Preliminary Feasibility and Efficacy of a Brief Behavioural Treatment for Insomnia after Acquired Brain Injury: A Case Series

doi:10.21203/rs.3.rs-4907203/v1

Download PDF

Research Article

Preliminary Feasibility and Efficacy of a Brief Behavioural Treatment for Insomnia after Acquired Brain Injury: A Case Series

https://doi.org/10.21203/rs.3.rs-4907203/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Insomnia after Acquired Brain Injury (ABI) is common and can negatively impact individuals’ rehabilitation, recovery and quality of life. The present study investigated the feasibility and preliminary efficacy of a Brief Behavioural Treatment for Insomnia (BBTI) in a community sample following ABI. Ten participants were recruited. Seven participants attended four weekly sessions of BBTI and kept a daily sleep diary. Participants completed a semi-structured sleep interview at baseline and self-report measures of sleep, anxiety and depression pre- and post-treatment as well as a treatment acceptability questionnaire post-treatment. Follow-up data were collected at one, two- and three-months post-treatment. Visual analyses of the data were performed on a case-by-case basis. Five participants (71%) demonstrated clinically significant improvements in sleep questionnaire measures, one showed treatment response and one (14%) showed nonresponse post-treatment. Treatment effects on sleep outcomes were either maintained or augmented at follow-ups. BBTI was found to be well-tolerable, as evidenced by high overall retention rates (70%) and positive feedback on the treatment acceptability questionnaire. These results provide preliminary evidence of BBTI being both feasible to use and efficacious in individuals with post-brain-injury insomnia. Larger-scale randomised controlled trials are needed to establish the effectiveness of BBTI following ABI.

Psychology

Acquired Brain Injury

Brief Behavioural Intervention

Insomnia

Sleep

Acquired Brain Injury (ABI) is one of the leading causes of neuro-disability worldwide, leaving individuals with profound physical, cognitive, and mental consequences post-injury (1). Sleep disturbances, including insomnia disorder, are among the most frequent complaints for people following traumatic brain injury (2). Insomnia, one of the most common and debilitating sleep disorders, is characterised by difficulty falling asleep, staying asleep, and/or waking up too early despite ample opportunity to sleep (3). The prevalence of insomnia disorder and symptoms is higher in stroke survivors (4) and those with a mild traumatic brain injury (TBI) (5) than in the general population (6).

A number of possible mechanisms may contribute to the high incidence and prevalence of sleep disturbances and insomnia following brain injuries, such as disruptions to the sleep-regulating brain regions and/or the associated pathways and neurotransmitter systems (7). In hospitalised patients, environmental factors like room sharing, noise, and light may also contribute to the onset and maintenance of insomnia and insomnia symptoms at the acute phase post-injury (8) or during rehabilitation (9).

The consequences of untreated sleep disruption are well evidenced in healthy individuals, with numerous studies demonstrating the impact of poor sleep on cognition, mood, learning, memory, and brain plasticity (10) that constitute the core modalities of neuropsychological rehabilitation and recovery after a brain injury. Emerging evidence demonstrates that the presence of a sleep disorder post-stroke is associated with negative recovery outcomes, including depression, disability and fatigue (11, 12) in addition to low functional and motor outcomes at admission to post-stroke rehabilitation (13). In animal models of ischaemic stroke, such neurological impairments (14) were improved by experimental manipulation of sleep states (15), suggesting that sleep may be a primary driver of functional recovery post brain injury. Despite these mechanistic links of sleep to ABI recovery and the well-established associations of insomnia with outcome in human stroke survivors, sleep is one of the least explored mechanisms in stroke functional recovery (16).

Non pharmacological interventions for sleep, such as Cognitive Behavioural Therapy for Insomnia (CBT-I), typically delivered over 6–8 sessions, show promising preliminary results for insomnia in stroke survivors (17, 18). However, the length of treatment and the lack of access to psychological therapy pose significant limitations to these approaches (19). Alternative and shorter behavioural interventions for insomnia have been developed (20) such as Brief Behavioural Treatment for Insomnia (BBTI) (21) that is based primarily on the principles of sleep restriction and stimulus control, which constitute the behavioural components of CBT-I. Previous evidence shows that stimulus control and sleep restriction (as part of a CBT-I intervention) resulted in rapid benefits for community patients post-TBI (22).

The feasibility and efficacy of BBTI have been successfully demonstrated in diverse populations. For instance, Buysse et al. (23) explored the efficacy of BBTI in a sample of older adults with chronic insomnia. The experimental group received a four-week long BBTI delivered by a nurse with no experience in sleep medicine, and the control group was provided with educational material for self-study. At post-treatment, compared to the control group the BBTI condition group showed improved outcomes on self-reported sleep questionnaires, sleep diaries, and actigraphy and met insomnia disorder criteria less often. These improvements were well-maintained at a six-month follow-up. A promising response to BBTI has also been found in individuals living with HIV (24), in combat-exposed military personnel (25) and in clients with treatment-resistant insomnia (26).

Following the same four-week BBTI protocol the main objective of the present study was to explore the feasibility and preliminary efficacy of the behavioural intervention for insomnia in a case series sample with insomnia after brain injury.

Design and Ethics

A case series design was adopted. The University of Glasgow College of Science and Engineering Ethics Committee reviewed and approved the study (Ref: 300200056).

Participants

Recruitment, inclusion, and exclusion criteria. Participants were recruited through a local branch of a UK-wide brain-injury charity (Headway) from 10th November 2016 to 10th November 2017. No monetary reward for participation was offered. Eligible participants had to have sustained a brain injury as an adult and report symptoms of poor sleep and insomnia. Participants taking hypnotic medication were eligible to participate, provided that they had not changed their medication in the three weeks prior to recruitment. Participants were excluded if they presented with a comorbid sleep disorder, were medically unstable, or self-reported a mental health disorder that required ongoing treatment from a healthcare professional on screening.

