Skip to main content
SpringerLink
Log in

Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder

  • Psychiatrics • Original Article
  • Published:
Sleep and Breathing Aims and scope Submit manuscript

Abstract

Background

Insomnia is a well-recognized co-morbid condition in veterans with post-traumatic stress disorder (PTSD) with negative personal and social consequences. Cognitive behavioral therapy (CBT) is considered an efficacious treatment, yet little attention has been devoted to treatment response in this population. The aim of this study was to identify factors that may predict clinical response to CBT for insomnia (CBT-I) in veterans with PTSD.

Methods

A retrospective chart review of 136 veterans with PTSD-related insomnia was conducted. Epworth Sleepiness Score (ESS), PTSD Checklist (PCL), and Insomnia Severity Index (ISI) were assessed at baseline. We converted prescribed antidepressant and hypnotic dosages before and after CBT-I to dose equivalent of fluoxetine diazepam, respectively. A 6-point reduction or greater in ISI scores at 6-month follow-up visit was defined as CBT-I responsiveness.

Results

CBT-I responsiveness was observed in 47% of veterans with PTSD. Seventy-seven percent completed treatment. Lack of perceived benefit was the most given reason for failure to return for follow-up. In contrast to hypnotics, antidepressants usage decreased in those who had experienced benefit from CBT-I (p = 0.001). Younger age, non-white race, and use of hypnotics prior to behavioral therapy were independently associated with lack of response to CBT-I.

Conclusions

While CBT-I ameliorates insomnia in veterans with PTSD, the use of hypnotics prior to instituting behavioral therapy may negatively affect the response rate to CBT-I. Future studies should examine whether racial and cultural influences on the generation of insomnia in veterans with PTSD affects the response to CBT-I.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Baird T, McLeay S, Harvey W, Theal R, Law D, O'Sullivan R, Initiative P (2018) Sleep disturbances in Australian Vietnam veterans with and without posttraumatic stress disorder. J Clin Sleep Med 14(5):745–752. https://doi.org/10.5664/jcsm.7096

    Article  PubMed  PubMed Central  Google Scholar 

  2. Maher MJ, Rego SA, Asnis GM (2006) Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management. CNS drugs 20(7):567–590. https://doi.org/10.2165/00023210-200620070-00003

    Article  CAS  PubMed  Google Scholar 

  3. Amin MM, Parisi JA, Gold MS, Gold AR (2010) War-related illness symptoms among operation Iraqi freedom/operation enduring freedom returnees. Mil Med 175(3):155–157

    Article  PubMed  Google Scholar 

  4. Seelig AD, Jacobson IG, Smith B, Hooper TI, Boyko EJ, Gackstetter GD, Gehrman P, Macera CA, Smith TC, Millennium Cohort Study T (2010) Sleep patterns before, during, and after deployment to Iraq and Afghanistan. Sleep 33(12):1615–1622

    Article  PubMed  PubMed Central  Google Scholar 

  5. Hughes JM, Ulmer CS, Gierisch JM, Nicole Hastings S, Howard MO (2018) Insomnia in United States military veterans: an integrated theoretical model. Clin Psychol Rev 59:118–125. https://doi.org/10.1016/j.cpr.2017.11.005

    Article  PubMed  Google Scholar 

  6. Applewhite L, Keller N, Borah A (2012) Mental health care use by soldiers conducting counterinsurgency operations. Mil Med 177(5):501–506

    Article  PubMed  Google Scholar 

  7. Wright KM, Britt TW, Bliese PD, Adler AB, Picchioni D, Moore D (2011) Insomnia as predictor versus outcome of PTSD and depression among Iraq combat veterans. J Clin Psychol 67(12):1240–1258. https://doi.org/10.1002/jclp.20845

    Article  PubMed  Google Scholar 

  8. McLay RN, Klam WP, Volkert SL (2010) Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments. Mil Med 175(10):759–762

