Cognitive Behavioral Therapy for Insomnia for Gulf War Illness (CBTi GWI)

VA Office of Research and Development

Status: Completed

Conditions: Gulf War Illness; Insomnia

Treatments: Behavioral: Cognitive Behavioral Therapy for Insomnia (CBTi)

Study type: Interventional

Funder types: Other U.S. Federal agency

Identifiers

NCT02782780

SPLD-12-15F

I21CX001428 (U.S. NIH Grant/Contract)

Details and patient eligibility

About

Sleep disturbance is a common complaint of Veterans with Gulf War Illness (GWI). Because there is clinical evidence that sleep quality influences pain, fatigue, mood, cognition, and daily functioning, this study will investigate whether a type of behavioral sleep treatment called Cognitive Behavioral Therapy for Insomnia (CBTi) can help Gulf War Veterans with GWI. CBTi is a multicomponent treatment where patients learn about sleep and factors affecting sleep as well as how to alter habits that may impair or even prevent sleep. The investigators hypothesize that helping Gulf War Veterans learn how to achieve better sleep with CBTi may also help to alleviate their other non-sleep symptoms of GWI.

Full description

Insomnia is common among Veterans with Gulf War Illness (GWI). Moreover, untreated insomnia is associated with significant medical and psychiatric morbidity. Cognitive Behavioral Therapy for Insomnia (CBTi) is a multicomponent treatment that seeks not only to teach patients about sleep and factors affecting sleep (e.g., circadian rhythm, age, social and work schedule) but the therapist will also to work with the patient toward minimizing unwanted arousal at bedtime and altering sleep habits to increase sleep propensity and regularity.

Because many Veterans with GWI suffer from a profound loss of physical and functional status that may prevent them from participating in treatments that require regular clinic visits, the proposed study will deliver CBTi by telephone to extend this effective form of behavioral sleep medicine to Veterans who have chronic illnesses and disabilities and/or who live in rural areas with limited access to trained CBTi providers. Recent studies suggest that telephone-delivered CBTi is as effective as CBTi delivered in-person.

The proposed trial will examine the efficacy of telephone-delivered CBTi for alleviating sleep and non-sleep GWI symptoms in a two-arm randomized controlled trial. Veterans who have GWI and persistent insomnia disorder will be randomized to a group that will receive CBTi right away or to a group that will receive treatment-as-usual (i.e., the control group). Veterans randomized to the control group will have the option of receiving telephone-delivered CBTi upon completion of post-treatment assessments. The primary outcomes will be effect sizes base on within-group comparisons of pre-to-post-treatment change and maintenance of treatment effects at 6 months in the CBTi group.

Enrollment: 165 patients

Sex: All

Volunteers: No Healthy Volunteers

Inclusion criteria

• Deployed to the Gulf Theater of operations, as defined by 38 CFR 3.317 in the years 1990-1991, in accordance with the inclusion/exclusion criteria set forth in the federal definition of Gulf War Illness as used for the Gulf War Registry.

  • This will be confirmed through VA records or by asking veterans to provide a copy of their DD214.

• Have Gulf War Illness (GWI) according to the Kansas case definition.

  • GWI symptom will be assessed with the Kansas Gulf War Military History and Health Questionnaire.

• Have an Insomnia Severity Index score greater than or equal to 14.

Exclusion criteria

• Have conditions or substances that may be associated with comorbid insomnia independent of GWI status, including:

  • a lifetime history of any psychiatric disorder with psychotic features
  • bipolar disorder
  • panic disorder
  • obsessive-compulsive disorder
  • alcohol or substance dependence
  • a history of alcohol or substance abuse within the past year

• Currently exposed to recurrent trauma or have been exposed to a traumatic event within the past 3 months.

• Pregnancy (because insomnia will worsen after 8 weeks).

• Prominent suicidal or homicidal ideation.

• History of sleep restriction therapy or cognitive restructuring therapies of beliefs related to sleep.

• Subjects concurrently enrolled in another clinical trial.

• Veterans who work night shifts or have extreme morning or evening tendencies as described below will be excluded in order to avoid the impact of circadian factors on evaluating insomnia.

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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165 participants in 2 patient groups

CBTi

Experimental group

Description:

CBTi is a multicomponent treatment that seeks to teach patients about sleep and the factors that affect sleep as well as to work with the patient toward altering sleep habits to increase sleep propensity and regularity. Specifically, participants will receive 8 weekly individual sessions of CBTi according to the VA CBTi protocol. The investigators will follow the semi-structured approach to treatment described in the VA CBTi protocol, which allows the case conceptualization to drive the order in which treatment components are introduced.

Treatment:

Behavioral: Cognitive Behavioral Therapy for Insomnia (CBTi)

Monitor Only

No Intervention group

Description:

Study participants who are randomized to the Monitor Only (MO) control group will be followed for 8 weeks of usual care (i.e., they will be advised to continue doing whatever they were doing to manage their GWI and insomnia symptoms without change dosage or frequency of treatment). Participants randomized to the Monitor Only condition will have the option of receiving CBTi delivered by telephone, at no cost to them, upon completion of post-study procedures.