OBJECTIVES:Experiential avoidance is the unwillingness to come into contact with aversive internal experiences. Trauma exposure is associated with greater experiential avoidance and insomnia symptoms. Experiential avoidance may perpetuate insomnia symptoms in patients with posttraumatic stress disorder (PTSD). We examined the relationship between experiential avoidance and insomnia symptoms among veterans with PTSD (based on the Clinician-Administered PTSD Scale for DSM-5). METHOD:The sample included 93 veterans (M = 54.7 years; 86.0% male) who attributed their sleep disturbance onset to experiences of trauma on the CAPS-5. Experiential avoidance, insomnia, sleep disturbance, daytime sleepiness, and daytime consequences were measured with the Brief Experiential Avoidance Questionnaire (BEAQ), Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and International Classification of Sleep Disorders (ICSD) items. We conducted multiple linear regressions with age, sex, and BEAQ as the independent variables and sleep variables as the dependent variables. RESULTS:There were significant positive associations between the BEAQ and the ISI, PSQI daily disturbance factor, ESS, and ICSD daytime consequences. CONCLUSIONS:Greater experiential avoidance was associated with worse insomnia symptoms and consequences, particularly daytime dysfunction. Experiential avoidance may be an overlooked, but relevant treatment target for patients with comorbid insomnia and PTSD.

BACKGROUND:Older adults with chronic insomnia often use benzodiazepine receptor agonists (BZRAs) despite known associated risks and non-pharmacological alternatives such as cognitive behavioral therapy for insomnia (CBTI). CBTI reduces insomnia severity and could potentially improve other outcomes such as the impact of pain on daily activities, even when BZRAs are deprescribed. Yet concerns that deprescribing may worsen pain (which is often comorbid with insomnia) can be a barrier to engagement in BZRA deprescribing. This study examined changes in pain outcomes associated with deprescribing BZRAs in the context of concurrent CBTI. METHODS:Secondary data analysis was conducted using data from a randomized clinical trial that successfully decreased BZRA use in older adults. Participants (n = 188), who were largely older (68% ≥ 65 years, 55 ≤ range ≤ 91) and male (65%), completed CBTI concurrently with a deprescribing intervention (blinded encapsulated BZRA taper or open pill cutter taper). Participants completed the Brief Pain Inventory (BPI) at baseline, one week posttreatment (1 WK), and at a six-month (6 M) follow-up. Analyses included mixed effects models among all participants and a subset aged 65+ as well as comparison of model results to minimal clinically important difference (MCID) thresholds. RESULTS:Mixed effects models demonstrated that pain severity did not change significantly over time, broadly or in participants aged ≥ 65 years. Significant reductions in pain interference in day-to-day living at 1 WK were observed broadly, although these reductions did not meet the MCID threshold and were no longer significant at 6 M follow-up. CONCLUSIONS:Combined BZRA deprescribing and CBTI did not meaningfully worsen pain in older adults. These results highlight the opportunity for using a combination of CBTI and deprescribing methods in patients with insomnia and comorbid pain, as well as a need for additional interventions to specifically address pain in older adults with chronic insomnia.

To describe temporal patterns of use of sleep aids (benzodiazepine receptor agonists [BZRAs], non-BZRAs [e.g., melatonin]) from baseline to 6FU associated with cognitive behavioral therapy for insomnia (CBTI) combined with BZRA tapering and to assess the odds of BZRA use at 6FU associated with non-BZRA use at baseline. Using diary data from a trial comparing CBTI combined with a masked BZRA taper method (MTcap) versus standard open BZRA taper (SGT), we determined the frequency of four temporal patterns of sleep aid use at 6FU relative to baseline: 1) “less BZRA-nonBZRA”, 2) “stable use BZRA-nonBZRA”, 3) “more BZRA-nonBZRA”, and 4) “less BZRA/more nonBZRA.” We also assessed the use of specific non-BZAs (e.g., melatonin) and whether non-BZRA use at baseline predicted patterns of sleep aid use at 6FU. Of 139 participants (71 MTcap; 68 SGT), 63