    Article  PubMed  Google Scholar 

  9. Hoge EA, Austin ED, Pollack MH (2007) Resilience: research evidence and conceptual considerations for posttraumatic stress disorder. Depress Anxiety 24(2):139–152. https://doi.org/10.1002/da.20175

    Article  PubMed  Google Scholar 

  10. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD, Clinical Guidelines Committee of the American College of P (2016) Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 165(2):125–133. https://doi.org/10.7326/M15-2175

    Article  PubMed  Google Scholar 

  11. Talbot LS, Maguen S, Metzler TJ, Schmitz M, McCaslin SE, Richards A, Perlis ML, Posner DA, Weiss B, Ruoff L, Varbel J, Neylan TC (2014) Cognitive behavioral therapy for insomnia in posttraumatic stress disorder: a randomized controlled trial. Sleep 37(2):327–341. https://doi.org/10.5665/sleep.3408

    Article  PubMed  PubMed Central  Google Scholar 

  12. Espie CA, Inglis SJ, Harvey L (2001) Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: analysis of outcome data at 12 months posttreatment. J Consult Clin Psychol 69(1):58–66

    Article  CAS  PubMed  Google Scholar 

  13. Troxel WM, Conrad TS, Germain A, Buysse DJ (2013) Predictors of treatment response to brief behavioral treatment of insomnia (BBTI) in older adults. J Clin Sleep Med 9(12):1281–1289. https://doi.org/10.5664/jcsm.3270

    Article  PubMed  PubMed Central  Google Scholar 

  14. Gagne A, Morin C (2001) Predicting treatment response in older adults with insomnia. J Clin Geropsychol 7:131–143

    Article  Google Scholar 

  15. Hayasaka Y, Purgato M, Magni LR, Ogawa Y, Takeshima N, Cipriani A, Barbui C, Leucht S, Furukawa TA (2015) Dose equivalents of antidepressants: evidence-based recommendations from randomized controlled trials. J Affect Disord 180:179–184. https://doi.org/10.1016/j.jad.2015.03.021

    Article  CAS  PubMed  Google Scholar 

  16. Lieberman JA, Tasman, A. (2006) Handbook of psychiatric drugs. John Wiley & Sons Incorporated,

  17. Perlis M, Jungquist C, Smith M, Posner D (2005) The cognitive behavioral treatment of insomnia: a treatment manual. Springer Verlag, New York

    Google Scholar 

  18. Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14(6):540–545

    Article  CAS  PubMed  Google Scholar 

  19. Weathers F, Litz B, Herman D, Huska J, Keane T (1993) The PTSD checklist: reliability, validity, & diagnostic utility. Paper presented at the Annual Meeting of the Internation Society of Traumatic Stress Studies, San Antonio, TX,

  20. Bastien CH, Vallieres A, Morin CM (2001) Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med 2(4):297–307

    Article  PubMed  Google Scholar 

  21. Pietrzak RH, Tsai J, Armour C, Mota N, Harpaz-Rotem I, Southwick SM (2015) Functional significance of a novel 7-factor model of DSM-5 PTSD symptoms: results from the National Health and resilience in veterans study. J Affect Disord 174:522–526. https://doi.org/10.1016/j.jad.2014.12.007

    Article  PubMed  Google Scholar 

  22. Armour C, Tsai J, Durham TA, Charak R, Biehn TL, Elhai JD, Pietrzak RH (2015) Dimensional structure of DSM-5 posttraumatic stress symptoms: support for a hybrid anhedonia and externalizing behaviors model. J Psychiatr Res 61:106–113. https://doi.org/10.1016/j.jpsychires.2014.10.012

    Article  PubMed  Google Scholar 

  23. Yang M, Morin CM, Schaefer K, Wallenstein GV (2009) Interpreting score differences in the insomnia severity index: using health-related outcomes to define the minimally important difference. Curr Med Res Opin 25(10):2487–2494. https://doi.org/10.1185/03007990903167415

    Article  PubMed  Google Scholar 

  24. Baraldi AN, Enders CK (2010) An introduction to modern missing data analyses. J Sch Psychol 48(1):5–37. https://doi.org/10.1016/j.jsp.2009.10.001

