Cognitive Behavioral Therapy for Insomnia vs Brief Behavioral Therapy for Insomnia in Military Personnel with Postconcussive Symptoms Following Mild TBI

Feb 07, 2025

Hundreds of thousands of post-9/11 service members and veterans have experienced a mild traumatic brain injury, also called mTBI or concussion. Even after recovery, they may continue to suffer from a variety of TBI-related symptoms, such as insomnia, headaches, dizziness, fatigue, irritability, anxiety, poor concentration, memory problems, or ringing in the ears.

Insomnia, diagnosed when trouble falling or staying asleep becomes chronic and impacts daily life, is one of the most common problems after TBI. This is especially problematic for the warfighter. Sleep is an essential biological function that is critical for optimal physical health as well as brain health and mental performance.

Sleep’s long-term disruption, then, can lead to a host of problems. It can impede reaction times, decision making, threat assessments, and alertness to avoid mistakes. It can increase risk for mental and physical health problems such as suicide, post-traumatic stress disorder (PTSD), and chronic pain. And it can worsen other TBI-related symptoms.

Is there help? What is the best approach?

Fortunately, Cognitive Behavioral Therapy for Insomnia (CBT-I) and Brief Behavioral Therapy for Insomnia (BBT-I) are effective treatments for insomnia that occurs alone or with other problems like depression or chronic pain. CBT-I and BBT-I are recommended before sleep medications because they are just as effective in the short term and more effective in the long term by teaching patients how to manage root causes of insomnia. The treatments are somewhat similar, but CBT-I is longer, more intense, and provides greater education and counseling. BBT-I is shorter and more straightforward.

Both approaches may be beneficial for service members following mTBI. However, the problem is that there are no scientific studies to guide clinicians on how to best treat insomnia in patients with TBI-related symptoms. It is also unknown if treating insomnia can improve other TBI-related symptoms or brain functioning assessed with objective cognitive measures and with markers in the blood.

Study to provide guidance

With this in mind, Kristi Pruiksma, PhD, DBSM, with The University of Texas Health Science Center at San Antonio and her STRONG STAR colleagues have designed a study to inform clinical practice guidelines for the treatment of insomnia following mTBI. The study seeks to recruit 160 service members with insomnia and prolonged TBI symptoms being seen at the Intrepid Spirit Center at Fort Cavazos in Killeen, Texas.

Half of study participants will receive CBT-I and half will receive BBT-I, with assessments conducted before and during treatment and after treatment completion. This will enable researchers for the first time to validate whether behavioral insomnia treatments are effective with mTBI patients, and of the two options, which works better for this population. Along the way, researchers also will examine whether insomnia treatment leads to improvements in other TBI-related symptoms and whether it leads to improved brain functioning, as assessed with biological markers in the blood.

Expected outcomes and benefits

The immediate benefit will be to study participants, all of whom will receive an evidence-based insomnia intervention as part of the study – including one that is non-medication based and will not cause negative side effects.

The broader benefit will come from scientific evidence to inform clinical practice guidelines on the optimal treatment of insomnia following mTBI, and even on the incorporation of insomnia treatment into TBI care.

For the military, this would allow leaders and administrators to allocate appropriate clinical resources and clinicians to leverage these brief, non-medication treatments to improve daytime functioning and readiness of warfighters.

The general population is expected to benefit as well, since many people have experienced mTBIs from car crashes, other accidents, falls, or while playing sports. Behavioral treatment for insomnia takes time, effort, and commitment. In evaluating their options and selecting a course of treatment, all individuals can benefit from knowing what treatment or treatments work best for their needs in their situation.

Crisis Response Planning for Military Personnel with Mild Traumatic Brain Injury

Jan 27, 2025

Research shows that individuals who have been diagnosed with a mild traumatic brain injury, also called mTBI or concussion, are nearly twice as likely to die by suicide as those who have not. This may be due in part to common symptoms of mTBI that overlap with suicide risk factors, including reduced problem-solving ability, difficulty regulating emotions, impulsivity, and feelings of hopelessness, of being a burden to others, and/or of being trapped or stuck in bad situation.

Research also shows that the vast majority of individuals who attempt suicide made the decision to end their life within three hours of their suicide attempt, and over half of military suicide attempts occur on the same day as first onset of suicidal thoughts.

These findings together highlight two important points in the effort to reduce military suicide rates:

If we wait until a service members report suicidal ideation before we intervene, we will miss opportunities to save lives. We need good upstream suicide-prevention strategies with the goal of preventing the onset or progression of suicide risk among patients who do not have a history of suicidal thoughts or behaviors and who are not reporting current suicidal thoughts.
With their heightened risk for suicide, service members seeking treatment for mTBI could potentially benefit greatly from this type of “upstream” prevention strategy.

