Mending Broken Sleep of Broken Brains
Authors:   , Ford Marthe Eleonora 
Published: January 2023

Chapter 1 introduces insomnia following acquired brain injury. The main aim of our thesis is to investigate whether cognitive behavioral therapy can be effective for people with traumatic brain injury or a stroke, with a special interest in the efficacy of blended cognitive behavioral therapy, combining face-to-face with online sessions.
Chapter 2 is a systematic review summarizing and appraising previous studies on the efficacy of non-pharmacological treatments for insomnia after brain injury in adults. The results of the systematic review showed evidence of the efficacy of CBT-I on insomnia symptoms in studies with small samples.
In Chapter 3 we describe a newly developed blended online cognitive behavioral therapy for insomnia (eCBT-I) for people with acquired brain injury, and our study protocol. The eCBT-I comprises six guided online sessions given on a weekly basis, combined with two face-to-face sessions and a smart-phone diary app for daily reporting of sleep. The eCBT-I has been adjusted to people with acquired brain injury and includes specific education about the nature and treatment of insomnia after brain injury.
Next, the question was whether people with acquired brain injury could benefit of the 6 weeks of eCBT-I. To answer this question, we first conducted a pilot study, presented in chapter 4. The primary aim of this study was to examine the effects of eCBT-I on sleep in 5 patients with post-stroke insomnia. Five sleep diary measures were assessed and all improved, significantly so for nocturnal awakenings. Moreover, after completion of the treatment, four out of five participants no longer fulfilled DSM-5 criteria for insomnia disorder. Cognitive deficits, psychiatric comorbidity or pain of the participants were no barrier to adhere and benefit from eCBT-I. Exploratory analyses revealed slight improvements on fatigue, emotional well-being and cognitive functioning post treatment. The findings justified a randomized controlled trail.
Chapter 5 describes a randomized controlled trial to evaluate the efficacy of eCBT-I developed specifically for people with insomnia following acquired brain injury (as described in chapter 3). In a multicenter study, 52 participants with insomnia and a history of traumatic brain injury or a stroke were randomized to eCBT-I or treatment as usual, with a 6-week follow up. Results showed that insomnia severity improved significantly more with eCBT-I than with TAU compared to baseline, both at post treatment and at follow-up. Moreover, clinical remission and/or a clinical meaningful improvement was attained by more participants of the eCBT-I group compared to the TAU group, both at post treatment and follow up. The effects of eCBT-I on secondary outcomes were less pronounced, as we found no clear benefits of eCBT-I over TAU on fatigue, emotional well-being, cognitive functioning, and societal participation. We conclude that eCBT-I is a feasible and effective treatment for insomnia following traumatic brain injury or a stroke.
In chapter 6 we describe a cross-sectional study to investigate the role of sleep-related beliefs and behaviors in insomnia in a population with acquired brain injury. Only a very limited number of items assessing sleep-related beliefs and behaviors were unanimously considered maladaptive by experts. These items were mostly confined to diminished perception of control and worry about sleep. Several supposedly maladaptive beliefs and behaviors were actually regarded as adequate coping with the consequences of the brain injury.
The final chapter 7 presents the general discussion. Based on our systematic review of merely small group studies, we concluded that CBT-I seemed effective for people with insomnia following traumatic brain injury or a stroke. Furthermore, based on our two empirical studies, we also concluded that blended CBT-I is effective and feasible for insomnia following traumatic brain injury or a stroke.