**Transcript of Cyberseminar**

**Mild TBI Diagnosis and Management Strategies**

**Deployment-Related Insomnia and Cognitive Behavioral Treatments**

**Presented by Adam Bramoweth, PhD**

**March 20, 2014**

Moderator:And with that, we are at the top of the hour. So at this time I would like to introduce Doctor Ralph DePalma who will be introducing our speaker for today. 

Dr. DePalma:Thank you Ms. Kessner, it is a pleasure to introduce Adam Bramoweth who will be discussing the very important issue of deployment related insomnia and the use of cognitive behavioral treatments for this condition particularly associated with mild traumatic brain injury. Thank you very much Adam, we are looking forward to your talk. 

Adam Bramoweth: Well thank you for inviting me and thank you everyone for signing on today. As has been said I will be talking about issues of deployment related insomnia and non-pharmacological cognitive behavioral treatments for insomnia. I am currently supported by the VA Advance Fellowship and Mental Illness Research and Treatment here at the VISN 4 MIRECC at VA Pittsburgh as well as the Department of Psychiatry at the University of Pittsburgh. 

My goal for today is I want to review insomnia including common risks and consequences of insomnia. I will go over some deployment related factors and how mild traumatic brain injury impacts insomnia. I will briefly describe cognitive behavioral treatments for insomnia as well provide a case example and lastly I will discuss some current dissemination and implementation efforts for CBT for insomnia. I will start with the survey. 

Moderator:Thank you Adam, as our attendees can see on their screen you do have a survey up and we would like to know - What is your primary position?  We understand that many of you wear many different hats and at the end of the survey, you will be able to provide a more specific detail of all the different positions you hold. But at this time, we are just trying to figure out what is your primary position. The options are: –  Clinician – Primary Care Provider;  Clinician in Behavioral Health;  Clinician in  Other Medical/Behavioral Health providers;  Research  Physician;  Research  Psychologist; or  Research  Other. It looks like the answers are still streaming in so we will give people a little bit more time to get their responses in. It looks like we have a pretty general idea; about forty-five percent of our audience are clinicians in behavioral health, that would be psychologists, psychiatrists and social workers. About a quarter of our audience are other clinicians, about four percent are research physicians, we have about six percent research psychologists, and seventeen percent identify as research other. Thank you for those replies. 

We do have one more poll question for you. I will go ahead and put that up right now. We would like to know - What is your experience with insomnia? The options are - I treat many Veterans with insomnia; I occasionally treat Veterans with insomnia; I rarely treat Veterans with insomnia; or I do not currently treat Veterans with insomnia. Again, it looks like we have quite a mixed bag. The responses are still streaming in so will give people a little bit more time. Great we have about a fifty percent response rate so we will go ahead and close the poll. It looks like about two-thirds of our audience treated many Veterans with insomnia; about fifteen percent occasionally treat them; about 5.6% rarely, treat Veterans with insomnia and fifteen percent do not currently treat Veterans with insomnia. Thank you for those replies. 

Adam Bramoweth: Thank you and it is good to see that, many of you are treating Veterans with insomnia but also good that there are some that are not and maybe this can help to give you more information on how to better treat Veterans with insomnia. 

First just a brief overview of the updated diagnosis criteria in the DSM-5. Insomnia is difficulty initiating sleep, maintaining sleep, or waking up earlier than you would like to with difficult going back to sleep. This causes clinically significant distress or impairments occurring at least three nights per week and lasting at least three months. This is occurring having an adequate opportunity for sleep. 

One of the main changes in DSM-5 is insomnia is really...

Moderator:I am sorry to interrupt Adam, Ralph do you have your line muted.

Dr. DePalma:Yes. 

Moderator:Okay I am hearing typing in the background so if anybody does not have their line muted please press so. Sorry Adam, go ahead. 

Adam Bramoweth: Sure. One of the changes from DSM-4 to DSM-5 is the change of the title of Insomnia Disorder instead of Primary Insomnia. It is obvious we only considered comorbid disorder now rather being primary or secondary to other disorders. You can specify it as being comorbid with other psychiatric disorders, other medical disorders or with other sleep disorders such as sleep apnea. 

You can also qualify it in terms of the time course of if the disorder has lasted less than three months it would be episodic; longer than three months persistent or chronic and if it is occurring at least twice within a year it would be considered a recurrent insomnia disorder. 

