Technological Developments in Treatment Delivery
A significant challenge in treatment delivery is overcoming barriers to dissemination. Servicemembers are often hard to reach because of their training, deployment, and relocation schedules. Additionally, the small number of qualified behavioral health specialists limits the availability of CBT-I (Siebern and Manber, 2011). Technologies that enable patients to obtain treatment without coming face to face with providers can dramatically improve dissemination. Several mental health-related smartphone and Internet applications have become available in recent years, and their creators claim that they can improve dissemination and treatment outcomes. Since these applications are still relatively new, there is little empirical evidence to support these claims of their efficacy as treatment modalities and tools. Telehealth (i.e ., the use of electronic information and telecommunications technologies, including telephone, Internet, and video conferencing, to support clinical care) has been used for a longer period and has shown efficacy in some studies, but the use of telehealth in treating servicemembers and veterans with sleep disturbances is a relatively unexplored area of research. Only one recent study has examined the efficacy of telephone-delivered CBT-I involving sleep restriction, stimulus control, sleep hygiene, cognitive therapy, and relapse prevention. The researchers observed that the patients receiving the treatment experienced greater improvements in sleep-related cognition and daytime insomnia symptoms than those in the control group (Arnedt et al., 2013). The interest in and market for these technological health care applications are growing rapidly, so further research into their use and efficacy is greatly needed.
The study described above used participants in the civilian population, but a similar study of servicemembers or veterans has not been conducted. However, Luxton, Mishkind, and colleagues (2012) examined the feasibility of using the two-way video functions of smartphones to conduct video chat therapy sessions between servicemembers and providers. The authors found that the barriers to successful implementation mainly included connection limitations, such as a lack of reliable wireless Internet or cellular service in certain areas. However, when a strong connection was established, the servicemembers were generally very comfortable using this platform to communicate. This research effort demonstrates the feasibility of using video chat and smart-phones to conduct therapy sessions between providers and servicemembers, which may be a more effective method than simple telephone communication. However, these findings need to be replicated to measure the added value of video interaction during teletherapy.
Several mental health treatment programs have also been developed for use over the Internet through designated websites. Such treatments have the advantages of convenience for patients, low costs, and high accessibility (Siebern and Manber, 2011). Evaluations of some of these programs have shown evidence of efficacy in reducing symptoms of insomnia and comorbid disorders (Espie et al., 2012; Thorndike, Ritterband, Gonder-Frederick, et al., 2013; Ritterband et al., 2009). A web-based CBT-I course delivered by a virtual therapist was used in an RCT to treat adults with chronic insomnia. Compared with treatment as usual and a placebo condition, this intervention was associated with significant improvements in sleep efficiency and sleep-wake functioning (Espie et al., 2012). Another online CBT-I program, called SHUTi (Sleep Healthy Using the Internet), was associated with significant improvements in insomnia severity scores, wake after sleep onset, sleep efficiency, fatigue, and mental health quality of life (Ritterband et al., 2009; Thorndike, Ritterband, Gonder-Frederick, et al., 2013). Because these studies included civilian participants, research on the use of online interventions with military populations is warranted. The Center for Deployment Psychology also has an online CBT-I program (Brim, 2013), but the efficacy of this program has not been systematically evaluated.
Recent efforts have promoted the use of smartphone applications as tools to aid in treatment delivery to servicemembers and veterans suffering from sleep disturbances and disorders. Unfortunately, the empirical evidence base for using smartphone applications in this manner is limited because they were developed only recently. One application, called PTSD Coach, was evaluated with veterans receiving treatment for PTSD at a VHA residential treatment program. The researchers noted that the participants generally felt very satisfied with PTSD Coach and perceived it to be helpful in managing their PTSD symptoms. The participants primarily used the application to manage acute distress and to help with sleep onset (Kuhn et al., 2014). However, quantitative data to measure symptom severity changes were not collected. Another application to aid in prolonged exposure (PE) therapy, PE Coach, contains tools designed to help therapists and patients improve implementation, fidelity, and homework adherence during treatment for PTSD. These tools are purported to help reduce PTSD symptoms, including sleep disturbances (Reger et al., 2013). However, no scientific evaluations have provided evidence in support of the claims made by PE Coach's developers. Additionally, this application targets sleep disturbances as symptoms of PTSD, not insomnia specifically.
Because the U.S. population uses smartphones extensively, these devices offer a highly accessible platform for delivering tools to aid in treatment to servicemembers and veterans. The two-way video capabilities of smartphones allow for face-to-face interaction between patients and providers who cannot meet for treatment in person. This method may bolster the effectiveness of CBT-I interventions delivered by telephone. Smartphone applications also provide easy ways to deliver tools to patients, which may complement treatments and improve adherence and outcomes. The highly customizable nature of these applications allows software developers to create a wide range of tools that may be useful to clinicians and patients. The use of wearable electronic devices (i.e., actigraphs and accelerometers) to measure sleep and activity may also help the military monitor the sleep habits of servicemembers (van Wouwe, Valk, and Veenstra, 2011). In fact, in our working group meeting, participants recommended increasing the use of technology for monitoring sleep and alertness as a primary strategy; however, the group also noted that these instruments must be validated before broader dissemination can be recommended.
More research is needed to identify the added value of smartphone applications and wearable devices, as well as the efficacy of treatments delivered by technological platforms to servicemembers and veterans. This research should drive the future development of technologies aimed at treating this population, because there may be clear benefits in reducing the stigma associated with visiting a behavioral health clinic. These technologies could also increase access for servicemembers living in remote locations and enhance the dissemination of evidence-based treatments.