Background: Cognitive behavioral therapy for insomnia (CBT-I) is an evidence-based psychotherapy that rapidly produces large improvements in sleep. Guidelines for management of chronic insomnia recommend that all patients receive CBT-I as the initial treatment, however, CBT-I is not routinely offered to patients. Instead, most patients are prescribed sedative-hypnotics that have adverse cognitive and behavioral effects. Evidence is needed to determine if proactive population-based outreach using social marketing strategies and providing patients with self-management CBT-I tools can improve care by simultaneously increasing the uptake of CBT-I and decreasing sedative-hypnotic use. Significance/Impact: Insomnia is a debilitating sleep disorder that disproportionally effects Veterans and is increasingly recognized as an urgent post-deployment health concern. The proposed pilot work supports a low- cost proactive population-level approach that, if proven effective, has great potential for transforming insomnia care. This work is directly responsive to the HSR&D priority area of Mental Health/PTSD, Women?s Health, Aging and Opioid/Pain by targeting outreach to these populations. The proposed work advances the HSR&D priority domain of Virtual Care/Telehealth by providing Veterans with self-management CBT-I tools to eliminate access barriers. Innovation: Proactive population-based outreach to improve insomnia care is an innovative and previously unexplored approach to rapidly and inexpensively promoting CBT-I uptake across diverse healthcare facilities for Veterans in need of safe and effective insomnia treatment. A second major innovation of this pilot work is incorporating self-management CBT-I tools into the direct-to-consumer marketing campaign, helping to shift the dominant clinical practice paradigm away from resource-intensive and inconvenient face-to-face therapy.
Specific Aims : We propose critical pilot work for a national randomized trial to compare the effect of a CBT-I marketing campaign with self-management tools to standard provider-delivered CBT-I.
Aim 1 : To develop compelling messages and appropriate channels for a CBT-I social marketing campaign using preferences and perspectives from key segments of the target audience.
Aim 2 : To determine patient preferences for self- management CBT-I tools included in the campaign.
Aim 3 :To obtain provider perspectives on eliminating barriers to CBT-I uptake through use of patient education and provision of self-management tools. Methodology: Social marketing methods will be used to create high-impact materials with compelling messages. We will refine materials using qualitative data collected from Veteran focus groups, with a focus on women Veterans, older Veterans and Veterans with chronic pain since these groups are at increased risk from sedative-hypnotics use. A patient engagement panel will be actively involved throughout the project to enhance research protocols, interpretation of findings and dissemination of findings. We will complete other preparatory work for the future trial, including conducting a focused needs assessment with primary care providers at potential future site locations. Next Steps/Implementation: This work allows us to be well-positioned for immediate launch of the future, large trial to evaluate the benefits of proactive outreach with self-management CBT-I tools. To facilitate multi- level engagement of stakeholders, we will disseminate findings online and in-person to providers and Veteran groups, utilizing recommendations from the Veteran Engagement Group, the Women?s Health Research Network, and our operational partners within the Office of Mental Health and Suicide Prevention.
This project addresses a critical gap in insomnia care. Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective and safe treatment for improving sleep outcomes yet is severely underutilized among Veterans. Proactive outreach to educate Veterans about CBT-I and provide CBT-I self-management tools is a promising approach to improving insomnia care by both increasing the use of CBT-I and decreasing high-risk medication use. Through the development and testing of a social marketing campaign to educate Veterans about CBT-I and to provide self-management tools, this work will prepare for a future multisite randomized trial to determine the effects of proactive outreach with self-management tools on sleep outcomes and use of CBT-I. If proven effective, this rapid and low-cost proactive outreach has great potential for transforming insomnia care in VA and the nation through increased used of CBT-I and reduction of harms associated with medication.