    Article  PubMed  Google Scholar 

  25. DeViva JC, Zayfert C, Pigeon WR, Mellman TA (2005) Treatment of residual insomnia after CBT for PTSD: case studies. J Trauma Stress 18(2):155–159. https://doi.org/10.1002/jts.20015

    Article  PubMed  Google Scholar 

  26. Petrov ME, Lichstein KL (2016) Differences in sleep between black and white adults: an update and future directions. Sleep Med 18:74–81. https://doi.org/10.1016/j.sleep.2015.01.011

    Article  PubMed  Google Scholar 

  27. Ruiter ME, DeCoster J, Jacobs L, Lichstein KL (2010) Sleep disorders in African Americans and Caucasian Americans: a meta-analysis. Behav Sleep Med 8(4):246–259. https://doi.org/10.1080/15402002.2010.509251

    Article  PubMed  Google Scholar 

  28. Ruiter ME, Decoster J, Jacobs L, Lichstein KL (2011) Normal sleep in African-Americans and Caucasian-Americans: a meta-analysis. Sleep Med 12(3):209–214. https://doi.org/10.1016/j.sleep.2010.12.010

    Article  PubMed  Google Scholar 

  29. Kohn LP, Oden T, Munoz RF, Robinson A, Leavitt D (2002) Adapted cognitive behavioral group therapy for depressed low-income African American women. Community Ment Health J 38(6):497–504

    Article  PubMed  Google Scholar 

  30. Benish SG, Quintana S, Wampold BE (2011) Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta-analysis. J Couns Psychol 58(3):279–289. https://doi.org/10.1037/a0023626

    Article  PubMed  Google Scholar 

  31. Lund BC, Abrams TE, Bernardy NC, Alexander B, Friedman MJ (2013) Benzodiazepine prescribing variation and clinical uncertainty in treating posttraumatic stress disorder. Psychiatr Serv 64(1):21–27. https://doi.org/10.1176/appi.ps.201100544

    Article  PubMed  Google Scholar 

  32. Lund BC, Bernardy NC, Vaughan-Sarrazin M, Alexander B, Friedman MJ (2013) Patient and facility characteristics associated with benzodiazepine prescribing for veterans with PTSD. Psychiatr Serv 64(2):149–155. https://doi.org/10.1176/appi.ps.201200267

    Article  PubMed  Google Scholar 

  33. Cates ME, Bishop MH, Davis LL, Lowe JS, Woolley TW (2004) Clonazepam for treatment of sleep disturbances associated with combat-related posttraumatic stress disorder. Ann Pharmacother 38(9):1395–1399. https://doi.org/10.1345/aph.1E043

    Article  CAS  PubMed  Google Scholar 

  34. Guina J, Rossetter SR, De RB, Nahhas RW, Welton RS (2015) Benzodiazepines for PTSD: a systematic review and meta-analysis. J Psychiatr Pract 21(4):281–303. https://doi.org/10.1097/PRA.0000000000000091

    Article  PubMed  Google Scholar 

  35. Matar MA, Zohar J, Kaplan Z, Cohen H (2009) Alprazolam treatment immediately after stress exposure interferes with the normal HPA-stress response and increases vulnerability to subsequent stress in an animal model of PTSD. Eur Neuropsychopharmacol 19(4):283–295. https://doi.org/10.1016/j.euroneuro.2008.12.004

    Article  CAS  PubMed  Google Scholar 

  36. Li S, Murakami Y, Wang M, Maeda K, Matsumoto K (2006) The effects of chronic valproate and diazepam in a mouse model of posttraumatic stress disorder. Pharmacol Biochem Behav 85(2):324–331. https://doi.org/10.1016/j.pbb.2006.08.015

