Cognitive Behavioral Therapy for Insomnia Treatment in a Military Deployed Operational Setting Utilizing Enlisted Combat Medics: A Quality and Process Improvement Project.
Despite the rigid diagnostic criteria, insomnia disorder is still prevalent, estimated to affect 6 to 10% of adults. (2) The prevalence of insomnia in the military is reported to be 50%. (3) The association of insomnia with health is well established. Sleep is frequently disturbed in post traumatic stress disorder and traumatic brain injury, (4) the 2 signature health concerns from Global War on Terror Additionally, there are concerns of insomnia affecting military operations. For example, Williams et al found that active duty Soldiers perceive 50% of their mistakes attributed to insomnia. (5) Their study also revealed that half of pilots surveyed reported falling asleep in the cockpit. While the presence of insomnia is concerning for Soldier performance, there is some evidence of improvement in military performance when interventions are made to improve sleep. In one study, (6) a comparison of 2 units was made, allowing the intervention unit accommodation of adolescent phase-delayed sleep regimen. Results showed improved marksmanship, sleep quality, mood, reduced sleep fatigue, and increased sleep duration. (6)
The prevalence of insomnia and perceived concern for reduced functioning is apparent in high prevalence (up to 20%) of hypnotic use among Soldiers. (4) There are obvious arguments against to the use of hypnotics in the military setting, such as potential impairment of psychomotor skills, sedation, and other adverse effects. Long-term use is also associated with concern for possible dementia and fractures. (7-9) Based on the risk and benefit appraisals, alternative treatments to pharmacotherapy have been evaluated. The greatest evidence comes from treatment strategies based on cognitive behavioral therapy (CBT) informed interventions. While there are heterogenous techniques and variations, these are often referred to as CBT-insomnia (CBT-I). At present, CBT-I is the recommended initial treatment for adults with chronic insomnia disorder. (10)
CBT-insomnia typically has a combination of psychoeducation, cognitive (restructuring dysfunctional beliefs), and behavioral (stimulant control, sleep restriction, etc) aspects. The psychoeducation component aims to increase sleep literacy of the patient. It attempts to increase basic understanding of normal and abnormal sleep, mainly designed to help achieve acceptance from the patient while also targeting attitudinal competency. The cognitive component, in our opinion, is the most technical aspect of CBT-I, requiring significant expertise and experience. It aims to identify dysfunctional beliefs held by the patient that negatively affects their expectations and perceptions of their sleep. Once these dysfunctional beliefs are identified, the next step is to challenge and introduce doubts into these thoughts via the process of cognitive restructuring. Most clinicians have a significant behavioral component to their CBT-I interventions. These may include stimulant control, sleep restriction, and sleep deprivation to help increase sleep inertia and improve sleep efficiency. There might also be some component of progressive relaxation techniques to reduce anticipative anxiety and tension. The overarehing goal is to optimally synchronize the sleep's Process C and Process S, a 2-process model of sleep regulation which is beyond the scope of this paper but can be reviewed elsewhere. (11)
Given the technical competency required to deliver CBTI, it is typically conducted by behavioral health practitioners. In a deployed setting, however, availability of trained personnel (psychologists, social workers, psychiatrists) is the limiting factor. We experienced these same constraints with only 2 therapists and a single psychiatrist caring for a population of approximately 9,400 service members at a remote location. Herein we describe a novel approach to enable enlisted healthcare extenders (behavioral health specialists and combat medics) to deliver CBT- I treatment using a PI/QI strategy based on typical Plan, Do, Study, Act (PDSA) cycles. We describe the PDSA cycles of our project and report our significant outcomes. A similar approach can be used by deployed healthcare teams such as combat operational stress teams (or equivalent) to help extend the first-line, evidence-based therapy for service members with insomnia.
Materials and Methods
The Institutional Review Board for the deployed location in the Middle East reviewed and approved our PI/ QI project for nonresearch determination. During the plan phase, teaching and CBT-I protocol deliverables were prepared by author R.A. Service members received treatment during the "Do" phase of the project. Outcomes as outlined below were reviewed and analyzed during the "Study" phase. Finally, feedback from patient outcome measures, enlisted combat medics, and behavioral health specialists were implemented into the original treatment protocol and delivery methods.
