A Web-Based Treatment for Insomnia
Principal Investigator: 
Denver VA Medical Center and the University of Colorado Medical Center

Over the past decade or so it has become increasingly clear that there is a link between sleep problems and suicide. Research has shown, for example, that people suffering from insomnia are two to three times more likely than those without sleep problems to think about suicide, attempt suicide, and die by suicide. And it is not simply that people with other problems, such as major depression or post-traumatic stress disorder, are more likely to both have sleep problems and attempt suicide. The evidence indicates that insomnia is a separate risk factor that itself makes a person more likely to think about and to attempt suicide.

Thus Sarra Nazem, a clinical research psychologist at the Denver VA Medical Center and the University of Colorado Medical Center, is testing an Internet-based intervention that is designed to help Veterans and Service Members address problems with insomnia. If it proves successful, it will offer a way to treat a large number of individuals for their sleep problems, which in turn should have a significant effect on a number of mental health issues affecting Veterans and active members of the Armed Services, including suicide.

At present it is not clear why insomnia should lead to an increased risk for suicidal ideation and suicide attempts, but psychological researchers have suggested a number of possible reasons. For example, poor sleep may make it difficult for a person’s brain to process the previous day’s emotional memories, disrupting the ability to make sense of and deal with strong emotions. Poor sleep may also harm an individual’s ability to cope with stress. But whatever the precise mechanisms, it seems likely that helping someone sleep better will have a number of benefits, one of which will be to decrease the likelihood of suicidal thoughts and suicide attempts.

As it happens, Nazem says, there is already a well developed and successful therapy for dealing with insomnia. It is called Cognitive Behavioral Therapy for Insomnia, or CBT-I, and studies have shown that it is just as effective as prescription medication for treating insomnia in the short term and more effective in the long term, particularly since the long-term use of sleep medications often leads to other problems. About 70 to 80 percent of individuals with insomnia are helped by CBT-I. It also has been shown to help with depression and other mental health issues.

The Veterans Health Administration has encouraged VA medical centers across the country to train their therapists in CBT-I and to offer the therapy to Veterans, and the results have been promising. Veterans who have been treated with CBT-I have generally seen the severity of their insomnia decrease significantly.

There is just one problem: there are many, many Veterans suffering from insomnia and not nearly enough trained therapists to provide the CBT-I treatment. One study found that as many as 93.5 percent of the men and women who served in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn have suffered from sleep disorders. But training therapists in CBT-I takes time and money, and although VA medical centers have made substantial efforts to increase access to the treatment, there remains a shortage of available providers to meet the growing demand for the insomnia treatment. The result has been waiting lists of Veterans wanting CBT-I.

One promising solution, Nazem says, is to provide the therapy over the Internet. Researchers have tested the effectiveness of self-administered CBT-I therapy using an interactive website that mirrors the interaction a person would have with a therapist, and they have found that these Web-based therapies can be just as effective in dealing with insomnia as face-to-face treatment. One advantage of the Web-based treatment is that the individual can spend much longer on the treatment than if working with a therapist. Other advantages are that there is no need for Veterans to schedule their treatment during clinic hours—they can access the treatment when it works best for them—and there are no travel demands, which is particularly important for Veterans living far from medical centers, who often forego treatment because of the time and money involved in traveling long distances to a clinic.

Thus Nazem will be testing one particular Web-based CBT-I called SHUTi (Sleep Healthy Using the Internet) on a group of Veterans. Although SHUTi has been shown to be effective in civilian populations, it has not been tested using a randomized controlled trial in a military population. That is what Nazem and her colleagues will be doing.

Their study will recruit 226 Veterans from the Eastern Colorado Health Care System who have reported problems with insomnia. Half of them will be assigned to take part in the Web-based SHUTi therapy, while the other half will go to an educational website to read about sleep disorders and ways to deal with them. Both will have access to their Web site for nine weeks. They will all be tested at four points in time—at the beginning, directly after the nine-week intervention (either the SHUTi therapy or the visit to the educational website), six months post-intervention, and one year post-intervention. They will be assessed not only on the level of their insomnia but on such things as depression, anxiety, and suicidal thoughts.

If the Web-based SHUTi treatment proves as effective in Veterans as it has been in the civilian population, it will offer a powerful tool for dealing with one of risk factors for suicide—that is, insomnia. But it has the potential to do far more than this. Because insomnia is such a widespread problem, affecting both Veterans and active military personnel, and because it exacerbates a number of mental health issues besides suicide, an effective Web-based treatment promises to improve the lives of many Veterans significantly and also contribute to improving the readiness of the military services. A good night’s sleep can be a powerful thing.

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