Increasing PTSD Treatment Engagement in Women Veterans: Role of CBT for Insomnia

背景：创伤后应激障碍（PTSD）是最常见的精神科服务相关疾病， 妇女退伍军人的状况，但许多妇女退伍军人没有接受循证心理治疗 创伤后应激障碍创伤后应激障碍和失眠症在女性退伍军人中高度共病，研究表明， 失眠是创伤后应激障碍发展和严重程度的危险因素，而健康的睡眠与改善 情绪，白天功能，增强学习和增加情绪调节。解决失眠问题 女性退伍军人的症状可能提供一个早期干预点，以减少失眠和一些创伤后应激障碍 症状，同时也提供了一种新的方法，以提高患者参与创伤后应激障碍治疗。 意义/影响：妇女的健康和心理健康（特别是创伤后应激障碍）是研究的优先领域， 弗吉尼亚女性退伍军人在创伤后应激障碍治疗中遇到多种障碍，包括：感知的耻辱， 症状/情绪失调和时间安排/时间限制。供应商报告延迟PTSD治疗 这是因为人们认为病人“没有准备好”开始创伤后应激障碍治疗。认知行为治疗 失眠（CBT-I;失眠的一线治疗）被认为是女性退伍军人高度接受的， 改善患有精神疾病的患者的睡眠，提供一种短暂的干预替代方案， PTSD的心理治疗方案，并在VA内广泛传播。 创新：以前的研究没有检查过创伤知情CBT-I对睡眠和精神疾病的影响。 患有失眠症和创伤后应激障碍的退伍军人中的症状。该项目将采用混合 方法的方法，收集新的信息，从妇女退伍军人，以确定促进者和障碍， 创伤后应激障碍和失眠治疗女性退伍军人。虽然有迹象表明，CBT-I可以作为 作为其他循证心理疗法的预备治疗，这将是第一项利用 创伤知情CBT-I协议，并检查心理健康治疗参与作为主要结果。 具体目标：具体目标是：1）反复完善创伤知情的结构和材料 CBT-I为初步试验做准备，2）初步测试创伤知情的CBT-I对PTSD治疗的影响 准备和参与妇女退伍军人的样本，和3）检查潜在的机制 潜在的变化，创伤后应激障碍治疗准备和参与随着时间的推移，女性退伍军人。 方法：拟议的项目将在VAGLAHS内执行。在目标1中，女退伍军人将 顺序地接收所述创伤通知的CBT-I协议。我们将从每个人那里获得定性反馈 参与者，并在对下一个参与者（预期）实施方案之前进行必要的改进 n=5）。在目标2中，将招募患有失眠症和创伤后应激障碍共病的女性退伍军人参加 一项行为干预研究，合格的参与者将被随机分配到 CBT-I（n=25）或常规护理后的PTSD心理教育（n=25）。参与者将完成措施 基线、治疗后和6个月时的睡眠、心理健康症状和PTSD治疗准备情况 随访所有参与者都将被推荐接受创伤后应激障碍治疗， 在6个月随访时进行评估。在目标3中，作为试点试验的一部分，我们将评估已知的PTSD障碍 在每个时间点进行治疗。我们将对试点试验完成者进行定性访谈， 未完成者（预期n=20），以更好地了解PTSD治疗准备的基础过程 以及患有失眠症和创伤后应激障碍的女性退伍军人的参与。 后续步骤/实施：研究结果将通过增加治疗选择直接告知患者护理， 尚未准备好开始创伤后应激障碍治疗的女性退伍军人。调查结果还将产生初步数据 告知未来VA优异奖申请涉及创伤知情CBT-I的有效性试验， 混合方法来检查患有失眠症和PTSD的女性退伍军人的治疗偏好。

Background: Posttraumatic stress disorder (PTSD) is the most common psychiatric service-connected condition among women Veterans, yet many women Veterans do not receive evidence-based psychotherapies for PTSD. PTSD and insomnia disorder are highly comorbid in women Veterans and research suggests that insomnia is a risk factor for PTSD development and severity, while healthy sleep is associated with improved mood, daytime functioning, enhanced learning, and increased emotion regulation. Addressing insomnia symptoms in women Veterans may offer an early point of intervention to reduce insomnia and some PTSD symptoms, while also providing a novel approach to improve patient engagement in PTSD treatments. Significance/Impact: Women's health and mental health (specifically PTSD) are research priority areas for VA. Women Veterans experience multiple barriers to PTSD treatments including: perceived stigma, severity of symptoms/emotion dysregulation, and scheduling/time constraints. Providers report delaying PTSD treatments due to perceptions of patients' “unreadiness” to begin PTSD treatments. Cognitive Behavioral Therapy for Insomnia (CBT-I; first-line treatment for insomnia) is perceived as highly acceptable to women Veterans, improves sleep in individuals with comorbid psychiatric conditions, offers a brief intervention alternative to psychotherapy protocols for PTSD, and is widely disseminated within VA. Innovation: No previous studies have examined the impact of trauma-informed CBT-I on sleep and psychiatric symptoms among women Veterans with comorbid insomnia disorder and PTSD. The project will utilize a mixed methods approach, gathering novel information from women Veterans to identify facilitators of and barriers to PTSD and insomnia treatments among women Veterans. While there are indications that CBT-I may serve as a preparatory treatment to other evidence-based psychotherapies, this would be the first study to utilize a trauma-informed CBT-I protocol and examine mental health treatment engagement as a primary outcome. Specific Aims: The specific aims are to: 1) Iteratively refine the structure and materials of trauma-informed CBT-I in preparation for a pilot trial, 2) Pilot test the effects of trauma-informed CBT-I on PTSD treatment readiness and engagement in a sample of women Veterans, and 3) Examine potential mechanisms underlying variations in PTSD treatment readiness and engagement over time among women Veterans. Methodology: The proposed project will be carried out within VAGLAHS. In Aim 1, women Veterans will sequentially receive the trauma-informed CBT-I protocol. We will obtain qualitative feedback from each participant, and make needed refinements before administering the protocol to the next participant (anticipated n=5). In Aim 2, women Veterans with comorbid insomnia disorder and PTSD will be recruited to participate in a behavioral intervention study and eligible participants will be randomly assigned to either trauma-informed CBT-I (n=25) or PTSD psychoeducation modeled after usual care (n=25). Participants will complete measures of sleep, mental health symptoms, and PTSD treatment readiness at baseline, post-treatment, and 6-month follow-up. All participants will be offered a referral to PTSD treatment and treatment engagement will be assessed at 6-month follow-up. In Aim 3, as part of the pilot trial, we will assess known barriers to PTSD treatment engagement at each time point. We will conduct qualitative interviews with pilot trial completers and non-completers (anticipated n=20) to better understand the processes underlying PTSD treatment readiness and engagement among women Veterans with comorbid insomnia and PTSD. Next Steps/Implementation: Findings will directly inform patient care by increasing treatment choices for women Veterans who are not yet ready to begin PTSD treatment. Findings will also generate preliminary data to inform future VA Merit Award applications involving an effectiveness trial of trauma-informed CBT-I and mixed methods to examine treatment preferences among women Veterans with insomnia and PTSD.