Another way to consider the development of insomnia is what is called a 3P Model, the 3P stands for Predisposing Factors; Precipitating Factors and Perpetuating Factors. My colleagues here in Pittsburgh, Anne Germaine and I decided to adapt the 3P Model to specific issues that military personnel or Veterans might deal with. These are some of the things that make up the 3P so on Predisposing it might be baseline factors, biological traits, psychological or social traits. Issues that might be stable might not change very much over the course of treatment or over the course of the disorder. The Precipitating Factors might be the initial cause of insomnia and the Perpetuating Factors might be more behavioral or cognitive in nature and issues that we can target and modify during treatment. 

Some specific issues that we identify Predisposing Factors might be adverse childhood events, which hare more common in persons in the military and are related to sleep disorders, increased rates of sleep disorders. Also people in the military maybe they had insomnia issues prior to joining the military in childhood or there could be some factors of just being in the military that might predispose someone to having insomnia part of moving around a lot or just part of the day to day military activities. 

Precipitating Factors might include deployment that could be to a combat or a non-combat zone but just deployment overseas; being involved in shift work or a regular scheduling and hyper-vigilance that might come along with being deployed in a dangerous area. 

Perpetuating Factors where being that sort of keep the insomnia ongoing, things such as nightmares, high-energy drink or caffeine consumption, other psychopathology like PTSD or depression, anxiety. Adjusting to a sleep schedule that could be adjusting to an irregular sleep schedule while deployed or even adjusting to a more normal sleep schedule after deployment. 

Other issues like financial stress, unemployment after leaving the military, family responsibilities upon returning home, as well as coping mechanisms such as alcohol or substance use. These are all features that can keep features of the insomnia ongoing. 

Insomnia in Veterans is much more prevalent when you compare them to the general population. In some studies beyond fifty percent and this is looking at self-reported insomnia, complaints of insomnia and not clinical diagnosis that you might find in medical records. If you just look at sleep disturbance rates, are very high and varying rates in different groups of Veterans and military personnel, Iraq Veterans one study found a report of thirty percent; Veterans who sustained a head injury close to sixty percent; and one study found ninety-four percent of Vietnam Veterans have some sleep disturbance. Those with PTSD have very high rates and in general, insomnia is among the most frequent complaints of recently deployed Veterans and is the most common initial complaint of those referred for mental health services. Insomnia is clearly a problem in this population. 

Insomnia is very highly comorbid with other psychiatric disorders especially depression, PTSD and anxiety. Once I found that when you compare people with insomnia versus good sleepers, those with insomnia were ten times more likely to have clinical depression and they are seventeen times more likely to have significant anxiety. Insomnia has also been found to be a risk factor in the development of disorders such as depression, substance use and medical disorders such as cardiometabolic problems. 

Insomnia is also linked to other outcomes such as usage of healthcare services. People with insomnia go to more doctors’ appointments, use more medications. Now at the individual level, people with insomnia have significantly higher healthcare costs. Those with insomnia syndrome or clinically diagnosed insomnia disorder have cost upwards of five thousand dollars a year and even good sleeper have insomnia related costs. At a population economic level, total costs of insomnia looking at direct treatment costs and indirect expenses is estimated to be about two hundred and fifty billion dollars a years. This is significant economic and personal problems. 

Insomnia is highly comorbid; here is a sampling of disorders that insomnia is linked with. In recent studies in military and Veterans found that Veterans upon returning home from combat related duties found that those with insomnia symptoms at time 1, several months later have significantly higher rates of PTSD symptoms. Also, a recent study in Veterans who committed suicide found that those Veterans who committed suicide those with sleep problems had died closer to their last office visit than Veterans without a sleep problem. These studies show that insomnia really can be a target for the treatment of other disorders as well, treating insomnia is going to help reduce that severity, but it may also help reduce other psychiatric severity and may be prevented in nature for something like suicide. 

Let us talk a little bit about how mild traumatic brain injury is linked to sleep disorders and insomnia. First mild traumatic brain injury is very common especially in today’s soldiers. It has become one of the defining injuries of Operation Enduring Freedom; Operation Iraqi Freedom; Operation New Dawn and that those who sustain a mild traumatic brain injury often have more than one. In civilians with mild TBI, fifty percent have a sleep disturbance of twenty-five to thirty percent having a diagnosis of sleep disorder. When you look at military personnel with the chronic mild traumatic brain injury lasting at least three months, almost all of them have some sort of sleep problems. Those that have undergone overnight sleep studies polysomography eighty-five percent were found to have hypersomnia, fifty-five percent with insomnia, fifty-four percent sleep fragmentation and thirty-five percent sleep apnea. Again, those with mild traumatic brain injury sleep disturbance is very common. 

