The Impact of Integrated CBT-I and PE on Sleep and PTSD Outcomes

综合 CBT-I 和 PE 对睡眠和 PTSD 结果的影响

• 批准号: 10011583
• 负责人: Peter Colvonen
• 金额: --
• 依托单位: VA SAN DIEGO HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2016
• 资助国家: 美国
• 起止时间: 2016-10-01 至 2022-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10011583
• 关键词: Address; Affect; Afghanistan; Aftercare; Alcohol consumption; Alcohol or Other Drugs use; Applications Grants; Biological; Chronic; Chronic Insomnia; Client; Clinic; Cognitive; Cognitive Therapy; Comorbid Insomnia; Control Groups; Cues; Data; Diagnostic; Disease; Distress; Drug usage; Education; Emotional; Exposure to; Extinction (Psychology); Female; Fright; Future; Health Care Costs; Hygiene; Impaired health; Impairment; Informed Consent; Intervention; Investigator-Initiated Research; Iraq; Learning; Literature; Mediating; Mediation; Mental Depression; Mental Health; Methods; Outcome; Participant; Patients; Population; Post-Traumatic Stress Disorders; Prevalence; Provider; Psychotherapy; Quality of life; Randomized; Recovery; Rehabilitation Outcome; Reporting; Research; Risk; Safety; Sleep; Sleep disturbances; Sleeplessness; Stimulus; Strategic Planning; Substance Use Disorder; Suicide; Symptoms; Time; Training; Trauma; Treatment outcome; Veterans; Vietnam; Vulnerable Populations; Waiting Lists; Work; brief intervention; clinical practice; clinically significant; cognitive ability; community reintegration; comorbidity; control trial; coping; diaries; effective therapy; evidence base; experience; follow up assessment; follow-up; habituation; health related quality of life; improved; infancy; innovation; long-term rehabilitation; male; novel; physical conditioning; preference; primary outcome; research and development; secondary outcome; sleep regulation; therapy development; translational research program; treatment center; treatment group; treatment optimization

The lifetime prevalence of posttraumatic stress disorder (PTSD) is approximately 30% among Vietnam Veterans and 11-17% among Iraq and Afghanistan Veterans. PTSD is associated with enormous health care costs, increased suicidality, depression, poorer quality of life and functioning, physical health, and increased substance use. Prolonged exposure (PE) is an efficacious treatment for Veterans with PTSD that decreases avoidance of feared, but safe, cues. Despite PE being one of the best available treatments for PTSD, 25 to 45% of PTSD patients still meet diagnostic criteria following treatment. High rates of comorbid disorders, such as insomnia, may interfere with the efficacy of PE and limit long-term rehabilitation outcomes. Among Veterans with PTSD, sleep disturbances are nearly universal with 70 - 87% reporting comorbid insomnia. Untreated insomnia can persist for years, is independently associated with impaired health-related quality of life, does not resolve following PTSD treatment, and can exacerbate daytime PTSD symptoms. Importantly, insomnia may interfere with the mechanisms of PE through safety learning, habituation to feared stimuli, emotional coping, emotional processing, and cognitive abilities necessary for successful treatment. Despite this, insomnia is not a primary intervention for Veterans with PTSD. Given these factors, it is critical to evaluate whether treating insomnia prior to PTSD will improve PTSD symptoms and quality of life outcomes. Cognitive behavioral treatment for insomnia (CBT-I) is the first line treatment of chronic and severe insomnia, which produces lasting improvements in sleep. By using CBT-I prior to, and integrated with, PE offers several novel advantages that will: 1) increase client-centered treatment by addressing the number one subjective complaint among Veterans with PTSD; 2) enhance PTSD outcomes and non-response rates by addressing insomnia-related factors that interfere with PTSD treatment; 3) act as a stepping stone and help to engage patients who are not initially willing to engage in trauma-focused PE; 4) increase rehabilitation outcomes by addressing the two leading disorders that independently affect quality of life for Veterans; 5) allow patients to address both symptoms of insomnia and PTSD within a shortened timeframe; 6) increase continuity by allowing patients to work with a single provider; and 7) decrease the risk of attrition between referral clinics and waitlists. To date, no studies have capitalized on available evidence-based CBT-I prior to PE to improve insomnia, PTSD, and quality of life outcomes. The proposed CDA-2 randomized control trial will evaluate the efficacy of integrating evidence based CBT-I into PE (CBTI-PE) compared to a non-active sleep component plus PE (hygiene-PE) to optimize PTSD, sleep, and quality of life outcomes in 90 Veterans. Our research has three overarching aims: Aim1 (primary outcome): Investigate the efficacy of CBTI-PE compared to hygiene-PE on PTSD symptoms among Veterans with comorbid PTSD and insomnia. Aim 2 (secondary outcomes): Examine the effects CBTI-PE on sleep and quality of life outcomes, when compared to a control group, in male and female Veterans with comorbid PTSD and insomnia. Aim 3 (Mediation): Investigate whether sleep mediates the relationship between treatment group and the decreases in PTSD symptoms. Approaching insomnia as an independent target integrated with PE represents a logical, innovative, and empirically-informed method for augmenting existing treatments and optimizing outcomes consistent with the 2014-2020 VHA Strategic Plan. Findings from the proposed study will directly inform clinical practice by investigating whether treating insomnia together with PTSD increases the recovery from insomnia, PTSD, and quality of life outcomes. This translational program of research will help vulnerable Veteran populations achieve optimal and enduring recovery outcomes as well as lay the groundwork for future studies to further investigate the mechanisms between insomnia and PTSD treatment outcomes and other comorbid disorders.

