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Evidence-Based Behavioral Treatments for Sleep Disorders Among Servicemembers

The following sections review the current empirical literature on evidence-based treatments for sleep disorders using samples of active-duty servicemembers or veterans. We focused our review on the treatment of insomnia and nightmares because these are the most common sleep disturbances among servicemembers. Also, unlike other sleep disorders, such as OSA, narcolepsy, or parasomnia, the causes of insomnia and nightmares in a military population are commonly related to military service or combat trauma and may require tailored treatments (Center for Integrated Healthcare, 2009).

Cognitive-Behavioral Therapy for Insomnia

CBT is often used by mental health clinicians to treat a range of mental health disorders. CBT techniques have been the subject of many research studies, and the empirical evidence base on CBT efficacy and effectiveness is quite robust (Butler et al., 2006). CBT for insomnia (CBT-I) has been shown to be a highly effective treatment for insomnia and for some other sleep-related symptoms (Mitchell et al., 2012). A course of CBT-I comprises multiple cognitive and behavioral techniques, most often including stimulus control, sleep restriction, and cognitive restructuring. Numerous meta-analyses of CBT-I and pharmacologic interventions show that CBT-I is just as effective, and often more enduring (in terms of the stability of treatment gains after active treatment has terminated), than medications for treating insomnia (Morin, Culbert, and Schwartz, 1994; Irwin, Cole, and Nicassio, 2006; Mitchell et al., 2012; National Institutes of Health, 2005).

In 2005, the National Institutes of Health published a conference statement on chronic insomnia, in which they recommended CBT-I as a highly efficacious treatment for insomnia. Unlike treatment with medication, CBT-I has been shown to produce beneficial effects that persist even after active treatment is discontinued, perhaps because the patient learns new skills that can be used long after direction from a therapist is removed.

The VA's Center for Integrated Healthcare, which serves to integrate primary care and mental health services, has advocated using cognitive and behavioral therapies in treating military members and veterans with sleep problems related to combat trauma. In its report summarizing recommendations from an expert panel held on this subject in 2009, the Center for Integrated Healthcare endorsed CBT-I and IRT (described below) as empirically supported treatments for insomnia and recurrent nightmares, respectively, within military and veteran populations (Center for Integrated Healthcare, 2009). This being said, most CBT-I studies have been conducted with civilian samples, which means less is known about the efficacy of CBT-I for servicemembers and veterans. The unique experiences of servicemembers and veterans may necessitate adaptations to CBT-I treatment protocols. In particular, although side effects are less common with behavioral approaches than with pharmacologic approaches, both stimulus control and sleep restriction therapies (two integral components of CBT-I) often result in at least temporary increases in daytime sleepiness, which could be problematic in operational settings. Furthermore, the dissemination of CBT-I to patients in the military health system and VHA has been slow. Nevertheless, CBT-I has shown promise in effectively treating military populations.

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