BACKGROUND:Black women and veterans experience disproportionally high rates of insomnia. Few studies have examined how treatment adherence and outcomes vary by racial identity. We found that cognitive behavioral therapy for insomnia (CBT-I) and an acceptance and commitment therapy (ACT)-based insomnia treatment similarly improve sleep outcomes for women veterans, and this analysis examined differences in adherence and outcomes of these treatments based on racial identity groups. PURPOSE:Analyses examined differences in adherence and treatment outcomes in Black compared with white women veterans who engaged in CBT-I or an ACT-based insomnia treatment (i.e., acceptance and the behavioral changes to treat insomnia [ABC-I]). METHODS:As part of a larger clinical trial (NCT02076165), 40 Black and 51 white women veterans with insomnia disorder completed five sessions of CBT-I or ABC-I. The Insomnia Severity Index (ISI) and sleep diaries were completed at baseline, posttreatment, and 3-month follow-up. The Credibility and Expectancy Questionnaire was completed at the end of the first treatment session. Multiple and fractional regression models were used to evaluate the association between race group and change in ISI, sleep diary sleep efficiency, and adherence to weekly sleep schedule prescriptions in CBT-I and ABC-I. RESULTS:Treatment benefits were comparable between Black and white women veterans; however, Black women had transiently lower adherence to sleep restriction time in bed recommendations in the week immediately after sleep restriction therapy was introduced in both treatments. There were no other differences between the groups. CONCLUSIONS:Future research is needed to understand potential barriers to early adherence to recommendations experienced by Black women veterans and to identify treatment adaptations to meet their needs.

We sought to determine the role of sleep-disordered breathing, insomnia symptoms, and sleep quality in the daytime function and quality of life of veterans with spinal cord injury. This cross-sectional cohort study took place in a Veterans Administration medical center in the midwestern United States. Thirty-eight male veterans with spinal cord injury (22 cervical, 16 thoracic; mean [standard deviation] age = 62.9 [9.5] years) completed baseline assessments within a larger clinical trial. Measures assessed sleep apnea severity (apnea-hypopnea index), insomnia symptoms (Insomnia Severity Index), self-reported sleep quality (Pittsburg Sleep Quality Index), daytime sleepiness (Epworth Sleepiness Scale), fatigue (Flinders Fatigue Scale), depression (Patient Health Questionnaire-9 item, excluding sleep item), functioning (Spinal Cord Independence Measure), and quality of life (World Health Organization Quality of Life). Bivariate correlations (alpha P < .05) were used to assess relationships between sleep (apnea-hypopnea index, Insomnia Severity Index, Pittsburg Sleep Quality Index, Epworth Sleepiness Scale) and function (Flinders Fatigue Scale, Patient Health Questionnaire-9 item, Spinal Cord Independence Measure, World Health Organization Quality of Life). Mean apnea-hypopnea index was 29.9 (26.6) events/h, mean Insomnia Severity Index was 9.4 (6.2), mean Pittsburg Sleep Quality Index was 9.0 (4.6), and mean Epworth Sleepiness Scale was 7.0 (5.2). There were no significant relationships between apnea-hypopnea index and function measures. Significant relationships emerged between worse Insomnia Severity Index and worse Patient Health Questionnaire-9, some World Health Organization Quality of Life subscales, and Spinal Cord Independence Measure as well as between worse Pittsburg Sleep Quality Index and worse Flinders Fatigue Scale, Patient Health Questionnaire-9 item, and some World Health Organization Quality of Life subscales (P < .05). Among veterans with spinal cord injury, insomnia symptom severity and poor sleep quality were associated with worse functioning, whereas sleep-disordered breathing severity was not. Insomnia and poor sleep quality represent modifiable contributors to poor daytime function. Research evaluating the impact of evidence-based insomnia treatments among individuals living with spinal cord injury is warranted. Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: Treatment of Sleep-disordered Breathing in Patients With SCI; URL: https://www.clinicaltrials.gov/study/NCT02830074 ; Identifier: NCT02830074. Badr AN, Zeineddine S, Salloum A, et al. Sleep and daytime function in people with spinal cord injury. J Clin Sleep Med. 2025;21(11):1903–1909.