Author R.A. is formally trained in CBT-1 and uses various methods and strategies in his clinical practice. However, during the development phase, literature seareh of the MEDLINE database was undertaken to find the most optimal combination of techniques using cognitive, behavioral, and psychoeducational strategies. No studies were found with head-to-head comparison among any of these strategies. There are standardized treatment protocols, (12) however, these were considered not ideal for 2 main reasons: (1) they are copyrighted protocols and were cost-prohibitive; (2) the workbooks are designed for experienced therapists and not practical for healthcare extenders such as combat medics.
Given this, we developed our own protocol with greatest emphasis on behavioral techniques and psychoeducation and a smaller cognitive component. The protocol was designed to enable someone with minimal training to deliver the cognitive, behavioral, and psychoeducation of CBT-I. Training of the treating medics relied on use of a checklist. This ensured no steps or components were missed and every patient received a standardized treatment.
The protocol consisted of a "provider packet" and "patient packet." The provider packet contained an initial sleep intake, initial sleep prescription, initial checklist, constructive worry sheet, dysfunctional beliefs challenge scripts, follow-up checklist, follow-up intake and prescription form, provider psychoeducation slides, and sleep log form. All of these items were standalone documents made available electronically to the students.
The patient packet contained initial sleep intake, initial sleep prescription, constructive worry sheet, sleep log form, and patient psychoeducation slides. All of these documents were standalone documents made available electronically to the students to print as a packet for a given patient as needed.
Training on Using Sleep Protocol
A single, 3-hour training workshop was conducted to educate combat medics and behavioral health specialists on the use of the sleep protocol. Both of these military occupational specialties (MOS) in the US Army fall under the "68 series." The combat medics (MOS 68W) receive training on supporting basic life functions with knowledge of medical care under fire and trauma care. The behavioral health specialists (MOS 68X) receive training on providing psychological first aid under the supervision of a behavioral health specialist. Neither of these 2 specialties have any training in CBT-I. The workshop audience consisted mainly of behavioral health specialists and combat medics assigned to an armor brigade. Following the training, a survey of pre- and posttraining confidence and satisfaction metrics were assessed.
PowerPoint slides were used to begin the workshop, providing an overview of both provider and patient packets. The first hour was spent on didactics which targeted understanding the Process C and Process S model of sleep regulation" and its role in sleep maintenance, normal sleep physiology, evidence for CBT-I, and understanding cognitions and behaviors and their effect on sleep and development of insomnia. For the second and third hour, cases were used to illustrate specific competencies necessary to effectively deliver the protocol. Training focused on assessment of sleep behavior using the initial sleep intake form, and skill to write initial and follow-up sleep prescription using provided forms within the provider packet. The students also learned to use the Dysfunctional Belief Challenge Scripts for cognitive restructuring. Additionally, students learned to assess and identify need for referral if there are concerns for organic sleep problems or psychiatric disorders. Finally, students were given templates for documentation of their encounters in the electronic health record and obtaining supervision from a supervising therapist.
The training underscored the accurate, exact, and unwavering use of the checklist. For example, the first item on the checklist is "Initial Intake Form completed." The initial intake form consisted of demographics, specific sleep questions to allow the provider to easily calculate sleep efficiency, review of systems to look for organic causes of insomnia, sleep satisfaction questions, a Patient Health Questionnaire-2, (13) suicide screening question, and a Generalized Anxiety Disorder Questionnaire-2. (14) Finally, in order to enable and operationalize a novice provider in tackling the most difficult part of CBT-I, identifying and challenging cognitive distortions and dysfunctional beliefs, the Dysfunctional Beliefs and Attitudes about Sleep (DBAS) was used. This scale was originally a 30-item questionnaire that was later validated in its shortened form as DBAS-16. (15)
Patients were entered into treatment by one of 2 distinct routes. One route involved patients presenting to the brigade aid station with pure sleep complaints with no additional psychiatric symptoms. Those patients were offered CBT-I, receiving treatment in a private room inside the aid station. The intake form was completed using the checklist, then screened for evidence of depression, anxiety, or organic sleep problems. If any of the conditions were positive, the treating medic was instructed to refer those patients to a credentialed provider. However, medics were instructed to immediately escort anyone with acute suicidally to the behavioral health providers. The other route for treatment was through the behavioral health clinic. During routine intake for behavioral health treatment, patients citing sleep difficulties were offered CBT-I treatment in addition to other psychiatric services. The treatment was delivered inside the behavioral health clinic by cither a trained behavioral health specialist (MOS 68X) or trained medic (MOS 68W) as the clinic had a shortage of behavioral health specialists.
