CBT-I Application to Military Populations and Evidence of Effectiveness
Our review identified five studies that assessed the use of CBT-I in veteran populations, all of which demonstrated its efficacy in reducing insomnia symptoms. Appendix C, Table C.1, describes these studies and their results. Overall, the results from these efforts show that when used to treat servicemembers and veterans, CBT-I reduces insomnia symptoms and core PTSD and depressive symptoms, with moderate to large effect sizes. Specifically, effect sizes reported for changes in the ISI ranged from 1.08 to 3.2, while those for sleep efficiency ranged from 1.4 to 1.57 (Talbot et al., 2014; Margo-lies, 2011; Gellis and Gehrman, 2011; Koffel and Farrell-Carnahan, 2014; Perlman et al., 2008). One study observed a 41-percent remission rate for insomnia among CBT-I patients, compared with a 0-percent remission rate among control group patients (Talbot et al., 2014). This is an important finding, because insomnia and PTSD are commonly comorbid in combat veterans. In fact, one study showed that insomnia was the most frequently reported symptom of PTSD in a sample of post-deployed service-members (McLay, Klam, and Volkert, 2010). To enhance dissemination, several studies tested different treatment modalities of CBT-I, including group settings (Perlman et al., 2008; Koffel and Farrell-Carnahan, 2014). These studies also showed positive results for reducing insomnia symptoms and may provide a useful strategy for enhancing dissemination.
Summary and Limitations of CBT-I
Overall, the studies on CBT-I in military populations show highly promising results, with similar effect sizes (i.e., in the moderate to large range) in terms of reducing insomnia symptoms and improving sleep continuity compared with the robust civilian literature on CBT-I treatment efficacy. The magnitude of these results is also comparable to reported effect sizes in studies of pharmacologic interventions, which have, to date, been only systematically studied in civilian populations. However, given the relatively small number of studies and the small sample sizes (N = 8-45), larger studies, including more randomized controlled trials (RCTs), are needed to identify the effectiveness of CBT-I in treating servicemembers and veterans with insomnia. Furthermore, many of the participants in these studies suffered from multiple conditions or used other treatments during the trials (e.g., medications) . Therefore, it is difficult to estimate the true efficacy of the CBT-I interventions used. Then again, positive results from these real-world samples may demonstrate the effectiveness of CBT-I. Moreover, given the finding from one study that showed that treating insomnia with CBT-I also reduced core PTSD and depressive symptoms, more research is needed to examine the efficacy of combined treatment strategies in commonly comorbid conditions (e.g., insomnia, PTSD, depression, and TBI; Margolies, 2011). Finally, even though CBT-I may be effective in treating insomnia in military populations, the dissemination of this treatment option has proven difficult, partly because there is a critical shortage of trained providers and partly because of a lack of provider knowledge about the existence of these treatments and a lack of availability at the traditional point of contact (i.e., primary care settings).
To address some of the dissemination challenges, the VHA began a national dissemination program to train mental health providers to deliver CBT-I to patients. This program involved a three-day CBT-I training workshop for clinicians (Manber, Carney, et al., 2012). Karlin and colleagues (2013) evaluated the effects of this dissemination program on clinician competency and patient health outcomes. After collecting data from 102 VHA clinicians and 182 veteran patients diagnosed with insomnia, the researchers found that clinician competency increased and patient insomnia symptom severity decreased significantly over the CBT-I training period. The study did not involve a control group, and the clinicians understood that their CBT-I competence was being observed and measured, so the results may not generalize to "real-life" clinical settings. However, the results show promise that the VHA's CBT-I dissemination program is having positive effects and may be a model for future large-scale dissemination efforts.
The Center for Deployment Psychology has also established workshops to train DoD behavioral health professionals on CBT-I techniques. In addition to in-person workshops, the center offers virtual CBT-I workshops and remote courses. Since the program started in October 2010, it has trained more than 1,400 providers and continues to provide consultation after workshop completion (Brim, 2013). However, evaluation of the efficacy of these programs in terms of provider knowledge, competence, adherence, and patient outcomes has yet to be conducted.
CBT-I remains one of the most efficacious treatment modalities for insomnia. The efficacy of CBT-I has been shown in military and veteran populations, and a study of the feasibility of its widespread implementation in the VHA has shown encouraging results. Treatment with CBT-I has the benefit of addressing the behaviors that perpetuate insomnia and producing lasting effects after the treatment stops. This benefit is not seen with pharmacotherapy, which is a very common front-line treatment modality prescribed to military members and veterans suffering from sleep problems (Schmitz, Browning, and Webb-Murphy, 2009). Policy changes are needed within the military health system and VHA to address this inconsistency between health care practice and the empirical evidence. Continued dissemination efforts, greater education about CBT-I for primary care providers, and more training for mental health care providers are needed in both the military health system and VHA to make CBT a front-line treatment for insomnia.