Study Objective Treatment of sleep-disordered breathing (SDB) with positive airway pressure (PAP) therapy has unique clinical challenges in individuals living with spinal cord injuries and diseases (spinal cord injury [SCI]/D). Interventions focused on increasing PAP use have not been studied in this population. We aimed to evaluate the benefits of a program to increase PAP use among Veterans with SCI/D and SDB.Methods Randomized controlled trial comparing a behavioral Intervention (n = 32) and educational control (n = 31), both including one face-to-face and five telephone sessions over 3 months. The intervention included education about SDB and PAP, goal setting, troubleshooting, and motivational enhancement. The control arm included non-directive sleep education only.Results Primary outcomes were objective PAP use (nights >= 4 hours used within 90 days) and sleep quality (Pittsburgh Sleep Quality Index [PSQI] at 3 months). These did not differ between intervention and control (main outcome timepoint; mean difference 3.5 [-9.0, 15.9] nights/week for PAP use; p = .578; -1.1 [-2.8, 0.6] points for PSQI; p = .219). Secondary outcomes included fatigue, depression, function, and quality of life. Only fatigue improved significantly more in the intervention versus the control group (p = .025). Across groups, more PAP use was associated with larger improvements in sleep quality, insomnia, sleepiness, fatigue, and depression at some time points.Conclusions PAP use in Veterans with SCI/D and SDB is low, and a 3-month supportive/behavioral program did not show significant benefit compared to education alone. Overall, more PAP use was associated with improved symptoms suggesting more intensive support, such as in-home assistance, may be required to increase PAP use in these patients.Clinical Trials Information Title: "Treatment of Sleep Disordered Breathing in Patients with SCI." Registration number: NCT02830074. Website: https://clinicaltrials.gov/study/NCT02830074?cond=Sleep%20Apnea&term=badr&rank=5 Graphical Abstract

BACKGROUND:Untreated sleep problems in both persons living with dementia (PLWD) and their family care partners (CP) impact their health and quality of life. This pilot study tested a sleep intervention program for both dyad members. METHODS:Thirty dyads were randomized to a 5-session Care2Sleep intervention (n = 15 dyads) or an information-only control group (n = 15 dyads) delivered in-person or by video-telehealth by trained sleep educators. Care2Sleep is a manual-based program, incorporating key components of cognitive behavioral therapy for insomnia, daily light exposure and walking, and problem-solving for dementia-related behaviors. Adherence with Care2Sleep recommendations was assessed. Sleep outcomes included actigraphy-measured sleep efficiency (SE) and total wake time (TWT) for dyads, and the Pittsburgh Sleep Quality Index (PSQI) for CP. Other outcomes for CP included the Zarit Burden Interview (ZBI) and positive aspects of caregiving (PAC). Outcomes were measured at baseline, posttreatment, and 3-month follow-up. A 2 (group) by 3 (time) mixed model analysis of variance tested treatment effects. RESULTS:Study feasibility was demonstrated, with 13 dyads completing all five sessions of Care2Sleep program and 14 completing the control condition. In the Care2Sleep group, the dyads adhered to recommended sleep schedules of 76% for bedtime and 72% for get-up time for PLWD, and 69% for bedtime and 67% for get-up time for CP. There were several nonsignificant trends in outcomes from baseline to 3-month follow-up between the two groups. For example, SE increased by 3.2% more for PLWD and 3.2% more for CP with Care2Sleep versus control. TWT decreased by 14 min more for PLWD and 12 min more for CP with Care2Sleep versus control at the 3-month follow-up. CP in Care2Sleep also showed improvement in the PSQI, ZBI, and PAC scores. CONCLUSIONS:A dyadic approach to sleep improvement is feasible. Larger trials are needed to test effects of this intervention for PLWD and their family CP. CLINICALTRIALS:gov: NCT03455569.

Objectives The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans. Methods Pilot randomized controlled trial consists of 2,009 veterans aged >= 65 years who received BZRA prescriptions from a Veterans Health Administration pharmacy (Colorado or Montana) during the prior 18 months. Active: Arm 1 was a mailed brochure about BZRA risks that also included information about a free, online cognitive behavioral therapy for the insomnia (CBTI) program. Arm 2 was a mailed brochure (same as arm 1) and telephone reinforcement call. Control: Arm 3 was a mailed brochure without insomnia treatment information. Active BZRA prescriptions at follow-up (6 and 12 months) were measured. Results In logistic regression analyses, the odds of BZRA prescription at 6- and 12-month follow-ups were not significantly different for arm 1 or 2 (active) versus arm 3 (control), including models adjusted for demographics and prescription characteristics (p-values >0.36). Conclusions Although we observed no differences in active BZRA prescriptions, this pilot study provides guidance for conducting a future study, indicating a need for a more potent intervention. A full-scale trial testing an optimized program would provide conclusive results. Clinical Implications Mailing information about BZRA risks and CBTI did not affect BZRA prescriptions. CLINICAL IMPLICATIONS Clinicians and healthcare organizations interested in reducing BZRA use in older veterans should consider interventions that are more potent than a mailed brochure about the risks of BZRA and information about accessing CBTI. The addition of a telephone reinforcement call to the mailed brochure was not sufficient to reduce BZRA prescriptions.

