. This project will include developing educational materials and guidelines for the clinical use of the CBT-I protocol, conducting an open trial of CBT-I in a small sample, and completing an RCT with 60 participants. We will monitor fidelity, feasibility, and acceptability; study Veterans' experiences; measure symptom and functional outcomes at post-treatment and 3-month follow-up; and evaluate potential moderators and mediators.
Insomnia is a highly prevalent problem for Veterans with psychotic disorders that is linked to significant distress and poor functioning, and represents a critical obstacle to rehabilitation and recovery. This study aims to develop guidelines and materials to assist providers in clinically tailoring the gold standard intervention for insomnia - Cognitive Behavioral Therapy for Insomnia (CBT-I) - so that it meets the unique needs of Veterans with psychosis and can be optimally effective for those with psychosis and insomnia. Results from this study will inform us as to whether CBT-I is feasible to implement, acceptable to Veterans, and effective in improving sleep and functional outcomes.
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