The initial checklist component was psychoeducation. The provider used his or her "provider psychoeducation slides" while the patient followed with their "patient psychoeducation slides." Both were identical slides on basic physiology, dysfunctional beliefs and behaviors about sleep, introduction to CBT-I concepts, and evidence for this modality. The provider version contained boxes with text and providers were instructed to read those verbatim as they lead the patient through the 12 slides.
The second component on the checklist focused on behavioral interventions. The provider was tasked to calculate the sleep efficiency and provide the patient with exact wake-up time and earliest bed-time. The idea was to reduce time in bed awake (improving sleep efficiency) and the associated frustration with forcing oneself to fall asleep, as well as sleep deprivation to enhance sleep inertia. The initial sleep prescription form took information from the intake form. For practical reasons, sleep logs were optional and all treatment decisions were based on self-reported times averaged over a week. The initial sleep prescription took baseline self-reported total sleep time (adding sleep at night and any additional naps), and added one hour to this time. This was total permitted time in bed. For example, if someone reported sleeping on average 5 hours per night, but spent 8 hours in bed, then their sleep efficiency is 63% (5/8x100). Using this example, the patient was asked about best daily wake-up time. They were required to wake up at this specific time for the next week even if they were not working. Patients were encouraged to take physical training or morning military formations into account. If, for example, the patient were to settle on daily wake-up time of 5 am, then, based on the above example, they were permitted to go to sleep no earlier than 11 pm (5 hours plus one additional hour for a total of 6 hours permitted in bed). It was stressed that they must only go to bed after 11 pm and only if they are sleepy. Regardless of what time they finally went to bed, they were still required to wake up at the agreed-upon daily wake-up time. Next, rules for sleep that are listed on the same initial sleep prescription form were reviewed. It emphasizes behaviors of stimulant control and sleep hygiene that highlights behavioral concepts.
Finally, the DBAS-16 from the initial intake form was reviewed. The providers were instructed to read verbatim the scripts related to DBAS-16 items that score 6 or more (Dysfunctional Belief Challenge Scripts Packet). This cutoff of 6 or more out of 10 on the Likert scale is informed by the validation data from the initial study (15) on DBAS-16. Identifying and challenging cognitive distortions require a significant amount of clinical expertise to do well. Therefore, the Dysfunctional Belief Challenge Scripts Packet was designed by the authors to challenge all 16 of the dysfunctional beliefs on the scale. The use of the scale permitted identification of the majority of these beliefs. It also then permitted the provider to select the ones he or she would challenge. Any question with 6 or more points was selected. For example, if a patient was high (scoring 6 or more) on questions 3, 5, and 15, the provider would first read the introduction statement verbatim: "I am going to talk to you about some common trends of maladaptive thoughts and beliefs that we notice among those people who suffer from sleep problems. These thoughts and beliefs can worsen their sleep problems. I would like to highlight some of those for you by reading them aloud and then providing you some explanations. I am selecting these because you scored high on these." Next, the provider would read the question and then our provided "challenge script" for that particular question. The cognitive component of this protocol was only addressed at intake. They were, however, given the constructive worry sheet to use on their own if needed. It entailed a column for what their worry might be and a column for potential actions they plan to take to address that concern. The patients were given a sleep log form that they could choose to complete.
At follow-up, the "Follow-up Sleep Intake and Prescription" form was used to record sleep data to calculate sleep efficiency, and self-reported sleep satisfaction. This form also provided a decision-tree for the provider:
* If Sleep Efficiency is 85% or greater, add 30 minutes (earliest bedtime is 30 minutes sooner but wake-up time stays the same).
* If Sleep Efficiency is 65% or less, subtract 30 minutes (earliest bedtime is 30 minutes later but wakeup time stays the same).