OBJECTIVES:To describe the implementation of a mentored staff-delivered sleep program in nursing facilities. DESIGN:Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS:This program was implemented in 2 New York City nursing facilities, with partial implementation (due to COVID-19) in a third facility. METHODS:Expert mentors provided staff webinars, in-person workshops, and weekly sleep pearls via text messaging. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework as a post hoc approach to describe key elements of the SLUMBER implementation. We measured staff participation in unit-level procedures and noted their commentary during unit workshops. RESULTS:We completed SLUMBER within 5 units across 2 facilities and held 15 leadership meetings before and during program implementation. Sessions on each unit included 3 virtual webinar presentations and 4 in-person workshops for each nursing shift, held over a period of 3 to 4 months. Staff attendance averaged >3 sessions per individual staff member. Approximately 65% of staff present on each unit participated in any given session. Text messaging was useful for engagement, educational reinforcement, and encouraging attendance. We elevated staff as experts in the care of their residents as a strategy for staff engagement and behavior change and solicited challenging cases from staff during workshops to provide strategies to address resident behavior and encourage adoption when successful. CONCLUSIONS AND IMPLICATIONS:Engaging staff, leadership, residents, and family of nursing facilities in implementing a multicomponent sleep quality improvement program is feasible for improving nursing facilities' sleep environment. The program required gaining trust at multiple levels through presence and empathy, and reinforcement mechanisms (primarily text messages). To improve scalability, SLUMBER could evolve from an interdisciplinary investigator-based approach to internal coaches in a train-the-trainer model to effectively and sustainably implement this program to improve sleep quality for facility residents.

BACKGROUND:Cognitive behavioral therapy for insomnia (CBT-I) is the gold-standard treatment for insomnia disorder in adults. Compared to young adults, older adults have increased risk for the development of conditions associated with chronic pain, which may impact the efficacy of CBT-I in improving insomnia symptoms in older adults. This study evaluated the effect of participant-rated pain on sleep-related outcomes of a supervised, non-clinician administered CBT-I program in older adult patients with chronic insomnia disorder. METHODS:Secondary analysis was conducted using data from a randomized controlled trial among 106 community-dwelling older adult veterans (N = 106; mean age 72.1 years, 96% male, 78.3% White, 6.6% Hispanic, 5.7% African American) with chronic (≥3 months) insomnia disorder. Participants engaged in five sessions of manual-based CBT-I in individual or group format within one Department of Veterans Affairs healthcare system, provided by non-clinician "sleep coaches" who had weekly telephone supervision by behavioral sleep medicine specialists. Insomnia symptoms (Insomnia Severity Index), perceived sleep quality (Pittsburgh Sleep Quality Index), fatigue (Flinder's Fatigue Scale), daytime sleepiness (Epworth Sleepiness Scale), and perceived pain severity (items from the Geriatric Pain Measure) were assessed at 4 time points: baseline, one-week posttreatment, 6-month follow-up, and 12-month follow-up. Mixed effects models with time invariant and time varying predictors were employed for analyses. RESULTS:CBT-I improved insomnia symptoms, perceived sleep quality, fatigue, and daytime sleepiness among older veterans with chronic insomnia. Participant-reported pain was associated with greater improvements in insomnia symptoms following CBT-I. Pain did not affect improvements in other sleep-related outcomes (-0.38 ≤ b ≤ 0.07, p > 0.05). Between-subjects differences in pain, but not within-subject changes in pain over time, appeared to play a central role in insomnia symptom improvement at posttreatment, with individuals with higher-than-average pain showing greater insomnia symptom improvement (ISI score reduction; -0.32 ≤ b ≤ -0.28, p ≤ 0.005). CONCLUSIONS:Pain did not meaningfully hinder the effects of CBT-I on sleep outcomes. Among older veterans with chronic insomnia disorder, individuals with higher pain exhibited slightly greater improvement in insomnia than those with lower levels of pain. These findings suggest that experiencing pain does not impair treatment response and should not preclude older adults with insomnia from being offered CBT-I.

