How effectively does CBT-I address the traumatic and functional causes of insomnia and sleep disturbance in Veterans?

Abstract

LAY SUMMARY Cognitive-behavioural therapy for insomnia (CBT-I) continues to be recommended as the first-line treatment for an increasing number of Veterans seeking help for insomnia. Unfortunately, these recommendations are made on the basis of evidence from the general public, who do not experience the same predisposing, activating, and maintaining causes of insomnia as Veterans. This review considers whether CBT-I really addresses the causes of insomnia among Veterans, which can be labelled as functional (e.g., caffeine use) and traumatic (e.g., nightmares). Nine randomized controlled trials of CBT-I delivered to Veterans having trouble falling or staying asleep were reviewed. Evidence was not consistent enough to support the continued recommendation of CBT-I as a first-line treatment for insomnia among Veterans. On a wider level, the authors question whether psychological causes of a mental health problem are always, or should be, fully considered in the process of creating clinical guidelines for treatment.

Posttraumatic sleep disturbances in veterans: A pilot randomized controlled trial of cognitive behavioral therapy for insomnia and imagery rehearsal therapy

“…Accordingly, this study evaluated outcomes for CBT‐I + IRT compared to CBT‐I alone for ex‐serving Australian Defence Force (ADF) personnel, in the context of PTSD and OSA risk. It was predicted that CBT‐I + IRT would lead to greater reductions in sleep disturbances than CBT‐I alone, as CBT‐I alone may not be able to address the functional and traumatic maintaining causes of insomnia in veteran populations (Rigley et al, 2022). This study used an IRT protocol with minimal exposure to nightmare content (Krakow & Zadra, 2006), in line with some uncontrolled studies that have reported improved outcomes for veterans (Nappi et al, 2010).…”

Veteran treatment completers’ and facilitators’ perceptions of cognitive behavioral therapy for insomnia and imagery rehearsal therapy for posttraumatic sleep disturbances.

“…Different IRT protocols have been evaluated and they vary in their level of exposure to nightmare content, which may impact treatment tolerability for posttraumatic sleep disturbances (Harb et al, 2013). Additionally, a recent review argued that CBT-I may not be able to address the maintaining causes of sleep disturbances in veterans, including traumatic factors (e.g., hypervigilance and nightmares; Rigley et al, 2022).…”