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CDA 20-227 – HSR&D Study

Pre-Funded | New | Current | Completed | DRA | DRE | Portfolios/Projects | Centers | Career Development Projects
CDA 20-227
Increasing PTSD Treatment Engagement in Women Veterans: Role of CBT for Insomnia
Gwendolyn C Carlson PhD
Sepulveda, CA
Funding Period: January 2023 - December 2027


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.

NIH Reporter Project Information:


Journal Articles

  1. Ravyts SG, Erickson AJ, Washington DL, Yano EM, Carlson GC, Mitchell MN, Kelly M, Alessi CA, McGowan SK, Song Y, Martin JL, Dzierzewski JM. A non-inferiority randomized controlled trial comparing behavioral sleep interventions in women veterans: An examination of pain outcomes. Journal of psychosomatic research. 2023 Oct 21; 175:111536.
  2. Saldana KS, Carlson GC, Revolorio K, Kelly MR, Josephson KR, Mitchell MN, Culver N, Kay M, McGowan SK, Song Y, Deleeuw C, Martin JL. Values Expressed by Women Veterans Receiving Treatment for Chronic Insomnia Disorder. Behavioral sleep medicine. 2023 Sep 25; 1-13.
  3. Martin JL, Carlson GC, Kelly MR, Song Y, Mitchell MN, Josephson KR, McGowan SK, Culver NC, Kay MA, Erickson AJ, Saldana KS, May KJ, Fiorentino L, Alessi CA, Washington DL, Yano EM. Novel treatment based on acceptance and commitment therapy versus cognitive behavioral therapy for insomnia: A randomized comparative effectiveness trial in women veterans. Journal of consulting and clinical psychology. 2023 Nov 1; 91(11):626-639.
  4. Moghtaderi I, Kelly MR, Carlson GC, Fung CH, Josephson KR, Song Y, Swistun D, Zhu R, Mitchell M, Lee D, Badr MS, Washington DL, Yano EM, Alessi CA, Zeidler MR, Martin JL. Identifying gaps in clinical evaluation and treatment of sleep-disordered breathing in women veterans. Sleep & Breathing = Schlaf & Atmung. 2023 Oct 1; 27(5):1929-1933.

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Prevention, TRL - Applied/Translational
Keywords: Career Development
MeSH Terms: None at this time.

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