Researchers develop trial to test an early intervention strategy

With this in mind, STRONG STAR investigators have developed a clinical trial to evaluate Crisis Response Planning (CRP) as a secondary or upstream suicide-prevention tool with service members diagnosed with mTBI. The project is led by led by Principal Investigator (PI) Hannah Tyler, PhD, of The University of Texas Health Science Center at San Antonio and Partnering PI Craig Bryan, PsyD, of The Ohio State University.

CRP is a single-session, evidence-based, suicide-prevention intervention. With CRP, individual patients converse with their therapist and collaboratively develop a crisis response plan – a tangible, easily accessible memory aid and problem-solving tool that aims to help the patient survive a potential future suicide crisis. CRP achieves these goals by promoting emotion-regulation techniques (i.e., self-management skills, social supports, and reasons for living) and problem-solving skills (i.e., clear actions to take when warning signs are present).

This two-arm study will be conducted in collaboration with the Intrepid Spirit Center at C.R. Darnall Army Medical Center on Fort Cavazos, Texas. Half of study participants will receive treatment as usual through the Intrepid Spirit Center, while the other half will have CRP added to their treatment.

What they expect to find

Participants will be assessed at their beginning of the study and at various intervals for three months following. Researchers expect that participants who receive the CRP will report decreased impulsivity, hopelessness, burdensomeness, and entrapment while also reporting increased positive emotional experiences, resulting in decreased risk of suicide.

Results could support CRP utilization as a simple, low-cost, and efficient upstream suicide prevention strategy that targets key suicide risk factors and promotes protective factors, decreasing suicide mortality.

Project MARCH: Multisite Advancement of Research on Chronic Posttraumatic Headache

Jul 24, 2023

Nearly 3 million U.S. service members have deployed since 9/11, with up to 690,000 estimated to have suffered a traumatic brain injury (TBI). Posttraumatic headache (PTH), or headache onset or worsening after a head or neck injury, is the most common and disabling symptom from TBI. Other co-occurring conditions, such as posttraumatic stress disorder (PTSD), also can compound or even cause headaches. A national study showed chronic PTH (lasting more than 3 months) among 60%-65% of veterans with service-related TBI. Other studies have shown high unemployment rates and decreased activity levels in this population even 10 years after injury.

Non-medication treatments are needed
However, military PTH is poorly understood, with little guidance from research on how to manage it effectively. Due to its similarity to migraines, PTH is typically treated with the same types of medications. However, medication does not cure PTH, and overuse can worsen it, while side effects cause many to avoid or discontinue their use. And since medications do not address contributing factors like PTSD, there is great need for non-medication treatments for co-occurring psychological problems.

A promising non-medication intervention
In the first large, randomized clinical trial for military-related headache, a group of investigators successfully treated manualized, multi-component, cognitive-behavioral therapy for migraine headache adapted specifically for military PTH. The research team led by Donald McGeary, PhD, of the University of Texas Health Science Center at San Antonio, used a treatment called Combined Cognitive-Behavioral Therapy for PTH. It led to significant, lasting improvement in PTH and related disability in veterans who had PTH and PTSD symptoms and was as effective as a top PTSD therapy in reducing PTSD symptoms. By comparison, veterans receiving treatment as usual at a U.S. Department of Veterans Affairs (VA) polytrauma center showed no significant improvement in disability.

Building on success of previous trial
Dr. McGeary’s group has designed a STRONG STAR-affiliated study to build on that success. The group will enroll 525 participants from clinics at seven VA and U.S. Department of Defense sites nationwide. Military personnel and veterans who have chronic PTH with or without PTSD will be assigned randomly to one of three treatment arms: Combined Cognitive-Behavioral Therapy (CCBT), Telemedicine-Based Combined Cognitive-Behavioral Therapy (TCBT), or treatment as usual. That will allow investigators to compare CCBT and TCBT to treatment as usual among patients with diverse demographics, trauma and headache histories, and comorbidities and when delivered in different military and VA settings. It also will provide evidence about the therapy’s efficacy when delivered via telehealth, compared to in-person in a clinic. The research group will include Co-Principal Investigator Blessen Eapen, MD, chief of Physical Medicine & Rehabilitation at the Greater Los Angeles Veterans Health Care System, who has extensive experience in military trauma research.

Potential relief for thousands
If successful, this study will provide a needed evidence-based, non-medication treatment for reducing PTH and PTSD symptoms and disability that can be widely disseminated in military and VA facilities to a diversity of patients. Validation of the treatment via telehealth would further expand access at smaller or more remote locations. CCBT and TCBT potentially could improve the lives of hundreds of thousands of service members and veterans, boost military readiness, and reduce military and VA disability costs. With the high prevalence of PTH in civilians, the treatment also could benefit the general public.