    Article  CAS  PubMed  Google Scholar 

  37. Group MoP-TSW (2017) VA/DoD clinical practice guidelines for management of post-traumatic stress. Washington, DC

  38. Rosen CS, Greenbaum MA, Schnurr PP, Holmes TH, Brennan PL, Friedman MJ (2013) Do benzodiazepines reduce the effectiveness of exposure therapy for posttraumatic stress disorder? J Clin Psychiatry 74(12):1241–1248. https://doi.org/10.4088/JCP.13m08592

    Article  CAS  PubMed  Google Scholar 

  39. van Minnen A, Arntz A, Keijsers GP (2002) Prolonged exposure in patients with chronic PTSD: predictors of treatment outcome and dropout. Behav Res Ther 40(4):439–457

    Article  PubMed  Google Scholar 

  40. Morin CM, Vallieres A, Guay B, Ivers H, Savard J, Merette C, Bastien C, Baillargeon L (2009) Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA 301(19):2005–2015. https://doi.org/10.1001/jama.2009.682

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Park K, Kim T, Kim W, An S, Lee E (2018) Cognitive behavioral therapy for insomnia reduces hypnotic prescriptions. Psychiatry Investig 2018:499–504

    Article  Google Scholar 

  42. Taylor HL, Rybarczyk BD, Nay W, Leszczyszyn D (2015) Effectiveness of a CBT intervention for persistent insomnia and hypnotic dependency in an outpatient psychiatry clinic. J Clin Psychol 71(7):666–683. https://doi.org/10.1002/jclp.22186

    Article  PubMed  Google Scholar 

  43. Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T (2008) Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep 31(4):489–495

    Article  PubMed  PubMed Central  Google Scholar 

  44. Bathgate CJ, Edinger JD, Krystal AD (2017) Insomnia patients with objective Short sleep duration have a blunted response to cognitive behavioral therapy for insomnia. Sleep 40(1). https://doi.org/10.1093/sleep/zsw012

  45. Association AP (2013) Diagnostic and statistical manual of mental disorders. 5th edition edn., Washington, DC

  46. Short NA, Allan NP, Stentz L, Portero AK, Schmidt NB (2018) Predictors of insomnia symptoms and nightmares among individuals with post-traumatic stress disorder: an ecological momentary assessment study. J Sleep Res 27(1):64–72. https://doi.org/10.1111/jsr.12589

    Article  PubMed  Google Scholar 

  47. Molnar F, Man-Son-Hing M, Hutton B, Fergusson D (2009) Have last-observation-carried-forward analyses caused us to favour more toxic dementia therapies over less toxic alternatives? A systematic review. Open Med 3:e31–e50

    PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

The views expressed in this manuscript do not communicate an official position of the Department of Veterans Affairs.

Author information

Authors and Affiliations

  1. VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY, 14215, USA

    Ali A. El-Solh, Sumit Patel, Leela Vanguru & Chathura Wijewardena

  2. Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Jacob School of Medicine, Buffalo, NY, USA

    Ali A. El-Solh, Sumit Patel, Leela Vanguru & Chathura Wijewardena

  3. Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA

    Ali A. El-Solh

  4. Drexel University College of Medicine, Philadelphia, PA, USA

    Nathan O’Brien

  5. StrongTower Behavioral HealthCare, Marietta, GA, USA

    Morohunfolu Akinnusi

Authors
  1. Ali A. El-Solh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nathan O’Brien
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Morohunfolu Akinnusi
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sumit Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Leela Vanguru
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chathura Wijewardena
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ali A. El-Solh.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest. Funding: The study was partially supported by the US VA Office of Research and Development, Department of Veterans Affairs, Clinical Service Research and Development (CX001656) 

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. A waiver of informed consent was granted by the Institutional Review Board because of the retrospective study design.

Disclaimer

The contents of this paper do not represent the views of the Department of Veterans Affairs or the United States Government.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

El-Solh, A.A., O’Brien, N., Akinnusi, M. et al. Predictors of cognitive behavioral therapy outcomes for insomnia in veterans with post-traumatic stress disorder. Sleep Breath 23, 635–643 (2019). https://doi.org/10.1007/s11325-019-01840-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11325-019-01840-4

Keywords

Search

Navigation