* If Sleep Efficiency is 66% to 84%, keep the same schedule, follow-up in a week.
The plan was to have a patient seen for 3 sessions, including the intake session. All intake and follow-up data was recorded in an electronic medical chart. Cases were supervised on an as-needed basis by author B.W. She also conducted a chart review for each case for safety and accuracy.
An Excel spreadsheet was maintained to account for all outcomes. A total of 25 service members underwent at least one session. The outcomes are discussed later in the Results section. The IBM SPSS application was used for the statistical analysis. Comparisons were done using nonparametric methods due to the small number of subjects in order to avoid false assumptions of normality.
Chart review by B.W. was conducted throughout the deployment to ensure safety and accuracy. Feedback was elicited about improvement to the Dysfunctional Belief Challenge Scripts Packet where it was noted that the language was too academic and inappropriate for the typical level of education of participants.
Baseline data and demographics are presented in Table 1. Training evaluation by the medics and behavioral health specialists showed significant satisfaction, perceived improvement in skill, and confidence in the treatment of insomnia using newly learned CBT based insomnia treatment skills (Table 2). A total of 25 patients underwent intake for CBT based treatment for insomnia during a 2-month period prior to the redeployment of the unit from the theater. A total of 64 sessions were delivered, averaging 2.56 sessions per patient. Outcome measures were calculated for intake (Session 1), Session 2 and Session 3, with total of 15 patients having data for all 3 sessions.
Learner's Training Evaluation
A training evaluation survey was completed (N=10, 30%) upon completion of the training workshop. Overall, there was positive response on postinstructional evaluation (Table 2). Using Wilcoxon Signed-Ranks Test, the pre- versus posttraining perceived skill (z=2.871; P<.01) and confidence (z=-2.844; P<01) levels to treat insomnia significantly improved.
Mean sleep efficiency significantly improved (Figure 1). A nonparametric Friedman's test of differences among repeated measures for sleep efficiency was conducted and rendered a [chi square] value of 19.54 which was significant (P<.01). Post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that posttest ranks were statistically significantly higher for Session 2 (z=-3.68; P<.01) and Session 3 (z=-3.11; P<.002) at follow-up when compared to Session 1. The change in ranks was nonsignificant between Session 2 and Session 3 (z=-0.08; P<. 94).
Total self-reported average sleep duration at intake was 4 hours, 32 minutes; Session 2 was 4 hours, 53 minutes and Session 3 was 5 hours and 11 minutes. However, nonparametric Friedman's test of differences among repeated measures for self-reported sleep duration was conducted and rendered a [chi square] value of 3.268 which was nonsignificant (P=.195).
Total Time in Bed
Average total time spent in bed (including both awake and asleep) was 8 hours and 4 minutes at intake. It significantly decreased to (Session 2) 5 hours, 46 minutes, and (Session 3) 6 hours and 5 minutes. Significance was measured using nonparametric Friedman's test of differences among repeated measures, rendering a [chi square] value of 14.68 which was significant (P<.01). A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that post-test ranks were statistically significantly lower for Session 2 (z=-3.43; P<.01) and Session 3 (z=-2.68; P<.007) in comparison to baseline intake values (Session 1). The change in ranks was nonsignificant between Session 2 and Session 3 (z=-1.59; P=.11).
Perceived Sleep Satisfaction
Subjective satisfaction with duration (Figure 2) and quality (Figure 3) of sleep was measured on a Likert scale with 5 as maximum satisfaction. The baseline (intake) mean satisfaction for perceived sleep duration was 1.36, SD 0.57 (N=25), Session 2 mean was 1.94, SD 0.64 (N=18), and Session 3 mean was 2.57, SD 1.01 (N=14). A nonparametric Friedman's test of differences among repeated measures for intake, Session 2 and Session 3 (N=14) was conducted and rendered a y; value of 16.77 which was significant (P<.01). A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that posttest ranks were statistically significantly higher for Session 2 (z=-2.97; P<.01) and Session 3 (z=-3.03; /><002) follow-up in comparison to baseline. The change in ranks was nonsignificant between Session 2 and Session 3 (z=-2.13; P<.03).
