Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans

Abstract

ImportanceThree of 4 adults in treatment for alcohol use disorder (AUD) report symptoms of insomnia. Yet the first-line treatment for insomnia (cognitive behavioral therapy for insomnia, CBT-I) is often delayed until abstinence is established.ObjectiveTo test the feasibility, acceptability, and preliminary efficacy of CBT-I among veterans early in their AUD treatment and to examine improvement in insomnia as a mechanism for improvement in alcohol use outcomes.Design, Setting, and ParticipantsFor this randomized clinical trial, participants were recruited through the Addictions Treatment Program at a Veterans Health Administration hospital between 2019 and 2022. Patients in treatment for AUD were eligible if they met criteria for insomnia disorder and reported alcohol use in the past 2 months at baseline. Follow-up visits occurred posttreatment and at 6 weeks.InterventionsParticipants were randomly assigned to receive 5 weekly sessions of CBT-I or a single session about sleep hygiene (control). Participants were asked to complete sleep diaries for 7 days at each assessment.Main Outcomes and MeasuresPrimary outcomes included posttreatment insomnia severity (assessed using the Insomnia Severity Index) and follow-up frequency of any drinking and heavy drinking (4 drinks for women, ≥5 drinks for men; number of days via Timeline Followback) and alcohol-related problems (Short Inventory of Problems). Posttreatment insomnia severity was tested as a mediator of CBT-I effects on alcohol use outcomes at the 6-week follow-up.ResultsThe study cohort included 67 veterans with a mean (SD) age of 46.3 years (11.8); 61 (91%) were male and 6 (9%) female. The CBT-I group included 32 participants, and the sleep hygiene control group 35 participants. Of those randomized, 59 (88%) provided posttreatment or follow-up data (31 CBT-I, 28 sleep hygiene). Relative to sleep hygiene, CBT-I participants reported greater decreases in insomnia severity at posttreatment (group × time interaction: −3.70; 95% CI, −6.79 to −0.61) and follow-up (−3.34; 95% CI, −6.46 to −0.23) and greater improvements in sleep efficiency (posttreatment, 8.31; 95% CI, 1.35 to 15.26; follow-up, 18.03; 95% CI, 10.46 to 25.60). They also reported greater decreases in alcohol problems at follow-up (group × time interaction: −0.84; 95% CI, −1.66 to −0.02), and this effect was mediated by posttreatment change in insomnia severity. No group differences emerged for abstinence or heavy-drinking frequency.Conclusions and RelevanceIn this randomized clinical trial, CBT-I outperformed sleep hygiene in reducing insomnia symptoms and alcohol-related problems over time but had no effect on frequency of heavy drinking. CBT-I should be considered a first-line treatment for insomnia, regardless of abstinence.Trial RegistrationClinicalTrials.gov Identifier: NCT03806491

Do sleep and circadian characteristics predict alcohol use in adult drinkers?

“…Multiple studies have demonstrated that treatments for insomnia, particularly cognitive‐behavioral therapy for insomnia (CBT‐I), improve insomnia symptoms but do not differentially impact drinking behavior relative to control conditions (reviewed in Miller et al., 2017; also Chakravorty et al., 2019). However, some studies suggest that CBT‐I may reduce alcohol‐related problems (Miller et al., 2023; Miller, Deroche, et al., 2021) and one study found reductions in alcohol craving in the group treated with CBT‐I that were statistically mediated by reductions in insomnia symptoms (Miller, Freeman, et al., 2021).…”

Error in Text

“…In the Original Investigation titled “Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial,” published online on June 21, 2023, and in the September 2023 issue, there was an error in the description of the Short Inventory of Problems (SIP) measure. As a result of a survey programming error, all scores for the SIP were based on 13 (not 15) items.…”