OBJECTIVES:To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents. DESIGN:Modified stepped-wedge unit-level intervention. SETTING AND PARTICIPANTS:Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs. METHODS:Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2. RESULTS:There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2. CONCLUSIONS AND IMPLICATIONS:SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

ObjectivesInsomnia may contribute to fewer value-consistent choices and less engagement in meaningful life activities. We sought to identify values commonly expressed by women veterans engaged in a trial testing psychological treatment of insomnia disorder.MethodsSeventy-four women veterans (mean age = 48.3 [& PLUSMN;13] years), meeting DSM-5 diagnostic criteria for insomnia disorder received an acceptance-based behavioral treatment for insomnia. In the first session, participants responded to questions regarding personal values and the impact of insomnia on those values. Responses were categorized into values domains informed by the Bull's Eye Values survey (level 1 categories) and the Valued Living Questionnaire (level 2 categories).ResultsRaters reached 100% agreement after independent coding and adjudication. Level 1 value categories in frequency order were: relationships (n = 68), personal care/health (n = 51), work/education (n = 46), pets (n = 12), and leisure (n = 5). The most frequently reported level 2 value categories were: family (other than marriage/parenting; n = 50), parenting (n = 31), work (n = 31), physical health (n = 30), and spirituality (n = 19). The level 1 value categories impacted by insomnia in frequency order were: personal care/health (n = 65), relationships (n = 58), work/education (n = 46), pets (n = 12), and leisure (n = 5).ConclusionsWomen veterans undergoing insomnia treatment highly value relationships and personal care/health, which should be considered patient-centered outcomes of insomnia treatments.Clinical Trials RegistrationNCT02076165.

Study Design:Cross-sectional cohort study. Objectives:To determine the role of sleep-disordered breathing (SDB), insomnia symptoms and sleep quality in the daytime function and quality of life of veterans with spinal cord injury (SCI). Setting:A Veterans Administration (VA) medical center in the Midwestern US. Methods:Thirty-eight male veterans with SCI (22 cervical, 16 thoracic; mean [SD] age = 62.9[9.5] years) completed baseline assessments within a larger clinical trial. Measures assessed sleep apnea severity (apnea-hypopnea index, AHI), insomnia symptoms (Insomnia Severity Index, ISI), self-reported sleep quality (Pittsburg Sleep Quality Index, PSQI), daytime sleepiness (Epworth Sleepiness Scale, ESS), fatigue (Flinders Fatigue Scale, FFS), depression (Patient Health Questionnaire-9 item, PHQ-9 excluding sleep item), functioning (Spinal Cord Independence Measure, SCIM), and quality of life (World Health Organization Quality of Life, WHOQOL-BREF). Bivariate correlations (alpha p<.05) were used to assess relationships between sleep (AHI, ISI, PSQI, ESS) and function (FFS, PHQ-9, SCIM, WHOQOL-BREF). Results:Mean AHI was 29.9(26.6), mean ISI was 9.38(6.2), mean PSQI was 9.0(4.6), and mean ESS was 7.0(5.2). There were no significant relationships between AHI and function measures. Significant relationships emerged between ISI and PHQ-9, some WHOQOL-BREF subscales, and SCIM as well as between PSQI and FFS, PHQ-9, and some WHOQOL-BREF subscales. Conclusions:Among Veterans with SCI, insomnia symptom severity and poor sleep quality were associated with worse functioning, whereas SDB severity was not. Insomnia and poor sleep quality represent modifiable contributors to poor daytime function. Research evaluating the impact of evidence-based insomnia treatments among individuals living with SCI is warranted.

Insomnia and pain disorders are among the most common conditions affecting United States adults and veterans, and their comorbidity can cause detrimental effects to quality of life among other factors. Cognitive behavioural therapy for insomnia and related behavioural therapies are recommended treatments for insomnia, but chronic pain may hinder treatment benefit. Prior research has not addressed how pain impacts the effects of behavioural insomnia treatment in United States women veterans. Using data from a comparative effectiveness clinical trial of two insomnia behavioural treatments (both including sleep restriction, stimulus control, and sleep hygiene education), we examined the impact of pain severity and pain interference on sleep improvements from baseline to post-treatment and 3-month follow-up. We found no significant moderation effects of pain severity or interference in the relationship between treatment phase and sleep outcomes. Findings highlight opportunities for using behavioural sleep interventions in patients, particularly women veterans, with comorbid pain and insomnia, and highlight areas for future research.