There are also some differences that have been found between different types of how a TBI is sustained. Those with a blast related injury may have more difficulty with insomnia or anxiety issues and those with a blunt related injury might suffer more from obstructive sleep apnea. 

Summary insomnia is highly prevalent especially in military and Veteran samples and populations. It is highly comorbid with psychiatric disorders, medical disorders, and issues such as TBI and is linked to also significant risks and development of other disorders and consequences such as healthcare costs and healthcare utilization. 

We will talk a little bit about treatment using cognitive behavioral therapy but first one more survey. 

Moderator:Thank you Adam I am going ahead and putting that up now. Thank you for your patience. The next survey question - what is your experience/exposure to CBT for Insomnia? 

The answer options we have here are: not at all familiar with CBT for Insomnia; I have heard of it but do not know much about it; heard of it and have referred Veterans; I use it occasionally or I use it regularly. Once again, we have quite varied responses from our audience members. We have about a sixty percent response rate. The answers have stopped coming in so it looks like we have right around twelve percent who are not familiar with it. About thirty-nine percent heard of it but do not know much about it. Thirteen percent have heard of it and have referred Veterans. About eleven percent use it occasionally and a nice twenty-one percent use it regularly. Thank you for those replies. 

Adam Bramoweth:Alright thank you for your responses and it is great to see that twenty percent use it regularly. But I think for me it is even mentioned here that many of you are not using it so this is an opportunity for you to learn more about it and hopefully become engage in CBT for insomnia following this talk. 

What is CBT for insomnia? It is multicomponent evidence based psychotherapy. I will go through the components briefly and I will get into that in detail as well. I am going to include education about what is insomnia; what is normal sleep; what is abnormal sleep. Stimulus control and sleep restrictions are the two main behavioral components of CBT for insomnia. Cognitive therapy dealing with thoughts, worries and anxiety about sleep as well as relaxation to help calm the mind and body to help prepare you for sleep. 

CBT for insomnia is nice because you can use all or just some of these components depending on your patient and you can really customize it to the individual. This is the recommended first line of treatment for insomnia beyond medications. It is brief, it can occur in only four to six sessions and sessions lasting forty to sixty minutes and even when you think of other briefer psychotherapies, this is still much briefer of depression and PTSD treatments are often twelve to sixteen sessions. This is a brief treatment. 

CBTI has its own language so these are some common terms I will be using while describing it. You have the sleep diary, which is a self-monitoring tool that can measure sleep behaviors and help calculate what sleep looks like over the course of a week and over the course of treatment. Time in bed is simply the amount of time someone is spending in bed and their total sleep time is how much sleep they are getting in a twenty-four hour period. It is usually concentrated at night but not always. Sleep onset latency or just sleep latency is how long it takes someone to fall asleep initially and wake after sleep onset is after falling asleep initially how much time they spend awake. Lastly, sleep efficiency is a calculation of total sleep time divided by time in bed that is a good proxy of sleep quality. The higher the sleep efficiency generally the better sleep quality someone is getting. 

Here is some common assessments and measures that we use in treatment of insomnia. Again, you have the sleep diary; the insomnia severity index is a brief insomnia specific measure. There are other sleep measures like the Pittsburgh Sleep Quality Index that is also commonly used. The Epworth Sleepiness Scale will allow you to get a sense of how sleepy someone is during the day. It can also be acted as a brief screened for sleep apnea if they have not been assessed. The dysfunctional beliefs about sleep scale lets you find out how strong someone believes about some common sleep myths. That can be very helpful in the cognitive therapy portion of treatment. There is also a morningness/eveningness scale can help you identify a patient’s chronotype to identify if they are a morning person and evening person and that can play a role in their treatment. It is also important to measure depression, anxiety, and other psychiatric and medical comorbidities during treatment that may impact their outcomes. 

I am going to start off with a case example, I am going to give you some of the baseline and background information. Then I am going to go through the treatment more specifically and we will come back after that and follow up with this case. TB was referred to me by his primary care physician for insomnia and sleep disruption. He is twenty-five Caucasian and a Veteran of the Marines. He had been medically retired and honorably discharged. He was service connected for TBI, PTSD, Migraines and Tinnitus. He served in Afghanistan for seven months in 2009 and 2010. He was combat exposed to sniper fire as well as four IED blasts one of which caused loss of consciousness. That one loss of consciousness was due to he was in a vehicle that triggered a detonation of and IED. This uprighted the vehicle, he slammed his head into the door and loss consciousness for about a minute. He had headache with dizziness and photophobia said he was dazed and confused for an hour and also suffered some back injuries as well. The other three IED blasts only resulted in headaches that resolved in about an hour. 