The baseline (intake) mean for satisfaction for perceived sleep quality was 1.40, SD 0.577 (N=25), Session 2 mean was 2.17, SD 1.15 (N=18), and Session 3 mean was 2.93, SD 1.07 (N=14). A nonparametric Friedman's test of differences among repeated measures for intake, Session 2 and Session 3 (N=14) was conducted and rendered a X2 value of 19.41 which was significant (P<.001). A post-hoc Wilcoxon Signed-Ranks Test with Bonferroni correction indicated that post-test ranks were statistically significantly higher for Session 2 (z=-2.75; P<.001) and Session 3 (z=-3.15; P<.002) follow-up in comparison to baseline. The change in ranks was also significant between Session 2 and Session 3 (z=-3.05; P<.002).
The checklist served as a process measure to ensure the medics applied the methods of behavioral sleep treatment accurately. All cases seen were reviewed by the authors with focus on calculation of sleep efficiency and sleep prescription. On average, these were performed correctly 86% of the time. Only minor errors related to conversion of minutes were seen.
No sleep deprivation related events were reported. Of the 25 Soldiers who underwent intake for CBT-I, 18 followed-up for a second session. None of these, including those that were lost to follow-up, were involved in behavioral incidents, including acute psychiatric exacerbation or need for medical evacuation. None required acute referral for hypnotic therapy.
We faced the clinical challenge of delivering safe and effective nonpharmacological treatment for Soldiers suffering from insomnia in a limited resource environment. Cognitive behavioral therapy based insomnia treatment has been shown to be an effective treatment. (16) Hence, the root cause of this situation was insufficient providers who could deliver CBT based insomnia treatment without relying on hypnotics. Hypnotics pose safety concerns. During the 4.5-month period of deployment, author R.A. observed one Soldier with priapism and another with drug-drug interaction, (17) both of which were likely due to their use of hypnotic medications.
We used formal QI/PI concepts to overcome the clinical obstacles in treatment delivery. We were effectively able to train medics in CBT based insomnia treatment (Table 2). The operationalization of this treatment, which otherwise requires a significant amount of training and experience, was made possible by a checklist procedural approach to treatment delivery. The protocolizaron of the techniques was likely the most important tool for challenging dysfunctional beliefs of those suffering from insomnia. The use of DBAS-16 as a rapid diagnostic tool in identification of such cognitions, followed by verbatim cognitive restructuring scripts, permitted us to easily enable the medics to challenge such dysfunctional beliefs. Additionally, the protocol with checklist-led sleep prescriptions enabled the medics to rapidly approach sleep efficiency-based decisions with an easy to use algorithmic approach.
This was not intended to be a research study, but rather operationalizing evidence-based CBT treatment for insomnia by healthcare extenders (medics) that has not been done in the past, especially in the operational environment. The project illustrates one potential answer to manpower constraints by utilizing readily available medical personnel. The nonparametric tests showed significant improvements in both sleep efficiency (and related total time spent in bed), as well as satisfaction with the quality and quantity of sleep. Interestingly, these improvements occurred very rapidly after just a single session. Data analysis for both sleep efficiency and satisfaction showed significant improvements from intake's first session to the second session. Further post-hoc analysis showed that a third session maintained the significance from the intake. Interestingly, although there was not a statistically significant increase in the actual sleep duration, both satisfaction with sleep quality and duration improved. This supports the perceptual nature of the insomnia experience.
Given its success in the operational setting, we plan to formally evaluate our checklist-based approach to insomnia treatment using combat medics with a control group to study the feasibility and efficacy of our protocol in nonoperational setting. Appropriate sleep is an important ingredient for both physical and psychological fitness on which mission success relics. Sleep can affect both of these domains, and broader delivery of CBT-I based sleep literacy as primary prevention and wellness strategy could be the next step with broader use of a similar, checklist-based approach to sleep education.
Insomnia is a major problem in the deployed environment. Safer alternatives to pharmacological treatment such as cognitive and behavioral based approaches require specialized skilled personnel that are not readily available. This limited resource environment can be mitigated by using healthcare extenders such as combat medics, behavioral health specialists, or equivalent personnel. Our QI/PI project provides a road map that could be replicated early into a deployment or other resource-constrained environments to effectively deliver cognitive and behavioral treatment for Soldiers with minimal effort and supervision.
