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Combined Treatment Modalities

Mental health clinicians often use multiple treatment options when treating particular patients, especially if their conditions are relatively severe or treatment-resistant. The appropriate combination of treatments for an individual patient depends greatly on the specific disorder(s), the severity of the disorder(s), and such factors as the patient's willingness to get treatment and the patient's family and social life. Comorbidities create additional challenges in selecting a course of treatment, because insomnia can be both a symptom and a cause of other disorders. To address these issues, clinicians may choose to provide multiple forms of therapy or prescribe a medication in conjunction with therapy. This latter technique allows the clinician to provide patients with immediate relief of symptoms while addressing the underlying causes of their disease and creating positive impacts that last beyond the course of treatment. There are many different combinations of treatment types available, and there have been several studies on specific treatment combinations for sleep disorders among veterans.

Applications of Combined Treatment Modalities to Military Populations and Evidence of Effectiveness

Our review identified five studies showing that veterans suffering from insomnia and PTSD-related nightmares can be treated effectively with a combination of CBT-I and another behavioral treatment (Harb, Cook, et al., 2009; Ulmer, Edinger, and Calhoun, 2011; Margolies et al., 2013; Swanson et al., 2009; Nakamura et al., 2011). Appendix C, Table C.4, provides details of these studies. Although most of the studies used small sample sizes or lacked control conditions, they demonstrate that combined treatment modalities may be able to effectively improve sleep quality and duration and reduce nightmares and symptoms of insomnia and PTSD. Effect sizes observed in these studies ranged from 0.24 to 2.05 for the PSQI, 1.7 to 2.17 for the ISI, and 0.4 to 1.85 for PTSD symptom severity scales.

For instance, Germain, Richardson, and colleagues (2012) compared the effects of treating veterans with chronic sleep disturbances using a combined behavioral treatment that included components of CBT-I and IRT versus a pharmacologic agent, prazosin, or a placebo. They found that both prazosin and CBT-I were significantly better than the placebo at improving sleep quality and quantity and reducing PTSD symptom severity, but there were no significant differences in outcomes between the two treatment groups. Specifically, 62 percent of participants randomized to one of the treatment conditions experienced sleep improvements, whereas only 25 percent of those in the placebo group improved.

Unfortunately, the authors did not evaluate the effects of an intervention combining prazosin and CBT-I. This is a critical issue, and further study to examine the effects of a combined prazosin/CBT-I intervention is warranted to determine the value of prescribing prazosin in conjunction with CBT-I when treating chronic sleep disturbances among veterans, as opposed to either treatment in isolation. The potential benefit of combined behavioral and pharmacologic approaches is that they can provide patients with both rapid symptom relief (through pharmacologic agents) and more-enduring symptom relief (through behavioral strategies). However, combining behavioral treatments with pharmacologic therapy may diminish enduring treatment effects by reducing the patient's self-efficacy, particularly if they attribute positive effects to the medication rather than to behavioral changes.

Summary and Limitations of Combined Treatment Modalities

The generalizability of the findings from some of the studies described here is limited by small sample sizes (all but Germain, Richardson, et al., 2012, and Nakamura et al., 2011) and a lack of control groups (Harb, Cook, et al., 2009; Swanson et al., 2009; Ulmer, Edinger, and Calhoun, 2011). These limitations emphasize the need for more robust research in this field. The studies of multiple treatments described here do not include all treatment options, but they do illustrate the point that multiple treatment modalities can be paired to successfully treat servicemembers and veterans with sleep problems. This research serves as a guide for military health system and VHA providers, who must find adaptive and creative ways of treating their patients successfully.

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