Increasing PTSD Treatment Engagement in Women Veterans: Role of CBT for Insomnia

Background: Posttraumatic stress disorder (PTSD) is the most common psychiatric service-connected
condition among women Veterans, yet many women Veterans do not receive evidence-based psychotherapies
for PTSD. PTSD and insomnia disorder are highly comorbid in women Veterans and research suggests that
insomnia is a risk factor for PTSD development and severity, while healthy sleep is associated with improved
mood, daytime functioning, enhanced learning, and increased emotion regulation. Addressing insomnia
symptoms in women Veterans may offer an early point of intervention to reduce insomnia and some PTSD
symptoms, while also providing a novel approach to improve patient engagement in PTSD treatments.
Significance/Impact: Women's health and mental health (specifically PTSD) are research priority areas for
VA. Women Veterans experience multiple barriers to PTSD treatments including: perceived stigma, severity of
symptoms/emotion dysregulation, and scheduling/time constraints. Providers report delaying PTSD treatments
due to perceptions of patients' “unreadiness” to begin PTSD treatments. Cognitive Behavioral Therapy for
Insomnia (CBT-I; first-line treatment for insomnia) is perceived as highly acceptable to women Veterans,
improves sleep in individuals with comorbid psychiatric conditions, offers a brief intervention alternative to
psychotherapy protocols for PTSD, and is widely disseminated within VA.
Innovation: No previous studies have examined the impact of trauma-informed CBT-I on sleep and psychiatric
symptoms among women Veterans with comorbid insomnia disorder and PTSD. The project will utilize a mixed
methods approach, gathering novel information from women Veterans to identify facilitators of and barriers to
PTSD and insomnia treatments among women Veterans. While there are indications that CBT-I may serve as
a preparatory treatment to other evidence-based psychotherapies, this would be the first study to utilize a
trauma-informed CBT-I protocol and examine mental health treatment engagement as a primary outcome.
Specific Aims: The specific aims are to: 1) Iteratively refine the structure and materials of trauma-informed
CBT-I in preparation for a pilot trial, 2) Pilot test the effects of trauma-informed CBT-I on PTSD treatment
readiness and engagement in a sample of women Veterans, and 3) Examine potential mechanisms
underlying variations in PTSD treatment readiness and engagement over time among women Veterans.
Methodology: The proposed project will be carried out within VAGLAHS. In Aim 1, women Veterans will
sequentially receive the trauma-informed CBT-I protocol. We will obtain qualitative feedback from each
participant, and make needed refinements before administering the protocol to the next participant (anticipated
n=5). In Aim 2, women Veterans with comorbid insomnia disorder and PTSD will be recruited to participate in
a behavioral intervention study and eligible participants will be randomly assigned to either trauma-informed
CBT-I (n=25) or PTSD psychoeducation modeled after usual care (n=25). Participants will complete measures
of sleep, mental health symptoms, and PTSD treatment readiness at baseline, post-treatment, and 6-month
follow-up. All participants will be offered a referral to PTSD treatment and treatment engagement will be
assessed at 6-month follow-up. In Aim 3, as part of the pilot trial, we will assess known barriers to PTSD
treatment engagement at each time point. We will conduct qualitative interviews with pilot trial completers and
non-completers (anticipated n=20) to better understand the processes underlying PTSD treatment readiness
and engagement among women Veterans with comorbid insomnia and PTSD.
Next Steps/Implementation: Findings will directly inform patient care by increasing treatment choices for
women Veterans who are not yet ready to begin PTSD treatment. Findings will also generate preliminary data
to inform future VA Merit Award applications involving an effectiveness trial of trauma-informed CBT-I and
mixed methods to examine treatment preferences among women Veterans with insomnia and PTSD.

Grant Number: 5IK2HX003332-03
NIH Institute/Center: VA
Principal Investigator: Gwendolyn Carlson