INTRODUCTION:Poor sleep is ubiquitous in skilled nursing facilities (SNFs) and is associated with a myriad of negative symptoms. Non-pharmacological interventions can improve sleep, yet sustainability has not been demonstrated. The Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER) trial will test whether a staff mentoring approach to address resident sleep issues positively impacts sleep quality and whether improved sleep benefits mood, cognitive performance, and activity engagement for residents living in SNFs.INTERVENTION:This is a four-year hybrid type I effectiveness/implementation randomized stepped-wedge trial using a comprehensive sleep improvement program conducted in three urban SNFs.METHODS:We will provide SNF staff with sleep promotion strategies over a four-month intervention. Staff will have access to in-person workshops, webinars, weekly sleep pearls via text messaging, environmental data, and expert program mentors. We will consent residents for data collection (at baseline, end of intervention, and three- and six-months post-intervention) including resident observations, questionnaires, and wrist actigraphy (to objectively measure sleep). We will also use selected Minimum Data Set 3.0 (MDS) measures.CONCLUSION:SLUMBER uses a unique strategy to iteratively improve sleep interventions through SNF staff buy-in, expert mentoring, and technological supports within a quality improvement framework. As a stepped-wedge trial, the initial SNF units provide opportunities for program improvement in subsequent units, accounting for variation across resident populations at different sites. Protocol limitations include strategies which may require substantial customization for greater spread. A comprehensive staff training program that addresses both sleep quality and related symptoms has the opportunity for considerable dissemination.TRIAL REGISTRATION:USGOV Clinical Trials ID: NCT03327324.

OBJECTIVE:This randomized comparative effectiveness trial evaluated a novel insomnia treatment using acceptance and commitment therapy (ACT) among women veterans. Participants received either the acceptance and the behavioral changes to treat insomnia (ABC-I) or cognitive behavioral therapy for insomnia (CBT-I). The primary objectives were to determine whether ABC-I was noninferior to CBT-I in improving sleep and to test whether ABC-I resulted in higher treatment completion and adherence versus CBT-I. METHOD:One hundred forty-nine women veterans with insomnia disorder (Mage = 48.0 years) received ABC-I or CBT-I. The main sleep outcomes were Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), and sleep efficiency (SE) by actigraphy (objective) and sleep diary (subjective). Measures were collected at baseline, immediate posttreatment, and 3-month posttreatment follow-up. Treatment completion and adherence were assessed during the interventions. RESULTS:Both interventions improved all sleep outcomes from baseline to immediate posttreatment and 3-month posttreatment follow-up. At immediate posttreatment, ABC-I was statically noninferior for sleep diary SE and objective SE, but noninferiority was not statistically confirmed for ISI or PSQI total scores. At 3-month posttreatment follow-up, ABC-I was noninferior for all four of the key outcome variables. There was not a statistically significant difference between the number of participants who discontinued CBT-I (11%) versus ABC-I (18%; p = .248) before completing treatment. ABC-I was superior to CBT-I for some adherence metrics. CONCLUSIONS:Overall, ABC-I was similar in effectiveness compared to CBT-I for the treatment of insomnia and may improve adherence to some behavioral elements of treatment. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

To assess the association of insomnia symptoms and psychiatric symptoms in patients with spinal cord injury or disease (SCI/D). In this cross-sectional observational study, veterans with SCI/D (n = 72; mean = 59.85 ± 10.4 years; 92 ClinicalTrials.gov ; Name: Treatment of Sleep-disordered Breathing in Patients With SCI; URL: https://clinicaltrials.gov/ct2/show/NCT02830074 ; Identifier: NCT02830074.