We thank Dr Ray win R. Huang, PhD, and Mr Troy H. Patience, Madigan Army Medical Center, Tacoma, Washington, for their expert assistance with statistical analysis and review of the project.
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MAJ Rohul Amin, MC, USA
CPT Brooke E. Wirtz, MS, USA
MAJ Amin is Division Psychiatrist, 7th Infantry Division, and Staff Psychiatrist and Internist, Madigan Army Medical Center, Tacoma, Washington.
CPT Wirtz is Brigade Behavioral Health Officer, 2nd Infantry Brigade Combat Team, 3rd Infantry Division, Fort Stewart, Georgia.
Table 1. Demographics and Baseline Data for Patients Undergoing Treatment for Insomnia. Demographics and Baseline Data Values SD N (Intake) 25 Mean Age (years) 23.8 5.513 Male (n=23) 92% Rank, E1-E4 (n=21) 84% Number of Sessions Attended by Each Patient (n=number of patients attending that many sessions) 1 (n=7) 28% 2 (n=5) 20% 3 (n=7) 28% 4 (n=4) 16% 5 (n=2) 8% Average Number of Sessions 2.56 1.294 Average Length of Insomnia (months) 13.96 9.813 Type of Insomnia Combined (n=21) 84% Initial (n=3) 12% Terminal (n=l) 4% Baseline Sleep Duration (hours) 5.12 1.716 Baseline Time in Bed (hours) 8.28 1.926 Baseline Sleep Efficiency* 61.80% Desired Sleep Duration (hours) 7.4 0.766 Average Number of Sleep Disruptions/Night 2.84 1.491 Average Number of Naps 0.9 1.291 Racing Thoughts on Pillow Present 72% Average Daily Caffeine Intake (drinks) 1.32 0.476 Prior Hypnotic Use (n=15) 60% Current Hypnotic Use (n=5) 20% * Defined as baseline sleep duration/baseline time in bed * 100. Table 2. Post-Training Survey assessing perceived satisfaction and effectiveness of training by learners. * Min Max Mean SE SD Effective goal 4 5 4.70 0.153 0.483 communications Effective learning 4 5 4.70 0.153 0.483 climate Instructor knowledgeable 4 5 4.90 0.100 0.316 Didactics important 4 5 4.90 0.100 0.316 Workshop important 2 5 4.50 0.342 1.080 Handouts important 4 5 4.90 0.100 0.316 PRIOR to this training, 1 4 2.10 0.314 0.994 CONFIDENCE level AFTER this training, 3 5 4.40 0.221 0.699 CONFIDENCE level PRIOR to this training 1 4 2.10 0.314 0.994 CONFIDENCE level AFTER this training, 3 5 4.20 0.200 0.632 SKILLS level Likelihood of using 3 5 4.40 0.267 0.843 training Likelihood of 3 5 4.30 0.300 0.949 implementing training Likelihood of 4 5 4.80 0.133 0.422 recommending this to patients Likelihood of 3 5 4.50 0.224 0.707 recommending this to other medical providers This training should be 1 5 4.10 0.433 1.370 provided to all medics in Advanced Individual Training Overall satisfaction 4 5 4.80 0.133 0.422 with training Min indicates minimum; Max indicates maximum. * Values from Likert scale: l=least; 5=most. Figure 1. Sleep efficiency (mean) results demonstrate significant continuous improvement from treatment session 1 through sessions 2 and 3. 1 60.36% 2 82.28% 3 85.20% Note: Table made from bar graph. Figure 2. Sleep duration satisfaction results demonstrate significant continuous improvement from treatment session 1 through sessions 2 and 3. 1 1.36 2 1.94 3 2.57 Note: Table made from bar graph. Figure 3. Sleep quality satisfaction results demonstrate significant continuous improvement from treatment session 1 through sessions 2 and 3. 1 1.4 2 2.17 3 2.93 Note: Table made from bar grapth.
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|Author:||Amin, Rohul; Wirtz, Brooke E.|
|Publication:||U.S. Army Medical Department Journal|
|Date:||Oct 1, 2017|
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