越南的创伤后应激障碍 (PTSD) 终生患病率约为 30% 退伍军人，以及伊拉克和阿富汗退伍军人的 11-17%。 PTSD 与巨大的医疗保健相关 成本、自杀率增加、抑郁、生活质量和功能较差、身体健康状况恶化以及 物质的使用。长期暴露 (PE) 是治疗患有 PTSD 的退伍军人的有效方法，可减少 避免害怕但安全的暗示。尽管 PE 是治疗 PTSD 的最佳方法之一，但 25 至 45% 的 PTSD 患者在治疗后仍符合诊断标准。合并症的发生率很高，例如 如失眠，可能会干扰 PE 的疗效并限制长期康复结果。 在患有 PTSD 的退伍军人中，睡眠障碍几乎是普遍现象，70 - 87% 的人报告有共病 失眠。未经治疗的失眠可能持续数年，与健康受损独立相关 PTSD 治疗后不能解决问题，并且可能会加剧白天的 PTSD 症状。 重要的是，失眠可能会通过安全学习、对恐惧的习惯来干扰体育运动的机制 成功治疗所需的刺激、情绪应对、情绪处理和认知能力。 尽管如此，失眠并不是患有创伤后应激障碍 (PTSD) 退伍军人的主要干预措施。考虑到这些因素，至关重要的是 评估在 PTSD 之前治疗失眠是否会改善 PTSD 症状和生活质量。 失眠认知行为治疗 (CBT-I) 是慢性和严重失眠的一线治疗方法 失眠，从而持久改善睡眠。通过在 PE 之前使用 CBT-I 并与 PE 集成 提供了几个新颖的优势，这些优势将：1）通过解决第一个问题来增加以客户为中心的治疗 患有创伤后应激障碍 (PTSD) 的退伍军人的主观抱怨； 2) 通过以下方式提高 PTSD 结果和无反应率 解决干扰 PTSD 治疗的失眠相关因素； 3）作为踏脚石并帮助 让最初不愿意参与针对创伤的体育锻炼的患者参与进来； 4）增加康复 通过解决独立影响退伍军人生活质量的两种主要疾病来取得成果； 5）允许 患者在更短的时间内解决失眠和创伤后应激障碍（PTSD）症状； 6）增加连续性 允许患者与单一提供者合作； 7) 降低转诊诊所之间的人员流失风险 和候补名单。迄今为止，还没有研究利用现有的基于证据的 CBT-I 在 PE 之前来改善 失眠、创伤后应激障碍 (PTSD) 和生活质量结果。 拟议的 CDA-2 随机对照试验将评估整合基于证据的 CBT-I 的功效 与非活动睡眠成分加 PE（卫生-PE）相比，PE（CBTI-PE）可优化 PTSD、睡眠、 90 名退伍军人的生活质量。我们的研究有三个总体目标： 目标 1（主要结果）： 研究 CBTI-PE 与卫生 PE 相比对患有 PTSD 症状的退伍军人的疗效 共病 PTSD 和失眠。目标 2（次要结果）：检查 CBTI-PE 对睡眠和睡眠的影响 与对照组相比，患有共病 PTSD 的男性和女性退伍军人的生活质量结果 和失眠。目标 3（中介）：调查睡眠是否中介治疗组之间的关系 以及 PTSD 症状的减少。 将失眠作为一个与 PE 相结合的独立目标代表了一种合乎逻辑的、创新的和 基于经验的方法，用于增强现有治疗并优化与现有治疗相一致的结果 2014-2020 VHA 战略计划。拟议研究的结果将直接为临床实践提供信息 研究将失眠与创伤后应激障碍 (PTSD) 一起治疗是否可以促进失眠、创伤后应激障碍 (PTSD) 和创伤后应激障碍 (PTSD) 的恢复 生活质量结果。这项转化研究计划将帮助弱势退伍军人群体 实现最佳和持久的恢复结果，并为未来的研究奠定基础 研究失眠与创伤后应激障碍（PTSD）治疗结果以及其他共病之间的机制。