When he came to see me, he was going to bed at about 3:00 AM, taking up to several hours to fall asleep. Once he fell asleep, he was not awake too often only waking up two to three times per night with minimal wake after sleep onset. Waking up in the early afternoon and he did not feel refreshed upon awakening. He said that his back pain contributed to sleep latency. He denied any significant worries at night and fears or ruminations that is keeping him up. He has the TV on to help reduce his tinnitus and during the day, he complains of fatigue, poor concentration, poor memory, and irritability some of that due to the insomnia, some of that also likely due to the TBI, PTSD, migraines. He is complex medically. 

His insomnia severity index is high in the clinically range. He was not acceptably sleepy during the day, which is common for many insomnia patients, and he had moderate depression. On the dysfunctional belief scale, these were some that he wrote that he felt the need to catch up after a poor night’s sleep. He was worried he would lose control over his sleep. That interfered with activities during the day and he felt medication was probably the only solution to his sleep problem. 

Now let us get into some more specifics about treatment. I would say with education it is important to talk to people about what is normal sleep, what is abnormal sleep. Many individuals that I have seen it takes them awhile to actually get into the clinic because they might think their sleep just really is not a problem. That is an important part of the education process. Go over that 3P Model of insomnia, discussing predisposing, precipitating and perpetuating factors and you can start to customize that model for the individual. I will usually draw this out with them to help them really understand the process. You can also talk to them about other sleep disorders especially sleep apnea or something like restless legs and how substances, diet and exercise can influence sleep. 

Here is an example of what 3P Model and generic version. Again, this is something I will either show them or I will draw out for them. I will also use a scheme up such as this to show them the relationship between thoughts, behaviors and emotions related to sleep and how they all interact with each other. 

Here is an example of a sleep diet that someone might fill out. This is some of the information that will collect: naps, time in bed; time actually trying to fall asleep. That can be important as it gives us a sense of how long they are spending in bed but not active trying to fall asleep. Their sleep onset latency, number of times awake, their wake after sleep onset and then what time they are waking up and what time they are getting out of bed and qualitative rating of the sleep. This is really key, this is what allows you to conduct a data driven treatment for your patients and really customize treatment based on their own information. 

Stimulus control focuses on strengthening the relationship between the act of sleeping and the bed and the bedroom. If I can give one piece of advice about getting better sleep it is waking up at the same time every day. That is my golden rule of sleep. If you can do that and if you can follow that, that really sets the stage for a healthy sleep pattern. Next is not going to bed unless they are sleepy. Sometimes people think it is time to go to bed or they feel more physically or emotionally tired and they go to bed and they try to fall asleep but they are really not ready. Going to bed when sleepy is about if you close your eyes, you think you will fall asleep and this is important. Next is really limiting the bed and bedroom only for sleep and sexual activity. You want to take other activities outside the bedroom. Even if it is reading and watching TV, that is just reducing the strength of the relationship between the bed, the bedroom and sleep. Next is if you cannot sleep, you want to get out of bed and only return to bed when you feel ready to fall asleep. Again, taking any time awake outside the bedroom if at all possible. Do not nap during the day or if a nap is necessary try to keep it brief and early in the day. Taking naps too late in the day will reduce your sleep drive and you want that sleep drive to be high come your bedtime. Lastly creating a buffer zone and avoiding other stressful activities in bed as well as taking time at the end of the day to calm down. You do not want to transition from a stressful or high-energy activity directly to sleep. 

The next key behavioral feature of CBT for insomnia is sleep restriction although it is better to describe that time in bed restriction especially when discussing this with your patients. Calling a sleep restriction can be a little bit scary because they are worried you are taking their sleep away, but you really are not. What you want to do is reduce their time in bed, you want to match their current total sleep time which you are getting from the sleep diaries add about thirty minutes and that is their new prescribed time in bed. You do not want to restrict them too much although you will probably see patients that say they are sleeping three or four hours a night, if that is what their sleep diary show then that is sort of the reality of their situation. If they are only sleeping that much, they are going to be self-restricting anyway. You do not want to restrict too much if you do not have to. 

Sleep restriction is contraindicated for some patients, those who have seizure disorder; bipolar disorder, too little sleep can trigger a seizure or bipolar manic episode. 

