Cognitive Behavioral Therapy for Insomnia in Posttraumatic Stress Disorder: A Randomized Controlled Trial

Study objectivesExamine whether cognitive behavioral therapy for insomnia (CBT-I) improves sleep in posttraumatic stress disorder (PTSD) as well as nightmares, nonsleep PTSD symptoms, depression symptoms, and psychosocial functioning.DesignRANDOMIZED CONTROLLED TRIAL WITH TWO ARMS: CBT-I and monitor-only waitlist control.SettingDepartment of Veterans Affairs (VA) Medical Center.ParticipantsForty-five adults (31 females: [mean age 37 y (22-59 y)] with PTSD meeting research diagnostic criteria for insomnia, randomly assigned to CBT-I (n = 29; 22 females) or monitor-only waitlist control (n = 16; nine females).InterventionsEight-session weekly individual CBT-I delivered by a licensed clinical psychologist or a board-certified psychiatrist.Measurements and resultsMeasures included continuous monitoring of sleep with diary and actigraphy; prepolysomnography and postpolysomnography and Clinician-Administered PTSD Scale (CAPS); and pre, mid, and post self-report questionnaires, with follow-up of CBT-I participants 6 mo later. CBT-I was superior to the waitlist control condition in all sleep diary outcomes and in polysomnography-measured total sleep time. Compared to waitlist participants, CBT-I participants reported improved subjective sleep (41% full remission versus 0%), disruptive nocturnal behaviors (based on the Pittsburgh Sleep Quality Index-Addendum), and overall work and interpersonal functioning. These effects were maintained at 6-mo follow-up. Both CBT-I and waitlist control participants reported reductions in PTSD symptoms and CAPS-measured nightmares.ConclusionsCognitive behavioral therapy for insomnia (CBT-I) improved sleep in individuals with posttraumatic stress disorder, with durable gains at 6 mo. Overall psychosocial functioning improved following CBT-I. The initial evidence regarding CBT-I and nightmares is promising but further research is needed. Results suggest that a comprehensive approach to treatment of posttraumatic stress disorder should include behavioral sleep medicine.Clinical trial informationTRIAL NAME: Cognitive Behavioral Treatment Of Insomnia In Posttraumatic Stress Disorder. URL: http://clinicaltrials.gov/ct2/show/NCT00881647.Registration numberNCT00881647

Associations between mindfulness, PTSD, and depression in combat deployed post-9/11 military veterans

Objectives: Combat experiences predict PTSD and depression in U.S. military veterans. However, few studies have investigated associations between mindfulness and these constructs. We examined main, direct, and indirect effects for mindfulness and combat experiences on veterans’ PTSD and depressive symptoms and investigated the explanatory value of mindfulness on outcome variance in these models. Methods: A total of 485 post-9/11 era military veterans with previous combat deployments residing in four major US cities completed online surveys asking about their combat experiences, mindfulness, and mental health. Two multivariable ordinary least squares regression models were specified to investigate main effects of mindfulness and combat experiences on veterans’ PTSD and depressive symptoms. Path models examined direct and indirect effects of combat experiences and mindfulness on these outcomes. Results: There were significant associations for mindfulness (β = − 0.68, p < 0.001), (β = − 0.67, p < 0.001) and combat experiences (β = 0.12, p < 0.001), (β = 0.09, p < 0.001) with PTSD and depression respectively. In both models, the addition of the mindfulness parameter significantly increased model R2. Path analysis demonstrated significant direct effects for mindfulness and combat experiences and indirect effects for combat experiences on PTSD and depressive symptoms through the mindfulness pathway. Conclusions: The associations of mindfulness with PTSD and depressive symptoms were greater in magnitude than the associations for combat experiences, and mindfulness explained a large and significant proportion of the variance in outcomes. Additional longitudinal research investigating how mindfulness skills and strategies may buffer against risk for PTSD and depression posed by combat experience is warranted in this high risk population