Untreated sleep problems in persons living with dementia (PLWD) and their caregivers impact health outcomes of both individuals and impair quality of care for caregivers. This study pilot tested preliminary effects of a dyadic sleep intervention program among this group. Thirty PLWD/caregiver dyads were randomized to a 5-session treatment (n = 15 dyads) or a similarly structured information-only control group (n = 15 dyads) via in-person or video-telehealth. Treatment was a manual-based program incorporating key components of cognitive behavioral therapy for insomnia (CBTI), daily light exposure and walking, and a problem-solving approach for dementia-related behaviors and caregiving challenges. Sleep outcomes included actigraphy-measured sleep efficiency (SE) and total awake time (TWT) at night for dyads, and Pittsburgh Sleep Quality Index (PSQI) for caregivers. Outcomes were measured at baseline, post-treatment, and 3-months follow-up (main outcome time point). Recommendation adherence in the treatment group was computed and a 2 (group) by 3 (time) mixed model analysis of variance was used to test the treatment effects (p<0.20 as the threshold). Two dyads in treatment and one control dyad did not complete all five sessions. Of 13 dyads who completed all sessions of the treatment program, average % days that the dyads met their sleep schedules were 76% bedtime and 83% get-up time for PLWD and 81% bedtime and 68% get-up time for caregivers. From baseline to 3-month follow-up, SE increased by 3.2% more for PLWD in the treatment group (n = 9) compared to control (n = 9, p = 0.48) and by 3.7% more for caregivers in the treatment group (n = 12) compared to control (n = 9, p = 0.17). TWT also reduced by 19 minutes more for PLWD and 14 minutes more for caregivers in the treatment group compared to control at the 3-month follow-up although this was not statistically significant. Caregivers in treatment also showed non-significant improvement on the PSQI (p>0.20). A dyadic approach to sleep improvement showed evidence of benefit among PLWD and caregivers. A larger study is needed to fully evaluate these effects and compare in-person to telehealth modalities.

Objective: Insomnia is known to exacerbate pain symptoms. The purpose of the present study was to compare the secondary effects of cognitive behavioral therapy for insomnia (CBT-I) against a novel treatment for insomnia called acceptance and behavioral changes for insomnia (ABC-I) among individuals with comorbid pain. Differences in the potential mechanisms through which these treatments impact pain were also examined.Methods: Data consisted of a secondary analysis from a randomized comparative effectiveness trial of CBT-I and ABC-I among women veterans with insomnia and comorbid pain. Pain outcomes, beliefs about sleep, and psychological flexibility were assessed at baseline, post-treatment, and at three-months follow-up.Results: At baseline, 93 women veterans reported comorbid insomnia and pain (mean age = 46.7; 33.3% Black, 24.7% Hispanic/Latina). Both CBT-I (n = 48) and ABC-I (n = 45) were associated with decreased pain intensity (p < .001, Cohen's d = 0.41-0.67) and pain interference (p < .001, Cohen's d = 0.71-0.77) at post-treatment and three-months follow-up, with results indicating that ABC-I was non-inferior to CBT-I for pain improvement. Both conditions were associated with greater psychological flexibility post-treatment, and CBT-I resulted in larger reductions in dysfunctional beliefs about sleep (p = .01, Cohen's d = 0.59).Conclusion: CBT-I and ABC-I both had positive secondary effects on pain with ABC-I being non-inferior to CBT-I with respect to its impact on pain. The mechanisms of change associated with these treatments may differ with CBT-I leading to greater reductions in dysfunctional beliefs. Hybrid treatments which incorporate an acceptance and commitment approach to both insomnia and pain warrant further examination.