You want to take that new prescribed time in bed and along with that established wait time, if at all possible you want to set that at the earliest time someone needs to wake up any day of the week. It might be for work, of school and try to make that your consistent wake time. Of course, you need to be a realistic about this. Now many Veterans, people in general want to sleep in all weekend or if they do not have to get up at 6:00 AM, they do not want to. You do not want to make it so strict that it is not just feasible for someone to keep this time, but again consistency is key. You set that prescribed wake time, you work backwards based on your chronotonal sleep time and that is your new time in bed. Over the course of treatments, you are going to be tracking their sleep with sleep diaries and measuring their sleep efficiency. When they start showing good sleep efficiency over ninety percent that is usually an indication that you can extend their time in bed and they will continue getting good sleep. You want to do it slowly, fifteen or twenty minutes a week, but over the course of four to six weeks, they may be getting extra hour or hour and a half in bed. 

You can also work the other direction if someone is hesitant to take away that much time in bed all at once, you can do sleep impressions where you would slowly take away fifteen or twenty minutes each week until sleep efficiency gets about ninety percent then start working backwards extending the time in bed. 

The next core feature is cognitive therapy and this is used to address general worries related to sleep or find those maladaptive dysfunctional beliefs about sleep using a scale such as the DBAS or just worry that they are bringing up in session. You would identify some of those thoughts and beliefs and then using what we call a guided discovery process, you want to challenge and change those thoughts. You want to ask them about the evidence for that belief and find out what is the worse that could happen. A lot of their worries about reality, they are worried something might happen like getting in a car accident, not doing well at work and getting fired, being late dropping their kids off at school. You want to find out what is really going on. Is it just a concern, what is the evidence? 

Then the final main component of CBT for insomnia is relaxation. This can be very helpful for individuals that have a lot of physical stress that comes along with their insomnia or more mental worries. I am a big of muscle relaxation, going systematically through muscle groups of the body, tensing, relaxing, really helping the patient understand what tension and relaxation feels like. If there are medical issues or pain issues that might prevent muscle relaxation, if you use half relaxation techniques or if it is more cognitive in nature you might do a meditation or even a mindfulness exercise. 

Briefly go over some of the evidence for CBT for insomnia. This is data from a study I was involved in a few years ago. These are not Veterans but this is a community sample, not a clinical trial, so just individuals coming in for treatment, thirty-two who had completed at least four sessions of CBT for insomnia. Along the Y-axis, you have number of minutes awake and along the X-axis, you have number of sessions. We start with session two, session one was a clinical interview, started collecting sleep diaries and started treatment in session two. As you can see in the green for sleep onset wait and see and the red for wake after sleep onset, just in one session you significantly reduce the time spent awake. That is staying stable across treatment. You do not see significant changes especially for awake after sleep onset, you see a trend of continual reduction of wake after sleep onset and again stabilization of sleep onset latency. A number that you can use is thirty minutes to fall asleep is often a general guideline so you see that falling asleep within thirty minutes and that is always good to see. 

Another way to look at it is looking at their sleep efficiency over the course of treatment. Again in that very first week you see a significant change from under seventy-five percent to about eighty-five percent right at that threshold of where we consider it to be normal. But you also see significant change across the rest of treatment from session three through session seven where they continue to make gains on sleep efficiency. 

Let us return to our case example. Session one, TB sleep diary, he was spending a lot of time in bed. His total sleep time was pretty good over seven and half-hours but as he had initially reported, it was taking him a long time fall asleep. This first week he averaged over two hours and also reported not much time spent awake in the middle of the night. Sleep conditions he was about seventy-five percent. He had been relying on an over the counter sleep aid which really helped him reduce the sleep latency and initially he was hesitant to set an early wake time but one of his goals was to return to work full time, go to school and he knew he needed to be up early. Talking with him and trying to develop a collaborative relationship is we agreed to try waking up much earlier than he is used to; he was willing to start off with this approach. So we set his time in bed from midnight to 8:00 AM. 

Next week he forgot his sleep diary but we talked about his sleep patterns. He had noticed that without a sleep aid, I asked him to try not to take it, that he got inconsistent sleep. But with his sleep aid, he got consistent good quality sleep. He decided to continue to use this over the counter sleep aid, establish a structured sleep schedule, get him to the time where he wanted to be falling asleep and waking up and then work on tapering the sleep aid while maintaining that sleep schedule. We started off a bit too aggressive, I think the both of us. We were not as realistic as we should have been so we changed it to a 2:00 AM to 10:00 AM time in bed, again giving him eight hours of opportunity. Next week he came in showed some nice improvement, time in bed was down to under seven hours with just over six hours of total sleep time, sleep onset latency was significantly reduced down to forty minutes from two hours. Again, very minimal wake after sleep onset. His sleep efficiency was also much improved eighty-seven percent. Again, he was getting good sleep with his sleep aid. He did not take it one night and noticed it was bad. So sticking with the plan, we are going to keep him on the sleep aid, then start shifting him earlier again, keeping the sleep quality high and then if it remains stable, work on tapering his sleep aid. 

