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: 9563953
• 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 2021-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9563953
• 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; Comorbidity; 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; 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 quality; 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.

在越南，创伤后应激障碍(PTSD)的终生患病率约为30% 退伍军人比例为11%-17%，伊拉克和阿富汗退伍军人比例为11%-17%。创伤后应激障碍与巨大的医疗保健有关 费用、自杀增加、抑郁、较差的生活质量和功能、身体健康，以及 物质使用。长期暴露(PE)是治疗退伍军人创伤后应激障碍(PTSD)的有效方法 避免害怕但安全的暗示。尽管PE是治疗创伤后应激障碍的最好方法之一，但25到 45%的PTSD患者在治疗后仍符合诊断标准。合并症发生率高，如 如失眠，可能会干扰PE的疗效，并限制长期康复结果。 在患有创伤后应激障碍的退伍军人中，睡眠障碍几乎是普遍的，70%-87%的人报告并存 失眠。未经治疗的失眠症可持续数年，与健康受损独立相关 生活质量，在创伤后应激障碍治疗后不能缓解，并会加剧日间创伤后应激障碍的症状。 重要的是，失眠可能会通过安全的学习、习惯性的恐惧来干扰体育的机制 刺激、情绪应对、情绪处理以及成功治疗所必需的认知能力。 尽管如此，失眠并不是患有创伤后应激障碍的退伍军人的主要干预措施。考虑到这些因素，至关重要的是 评估在创伤后应激障碍之前治疗失眠是否会改善创伤后应激障碍症状和生活质量。 认知行为治疗失眠(CBT-I)是治疗慢性和重度失眠的一线药物 失眠，这会带来持久的睡眠改善。通过在PE之前使用CBT-I并与其集成 提供几个新的优势，将：1)通过解决头号问题增加以客户为中心的治疗 患有创伤后应激障碍的退伍军人的主观抱怨；2)通过以下方式提高创伤后应激障碍的结局和无反应率 解决干扰创伤后应激障碍治疗的失眠相关因素；3)充当垫脚石，帮助 让最初不愿意从事创伤为重点的PE的患者参与；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的结果；5)允许 患者在较短的时间内解决失眠和创伤后应激障碍的症状；6)增加连续性 通过允许患者与单一提供者合作；以及7)减少转诊诊所之间的人员流失风险 还有候补名单。到目前为止，还没有研究在PE之前利用现有的基于证据的CBT-I来改善 失眠、创伤后应激障碍和生活质量结果。 建议的CDA-2随机对照试验将评估整合循证CBT-I的疗效 与非活动睡眠成分加PE(卫生-PE)相比，注入PE(CBTI-PE)可优化创伤后应激障碍、睡眠 90名退伍军人的生活质量。我们的研究有三个主要目标：AIM1(主要成果)： 探讨CBTI-PE与卫生学-PE对退伍军人创伤后应激障碍症状的疗效 同时患有创伤后应激障碍和失眠。目标2(次要结果)：检查CBTI-PE对睡眠和 与对照组相比，患有创伤后应激障碍的男性和女性退伍军人的生活质量结果 还有失眠。目标3(调节)：调查睡眠是否调节了治疗组之间的关系 创伤后应激障碍症状的减少。 将失眠作为一个独立的目标与PE相结合代表了一种合乎逻辑的、创新的和 扩大现有治疗和优化结果的经验性方法符合 2014-2020年VHA战略计划。拟议研究的结果将通过以下方式直接为临床实践提供信息 研究失眠与创伤后应激障碍联合治疗是否能促进失眠、创伤后应激障碍和 生活质量结果。这项研究的翻译计划将帮助脆弱的退伍军人群体 实现最佳和持久的恢复结果，并为未来的研究奠定基础，以便进一步 研究失眠与创伤后应激障碍的治疗结果及其他共病之间的机制。