Long-term use of benzodiazepines or z-drugs (benzodiazepine receptor agonists; BZAs) is not advised for older adults due to adverse outcomes.1, 2 While studies of BZA prescribing patterns show increasing rates of co-prescribing of BZAs (e.g., benzodiazepines with z-drugs),3 to our knowledge, studies examining patient-reported rates of use of more than one BZA (multi-BZA) are lacking. This study aims to estimate rates of patient-reported multi-BZA use among older adults and to examine associations between multi-BZA use and sleep characteristics. Telephone screening surveys were conducted for an ongoing BZA deprescribing clinical trial (NCT03687086)4 to recruit adults aged ≥55 in California who were receiving care through the Department of Veterans Affairs or University of California, Los Angeles and were prescribed at least one of five targeted BZAs (alprazolam, clonazepam, lorazepam, temazepam, zolpidem) chosen for practicality for the dose reduction component of the trial. Screeners between February 2019 and October 2022 were analyzed. Our institutional review boards approved the study, including a waiver of documented consent. Participants reported whether they used each targeted BZA for sleep over the past 3 months (yes/no for each) and were classified as multi-BZA (>1), single-BZA (1), or non-BZA (0) users based on the number of “yes” responses. BZA use frequency was estimated by asking participants how many nights in a typical week during the past month they had taken each BZA. We did not assess for concurrent use in the multi-BZA group. Participants were asked if their sleep problems have lasted <3, 3–12, or >12 months (dichotomized as ≤3 months and >3 months) and if their sleep quality in the last month was “very good,” “fairly good,” “fairly bad,” or “very bad” (dichotomized as “very/fairly good” and “very/fairly bad”). Self-reported time asleep and time in bed were used to compute sleep efficiency (time asleep/time in bed), which was categorized as excellent (≥90%), good (≥85%), and fair (≥80%).5, 6 Analyses compared sleep characteristics between multi-, single-, and non-BZA users in unadjusted and adjusted (for site, age, gender, race, ethnicity) logistic and linear regression models (alpha = 0.05). Pairwise comparisons and predicted margins for comparisons (multi- versus single-BZA or non-BZA) were estimated and adjusted predicted margins from adjusted models plotted using Stata/SE 17.0 (StataCorp LLC, College Station, Texas). We screened 793 of 8514 potential participants (see Table 1 for sample characteristics). Multi-BZA was reported by 13.9% of participants in the past 3 months. Among multi-BZA participants, 87.3% reported taking 2 BZAs, most commonly alprazolam-zolpidem (28.1%) and lorazepam-zolpidem (25.0%). Most participants (96.5%) reported sleep problems greater than 3 months and fairly/very bad sleep (68.0%). Mean sleep efficiency was 67.7% (SD = 18.3%). Only 10.5% had high sleep efficiency (≥90%). In unadjusted models, multi- versus single-BZA status was associated with a 9.8% increase in poor sleep quality (p = 0.03). There were no other significant differences in sleep characteristics for multi- versus single- or non-BZA users (p-values ≥0.51). No differences were observed for multi- versus single- or non-BZA users for categorical sleep efficiency variables (p-values ≥0.07). In adjusted logistic and linear regression models, predictive margins for multi- versus single- or non-BZA were not significant for sleep problem chronicity, sleep quality, and sleep efficiency as a continuous variable (p-values ≥0.07). Figure 1 summarizes these findings. We found 1 in 8 older patients prescribed a BZA for sleep reported multi-BZA use over the past 3 months. Multi-BZA use was unrelated to chronicity of sleep problems, sleep quality, or sleep efficiency, suggesting that multi-BZA use was not associated with improved or worse sleep. The findings reflect patient reported use of BZA medications rather than prescriptions. Regardless of whether multi-BZA use was simultaneous or staggered, these findings are concerning since elimination half-life of these medications, which can be longer in older adults, may lead to overlap even when these medications are taken at different times or days. Amplification of adverse effects (e.g., cognitive impairment, falls2) is a concern during these periods of overlap. Through our experiences screening patients, we understand multiple factors might contribute to multi-BZA use. Some patients take benzodiazepines for anxiety and z-drugs for insomnia. Some patients whose medication quantity is limited request another medication from the same class to have “enough,” or patients may have multiple prescribing clinicians who are unaware of other BZA prescriptions. Study limitations include not recording reasons for multi-BZA use, inquiring about five BZAs only, not assessing concurrent use, and focusing on insomnia indications, thereby potentially underestimating multi-BZA use in daytime users. Future research should address these limitations to better characterize multi-BZA use. Sara Ghadimi: Conception and design, acquisition of data, analysis and interpretation of data, manuscript drafting, final approval of manuscript. Austin Grinberg: Acquisition of data, analysis and interpretation of data, manuscript drafting, final approval of manuscript. Michael N. Mitchell: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Cathy Alessi: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Alison A. Moore: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Jennifer L. Martin: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Joseph M. Dzierzewski: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Monica Kelly: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Safwan Badr: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Andrew Guzman: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Jason P. Smith: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Michelle Zeidler: Analysis and interpretation of data, manuscript drafting, final approval of manuscript. Constance H. Fung: Conception and design, acquisition of data, analysis and interpretation of data, manuscript drafting, final approval of manuscript. We are grateful for the contributions and efforts of the sleep research staff at VA Greater Los Angeles Geriatric, Research, Education and Clinical Center and UCLA. The authors declare no conflicts of interest. The National Institute on Aging and the Department of Veterans Affairs did not have any direct role in the analysis or writing of this manuscript. The findings do not necessarily reflect the views of the NIA or Department of Veterans Affairs. This work was supported by NIA R01AG057929 (to Constance H. Fung), VA HSR&IIR 17-234 (from the United States Department of Veterans Affairs to Constance H. Fung), UCLA CTSI UL1TR001881, VA Research Career Scientist Award (VA HSR&D RCS 20-191 from the United States Department of Veterans Affairs to Jennifer L. Martin) and NIH/NHLBI (K24 HL143055 to Jennifer L. Martin). The contents of this paper do not represent VA or NIH views or the United States Government.