Session four, he was a no-show. He had been trying to participate in an outpatient pain program as well as continuing with CBT for insomnia, however he never rescheduled so I was not able to follow up with him. I think that may have been a sign of back pain, it was a bigger issue for him than the insomnia and he wanted to really focus on that. What did we learn about CBT for insomnia and about this case? It is multicomponent evidence based. It is a brief therapy, a key feature is being collaborative with your patient and finding out what are the realistic goals versus idealistic. Patients come in saying they are on eight hours of good sleep. A couple might be six and a half hours of good consolidated sleep; many patients end up being happy with that. You want to pay attention to adherence issues as well as features of comorbid disorders. Some of the things that he was struggling with especially the pain maybe issues related to his TBI affected part of his treatment outcomes. Those are important issues to be taken into account when developing a treatment plan and going through components of CBT for insomnia. 

Alright now to finish up I will talk about of the dissemination efforts in the VA and others or adaptations that have been made for CBT for insomnia. First of all, there is a nationwide dissemination nationwide training program in the VA where you can get trained in CBT for insomnia. There is the website through the internet. Today about four hundred clinicians have been trained and the goal is to train approximately a thousand.  And there are more details on the website about how you can get trained. But if you regularly provide psychotherapy and you get approval from your local site and you are willing to commit to see patients with insomnia you may be eligible and that can include psychologists, psychiatrists, social workers or psychiatric nurses.  

Here is a screen shot of the portal, it gives you some more information and links you to a SharePoint site where one of the tabs is get you access to resources. The manual is still being finalized, but you can access a sleep diary, you can access a lot of assessment treatment tools I talked about as well as patient handouts that are used in treatment. A lot of good resources all available. Also on the website is you can find out who has been trained by VISN. So if you are not sure who at your VA has been trained, you can find out if anyone has. 

Here is some evidence of a recent paper about the roll-out that shows there are significant changes and I think it is approximately seven hundred Veterans who have gone through this treatment with about I think three hundred of the clinicians who have been trained. You see significant change in insomnia severity; you see a significant reduction of depression; you also see significant improvements in various quality of life measures. 

One way you can also find out if your VA has insomnia consults available is through the Behavioral Health Consult Menu. This is what it looks like here at Pittsburgh, so you might want to check out if you are not sure who is treating Veterans with insomnia using CBTI. You may have insomnia consult services available. If you do not you may want to nominate some people to get trained. 

Some other forms of CBTI, the VA also has efforts to use CBTI through the video tele-health and this might be appropriate for a rural Veteran who cannot come into an urban setting that is probably more likely to have someone trained in CBTI. It might be a Veteran with inconsistent transportation, or other duties during the day that does not always allow them to attend a medical center. And there may not be a CBTI provider within the VISN so this will allow them to connect with someone who is trained and can provide the service. The VA has also developed a mobile application, the CBTI coach. It is free to download through iTunes and I believe it is available for android as well. It has all the features of the in person therapy, it has a sleep diary that will calculate your prescribed time in bed and give you recommendations. This can be used on your own or in conjunction with an in person therapist. 

There have also been some preppers to take CBTI, which is already briefed, make it even briefer and more accessible.  At the University of Pittsburgh, they developed brief behavioral treatment for insomnia, which involves two in person sessions, weeks one and three and two full follow-ups. Really only the first session is a full clinical hour with all the follow up sessions being briefer, usually less than thirty minutes. This is also developed to be delivered by a non-psychologist so to be delivered by a social worker, the PA, the counselor. There is a lot of training right now is often for the psychologist outside the VA. Brief behavioral treatment of insomnia is a great way to increase access to care. 

There are also some websites, this is one that developed through DoD funding after deployment got ordered and it has lots of different modules about issues commonly seen in military personnel and Veterans after deployment one of which is sleep, here in the red box. If you go under sleep, it is a self-managed evidence-based CBT treatment program. Again, it has all the main components that we have been through. It shows videos, it has sleep diaries that will calculate your prescribed sleep time. It is another good option for a Veteran who might want to try this on the run before coming in and seeing a therapist or clinician. It is another way to increase access to care. It is free, all you have to do is sign up and it can be used by civilians as well. 

