Insomnia Treatment Acceptability and Preferences of Male Iraq and Afghanistan Combat Veterans and Their Healthcare Providers

Article excerpt


Sleep disturbance is one of the most frequently cited symptoms among soldiers returning from the Iraq war [1]. Physiological, psychological, military, and civilian readjustment stressors can initiate insomnia in Operations Iraqi Freedom/Operation Enduring Freedom (OIF/ OEF) Veterans. In response to acute sleep problems, patients may develop ineffective strategies to obtain sleep, poor sleep habits, and sleep-related dysfunctional cognitions. These responses perpetuate sleep difficulty and lead to chronic insomnia [2].

Insomnia is highly prevalent in patients with traumatic brain injury (TBI) [3], the leading injury in the current combat theaters of operation, and may be more common in mild than moderate or severe injuries [4]. Insomnia symptoms are reported by 50 percent of TBI patients, and 29 percent meet diagnostic criteria for an insomnia syndrome [3]. TBI patients report that insomnia interferes with daily functioning and exacerbates symptoms such as cognitive deficits, irritability, pain, and fatigue [3]. Difficulty with sleep onset and maintenance was reported by 93.5 percent of OIF/OEF Veterans seen at a Department of Veterans Affairs (VA) Polytrauma Network Site [5]. Sleep impairment is common in disorders associated with polytrauma such as posttraumatic stress disorder (PTSD) [6], depression [7], and pain [8]. These disorders are highly comorbid with TBI and may be better predictors of sleep disturbance than mild TBI [5,9]. In an analysis of the "polytrauma triad" (PTSD, pain, and TBI), PTSD was the major contributor to sleep difficulty in Veterans, and when it occurred with TBI, sleep disturbance increased [5]. Given the prevalence and effect of insomnia in mild TBI and polytrauma patients, tailored insomnia interventions are needed for this unique Veteran population.

In 2005, a National Institutes of Health State-of-the-Science panel recognized cognitive-behavioral treatment (CBT) as a first-line therapy for insomnia [10]. Two single-case design studies used CBT for insomnia (CBT-I) for mild-to-severe TBI patients in the non-Veteran population [11-12]. Cognitive deficits did not limit the subjects' ability to understand the treatment rationale, to self-monitor sleep, to demonstrate insight, or to benefit from CBT-I. Significant statistical and clinical reductions in insomnia, night-to-night variability, and fatigue were found and intervention effects were maintained at 1 and 3 months posttreatment. CBT-I improved sleep in conditions associated with traumatic injuries such as depression [13] and pain [14] in the non-Veteran population and PTSD in Veterans, including the OIF/OEF cohort [15]. These findings suggest that OIF/OEF Veterans who have experienced traumatic injuries may benefit from CBT-I. Unfortunately, nothing is known about this Veteran cohort's views on the acceptability of and preference for insomnia treatments.

Acceptability represents a favorable attitude toward a treatment option based on careful consideration of the treatment attributes (e.g., appropriateness, suitability, effectiveness, risks, and convenience). Patients' perceptions of treatment attributes influence their preferences for treatment. Treatment preferences denote patients' choices of treatment, that is, the treatment option patients want to receive to manage the presenting clinical problem [16]. Eliciting patient preferences is a key element of patient-centered care [17]. An increasing number of studies involve assessing participants' perception of treatment preferences, yet there is limited knowledge of patients' views regarding acceptability of and preferences for insomnia treatments [16].

Two studies found that behavioral interventions for insomnia were more acceptable and suitable than pharmacological treatment [18-19]. Morin et al. found the short-term effects of behavioral and medication treatments were rated equivalently by participants, but participants thought nonpharmacological treatment would be more effective in the long term, have fewer side effects, and have a more beneficial effect on daytime functioning than pharmacotherapy [18]. …


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