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

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.