Brief summary. Insomnia is highly prevalent, especially among Military personnel and Veterans. It is highly comorbid with psychiatric and medical disorders and is a risk factor for development of disorders. It has been linked to significant health outcomes such as costs and usage of healthcare services. The treatment is available; it is brief, effective and can be adapted. There are current dissemination efforts in place and new ones are ongoing. 

I would like to briefly acknowledge some of my mentors and collaborators here in Pittsburgh as well as Philadelphia and California. I will be able to take any comments or questions. 

Moderator:Great, thank you so much. For our attendees that joined us after the top of the hour, to submit your questions and comments, please use that Q&A box located in the upper right hand corner of your screen. Just type your question or comment into the lower box and then press the speech bubble and that will get it submitted. We do have some questions here. 

The first one – do you have any thoughts about why different ideology of MTBI lasts versus blunt trauma has a differential impact on apnea and insomnia? Do you think PTSD related to blast injury plays a role?

Adam Bramoweth:That is a great question and that is a bit outside of my area of expertise. That is something I can look into more, I think this is newer research. Unfortunately, I cannot give you much more of an explanation about the different types of TBI injuries and why it might be related to different sleep disorders. 

Moderator:Thank you for that reply. You mentioned chronotype might influence treatment. What would you suggest for a Veteran whose chronotype may not fit their work or other schedule?

Adam Bramoweth:That is a challenging issue and sometimes a Veteran or someone in the military has a night shift or rotating shift and it can be a real struggle to map that to their treatment. You can use Melatonin effectively; you can use bright light therapies to supplement CBT for insomnia to help manage the challenges that come along with rotating schedules. That is when following a consistent schedule when the opportunity allows becomes even more important. The patient really has to be vigilant about following consistent wake times whether it is a night schedule or a day schedule. There are medications that may be helpful and get help with alertness so that definitely has a challenge to it. Sometimes it might be a matter of if they cannot function very well at work maybe talking to employers about changing their schedule. 

Moderator:Great thank you for that reply. The next question we have – what do you do with Veterans that report on sleeping less than five hours per night. 

Adam Bramoweth:I have seen that quite a bit you have to work with the information they provide you. You might want to, if available, the sleep disorder center at your VA may have Acti  watches, an objective way to measure their sleep and they may have sleep state misperception where they think they are sleeping much less than they are and it is really non-restorative sleep rather than sleep deprivation. Again you want to set up realistic schedules for them, try to use sleep deprivation and some sleep drive to get them first good quality sleep, condensed sleep and do the best you can to extend it to a more reasonable total sleep time that is appropriate for them and appropriate for their ability to function during the day. Again, it is possible that supplements with medication might be in order; you might need to have a sleep study to find out if something else is going on. But that can be a challenge when they are reporting less than five hours of sleep. 

Moderator:Thank you. We have a similarly related question. How would you approach making sleep restriction prescriptions with a Veteran you suspect has sleep state misperception reporting less than three hours of sleep per night? 

Adam Bramoweth:Again a similar approach, you want to talk with them maybe check into evidence how can you be sure you are awake/asleep. Act speaker B [sp] can be very helpful in this instance, it could be something if they have a bed partner you can ask their opinion. You can say how much do you think your bed partner is getting and again it is about finding out what is the reality of what is going on and how that is impacting their daytime functioning. Sometimes you get patients in that report very little sleep but I have been referred a Veteran who was getting four hours of sleep, he was not worried about it, but his primary care physician was worried. There was not much to do, he was not complaining much during the day and was doing fine on four hours of sleep. That might be the rare case, but it can happen. 

Moderator:Great, thank you. The next question – how do you address hypervigilance at night? For example perimeter checking, anxiety with noises, etcetera.

Adam Bramoweth:Insomnia being so highly comorbid with PTSD is that is often some common behaviors you will see. You might want to combine aspects of CBTI with aspects of exposure therapy or as part of a course of light exposure therapy or cognitive processing therapy that helps you address both the hypervigilance issues as well as the sleep issues. I had a case that I consulted on a while back where a Veteran could not fall asleep without his gun and it was really a safety measure for him. You might just want to work around that initially and stabilize the sleep first with the perimeter checks or with safety checks allow that to take place. You might want to develop a hierarchy of how to reduce that in the construct of also engaging in healthy sleep behaviors and a good sleep schedule. 

Moderator:Thank you. The next question we have – what recommendations do you have for treating people who do shift work?

Adam Bramoweth:Similar to those previous questions is you have to be even more vigilant about following a schedule when you are a second shift, a third shift, a first shift and supplement that with use of Melatonin to help shift your internal prototype as well as using light therapy and avoiding light when you need to. It definitely becomes a more challenging case, but there are some methods that can help that individual on shift work to adapt to that schedule. 

