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 女性退伍军人的状况，但许多女性退伍军人没有接受循证心理治疗 治疗创伤后应激障碍。创伤后应激障碍和失眠障碍在退伍军人中高度并存，研究表明 失眠是创伤后应激障碍发展和严重程度的风险因素，而健康的睡眠与改善有关 情绪、日间功能、增强学习和加强情绪调节。解决失眠问题 女性退伍军人的症状可能为减少失眠和一些创伤后应激障碍提供早期干预 同时也提供了一种新的方法来提高患者对创伤后应激障碍治疗的参与度。 意义/影响：妇女健康和精神健康(特别是创伤后应激障碍)是以下领域的优先研究领域 弗吉尼亚州女性退伍军人在接受创伤后应激障碍治疗时遇到了多种障碍，包括：感觉到的耻辱，严重程度 症状/情绪失调，以及日程安排/时间限制。提供者报告延误创伤后应激障碍的治疗 由于患者对开始创伤后应激障碍治疗的“准备不足”的看法。认知行为疗法 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个人的睡眠，提供一种短暂的干预替代方案 创伤后应激障碍的心理治疗方案，并在退伍军人事务部广泛传播。 创新：以前没有研究过创伤相关CBT-I对睡眠和精神疾病的影响 患有失眠障碍和创伤后应激障碍的女性退伍军人的症状。该项目将利用混合的 方法，从女退伍军人那里收集新的信息，以确定促进者和障碍 女性退伍军人的创伤后应激障碍和失眠治疗。虽然有迹象表明CBT-I可能作为 作为其他循证心理疗法的预备治疗，这将是第一项利用 创伤告知CBT-I方案，并检查精神健康治疗参与度作为主要结果。 具体目标：具体目标是：1)反复改进创伤信息的结构和材料 CBT-I正在为先导试验做准备，2)先导测试创伤信息CBT-I对创伤后应激障碍治疗的影响 对女性退伍军人样本的准备情况和参与度，以及3)检查潜在的机制 女性退伍军人中创伤后应激障碍治疗准备和参与度随时间的潜在变化。 方法：拟议的项目将在VAGLAHS内进行。在目标1中，女性退伍军人将 按顺序接收创伤通知CBT-I方案。我们将从每个人那里获得定性的反馈 参与者，并在将协议管理给下一参与者之前进行必要的改进(预计 N=5)。在目标2中，将招募患有失眠障碍和创伤后应激障碍的女性退伍军人参加 行为干预研究和符合条件的参与者将被随机分配到创伤知情组 CBT-I组(n=25)或PTSD心理教育组(n=25)。参与者将完成测量 基线、治疗后和6个月时的睡眠、心理健康症状和创伤后应激障碍治疗准备情况 后续行动。所有参与者将被转介到创伤后应激障碍治疗，治疗参与度将为 在6个月的随访中进行评估。在目标3中，作为试点试验的一部分，我们将评估创伤后应激障碍的已知障碍 每个时间点的治疗参与度。我们将对试点试验完成者进行定性访谈，并 未完成者(预计n=20)，以更好地了解创伤后应激障碍治疗准备情况的基础流程 以及患有失眠和创伤后应激障碍的女性退伍军人的参与度。 下一步/实施：研究结果将通过增加以下方面的治疗选择直接为患者护理提供信息 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 向未来的VA优秀奖申请提供信息，涉及创伤信息CBT-I的有效性试验和 用混合方法检查患有失眠和创伤后应激障碍的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.