An estimated 20% of military service members suffer from clinically significant insomnia, 20% from nightmares, and 15% from posttraumatic stress disorder (PTSD). These disorders are highly interrelated, as they commonly occur together and can each worsen symptoms of the others and make them more difficult to treat.

When these conditions become chronic, they can impair both physical and psychological health and decrease quality of life. Therefore, effective and efficient treatments are sorely needed to help hundreds of thousands of affected service members. Fortunately, there are evidence-based treatments for all three conditions. Unfortunately, these treatments typically focus on one of the disorders and do not specifically address the interplay of vexing comorbidities. Addressing all three conditions, then, typically requires separate individual treatments in succession. That can take months to complete, causing discouragement, interfering with personal and military schedules, and otherwise leading to high patient drop-out rates.

Proposing a faster, three-pronged treatment approach

After previous success in using condensed approaches to deliver evidence-based therapy for PTSD, STRONG STAR investigators have developed a research study to evaluate an accelerated treatment method that integrates front-line therapies for co-occurring insomnia, nightmares, and PTSD.

The study is led by Carmen McLean, PhD, with the VA’s National Center for PTSD and Stanford University. It will begin with a pilot study in San Antonio involving service members at Wilford Hall Ambulatory Surgical Center and, based on the pilot study’s success, move on to a full-scale randomized clinical trial (RCT).

All participants will receive Written Exposure Therapy for PTSD, also known as WET. This brief, five-session treatment was shown in a previous STRONG STAR trial to be as effective as a longer, gold-standard treatment for PTSD in military service members.

Concurrently, participants will receive one of two sleep interventions. Half will receive education in good sleep hygiene, which involves establishing a sleep environment and sleep behaviors that are conducive to good sleep in both quantity and quality. The other half will receive an accelerated form of Cognitive-Behavioral Therapy for Insomnia and Nightmares, known as CBTi+n. CBTi+n was developed as a way to combine separate, evidence-based treatment approaches for insomnia and nightmares. The combined therapy has shown promise in initial clinical trials where it was delivered once weekly for six weeks.

The pilot study for this project will evaluate the conjoint delivery of WET and CBTi+n and the optimal schedule for an accelerated treatment format. Based on the success of the pilot study, investigators aim to develop a large RCT to determine the treatment’s efficacy. Their primary aim is to examine how well cognitive-behavioral treatment for insomnia and nightmares reduces sleep problems when integrated with PTSD treatment and delivered in an accelerated treatment format. They also want to explore the impact of the added sleep treatment on PTSD symptoms.

Expected benefits

If CBTi+n integrated with WET in an accelerated treatment format is found efficacious, it could be broadly disseminated throughout the military health system and make it easier for service members to seek and complete treatment for—and potentially recover from—co-occurring PTSD, insomnia, and nightmares. This could greatly benefit the mental and physical health and quality of life for individual military personnel and positively impact military readiness. The same treatment method likewise could be well utilized by VA and civilian providers to help veterans and members of the general public who suffer from the same conditions. In addition, this novel treatment approach could serve as an implementation model for addressing other psychological health disorders in service members, veterans, and civilian populations.