Moderator:Thank you. Is there research on the use of CBTI in a group format?

Adam Bramoweth:There is and it is found to be successful and I think it is a matter of being adept in group therapy first of all and then being able to apply the CBTI format and being able to attend to the individual differences of people in the group. You have people with different schedules with different what might be initiation insomnia, maintenance insomnia but absolutely there is research out there and there are efforts to deliver CBTI in improved format. 

Moderator:Thank you. This one has a little correction so I am going to have to piece it together. I was glad to see a case where Veteran failed to show for his appointment, a common theme among OEF, OIF, OND Veterans in addition to poor follow through with sleep diaries and other assignments. I know there is no magic bullet, but do you have recommendations to improve follow through?

Adam Bramoweth:It is developing a rapport is of course important. I have gotten some feedback from other colleagues and how it might differ working with military and Veterans is you might take a more direct approach in really prescribing what they need to do rather than being as collaborative. I think it really depends on the person but some Veterans may be more open to just tell me what to do and I will do it. That might be one alternative approach but finding that balance between making these difficult behavior changes in a realistic way is absolutely key. If you need to go a little bit slower I found success being a little bit more aggressive in some cases, but there are definitely instances especially if a Veteran has comorbid PTSD, comorbid TBI. Their attention may not always be there, you might need to break it down into smaller components and slow down the process so this can be a brief therapy but it may not work for all patients and slowing down, focusing on different components at different times of treatment. Or you might need to address other issues like nightmares or pain before being able to focus on sleep. 

Moderator:Thank you. Are you aware of any data, evidence or resources on whether sleep insomnia affects suicide risk in Veterans?

Adam Bramoweth:I believe it does and I know insomnia is a risk factor. There is one study where those who had committed suicide with a sleep disorder were deceased much closer to their last appointment. I do not know the data off hand but I believe there is data that shows insomnia is a risk factor for suicidal behavior and suicide completion. 

Moderator:Thank you. What considerations do you need to take in the manual form of CBTI when working with Veterans who have mild traumatic brain injury?

Adam Bramoweth:I think you want to pay attention to maybe some of the concentration memory concerns; you do not want to throw too much information at them. Again treatment might want to be slowed down or focused on certain concepts. There is a lot of fatigue that is involved in TBI so that is something you might want to attend to is how to balance the construct of fatigue for sleepiness. Maybe how to avoid spending too much time resting, which again may impact later sleep at night or resting might  turn into mapping. I think those are some of the TBI specific issues that may play important role in the treatment of insomnia. 

Moderator:Thank you for that reply. We are going to continue on with the Q&A but I just want our attendees to note that I have put up the feedback survey now. Please take just a moment and respond to these questions while we continue on. The next question we have – do you have any special suggestions for treating insomnia comorbid with apnea?

Adam Bramoweth:Sure, that is another challenging case is when someone has both sleep apnea and insomnia is you are spending a lot of time awake in bed and you might not be wearing the mask and the mask might cause and you are very attentive to it not being comfortable. There are ways where you can focus on – one making sure when the mask is as comfortable as possible. Again, going through some desensitization techniques. And in following along with this you do not want to get into bed until you are ready to fall asleep with sleep apnea being sure you are wearing the mask anytime you are in bed. Some of those relaxation techniques again might also be important to reduce any distress that comes along with being awake, being anxious, wearing a C-PAP mask. It does make it more challenging and it is important to be sure that someone is wearing throughout the night. If they are not wearing the mask they are being awakened physiologically so the insomnia becomes secondary in that case. Maybe first and foremost is making sure they are wearing the C-PAP throughout the night, it is working effectively and then following up with the more structured schedule that can address the insomnia issues. 

Moderator:Thank you. We have just one pending question. Do you think VA could benefit from a step care model where some patients can be treated with sleep hygiene intervention education in two to three sessions and others can be referred on for further specialty care if necessary?

Adam Bramoweth:I do, I agree with the step care model but there are some patients that may be one session of information or getting referred to something like after deployment where they can manage it on their own. I think that is appropriate for some patients. Others while just the insomnia is more severe or they have some comorbid disorders that needs more attention again that could be in a primary care setting or maybe they need to see the psychologist who might even have further specialization certification in behavioral sleep medicine who can deal with the very complex cases. I think the step care model can fit within the VA especially the way that the pacts are working and integrated primary care mental health. I think insomnia fits into that very well. 

Moderator:Great thank you so much for taking the time to address the field with your expertise. It looks like people got a lot out of it. I want to thank our attendees for joining us today.

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