BBTI Intervention

Brief Behavioural Treatment for Insomnia (BBTI) is a four-session behavioural insomnia intervention, with two sessions typically delivered in person and two over the phone (21). BBTI is based on the well-established behavioural principles of sleep restriction and stimulus control (27) but also includes education on sleep regulation and hygiene (23). These components provide a rationale for the four main rules of BBTI, specifically: (1) Reduce time in bed, (2) Don’t go to bed unless sleepy, (3) Don’t stay in bed unless asleep and (4) Wake up at the same time every day, no matter how much you slept the night before (21).

The intervention was tailored to the needs of the participants with respect to their post-brain injury memory and cognitive abilities and thus deviated from the original planned procedure as outline by Troxel and colleagues (21). More specifically, all sessions were delivered in person in a convenient place and time for participants, compared to having sessions II and IV over the phone. The location was the charity premises and the time was during their usual visiting times as it was the most convenient for all participants to attend. Secondly, session I was delivered to small groups (2–3 participants) rather than individually due to research resources. Third, discussion on how and why sleep is affected following a brain injury was included in the educational component of session I. Participants were provided with a paper workbook and were asked to keep a daily sleep diary throughout the intervention and to address the frequent post-brain-injury memory problems, participants received daily morning reminders to complete their sleep diary. The content of the individual sessions is outlined in a schematic graph in Fig. 1.

Questionnaire measures

Sleep. A semi-structured Sleep History Interview, was developed by the research team to capture rich in-depth information on the participants’ sleep routine, identify the presence of sleep disorders and any consequences of sleep disturbances on daily functioning (28). This interview allowed establishing the subjective impact of the brain injury on the individuals’ sleep.

A sleep diary (29) was used to collect daily information on participants’ sleep patterns (10 items) and quality (2 items). To rate the subjective sleep quality, a scale from 0 to 4 was used, with higher scores indicating better sleep quality. Sleep diary parameters were calculated as: TWT − total wake time, i.e. sleep onset latency and any wakefulness after sleep onset; SE − sleep efficiency, i.e. total sleep time over time in bed, multiplied by 100 and SQ − subjective sleep quality

Sleep quality was assessed using the Pittsburgh Sleep Quality Index [PSQI; (30)], a well-established self-report measure validated for use with people after brain injury (31). Scores on each of the seven clinically relevant sleep quality components range from 0 to 3, yielding a global score with range from 0 to 21, where higher scores indicate poorer sleep quality. In the brain injury population, a cut-off score of 8 has been recommended to discriminate good and poor sleepers (32).

The Sleep Condition Indicator [SCI; (33)] was employed to obtain an assessment of insomnia symptoms. The SCI comprises 8 items with scores for each item ranging from 0 to 4 with higher total scores indicating better sleep. A score of 16 or higher is indicative of no insomnia disorder.

Depression and Anxiety. The Hospital Anxiety and Depression Scale [HADS; (34)] was used to monitor changes in anxiety and depression over the course of the study. The HADS is composed of seven depression and seven anxiety items, each rated on a scale from 0 to 3. The level of depression and anxiety is classed as normal (total score of 0 to 7), mild (total scores of 8 to 10), moderate (total scores of 11 to 14) and severe (total scores of 15 to 21).

Treatment acceptability. A Treatment Acceptability and Credibility Questionnaire was developed for the purposes of this study to gain a better understanding of the participants’ overall experience of the intervention. Participants were asked to rate 13 closed-ended questions on a scale from 0 to 7, with higher scores indicating greater satisfaction with the intervention. Further, three open-ended questions asked about liked and disliked aspects of the intervention and additional comments.

Procedure

Baseline

Interested participants were screened for eligibility and those meeting inclusion criteria received a detailed information sheet about the study before written consent was obtained. Pre-treatment measures were collected by VZ and MG, including demographic characteristics, Semi-structured Sleep Interview, PSQI, SCI and HADS. Participants were provided with a paper copy of the sleep diary. They were asked to complete it daily in the morning and bring it to the first intervention session in a week’s time. As daily completion was essential, participants were offered daily text message reminders.

Intervention Sessions (I-IV)

The intervention was delivered over four weeks (one session per week) after baseline in accordance with the protocol. The intervention was delivered by the first author (MG) who had training and extensive research experience delivering CBT-I and subsequently by the third author (VZ).

Post-Treatment and Follow-Up Sessions

A week after finishing the intervention, participants completed the post-treatment measures, consisting of the same questionnaire battery as pre-treatment. Additionally, participants filled in the Treatment Acceptability and Credibility Questionnaire. If participants agreed, follow-ups were scheduled for a month’s, two-months’ and three-months’ time to monitor progress. At these sessions, the same battery of measures was completed and sleep diary data for seven days were obtained at the end of each follow up session.

Treatment outcomes: Participants were regarded as showing a clinically significant improvement if at least two of the following criteria were met: (1) PSQI score of < 8, (2) SCI score of ≥ 16, (3) TWT ≤ 30 min, SE ≥ 85%, SQ ≥ 2 (any two out of three) and (4) no current self-reported sleep problems.

BBTI Feasibility

Retention and attendance

Ten individuals approached the researchers, and all were found to be eligible to participate. One participant withdrew before starting the intervention, and two withdrew after the first BBTI session (I), resulting in seven (n = 7) participants completing the study with an overall study drop-out rate of 30% and intervention dropout rate of 22.22%. One participant paused treatment due to a worsening of a family member’s medical condition and resumed when their condition stabilised. All participants completed all BBTI sessions.

Participant Characteristics. The sample consisted of six males and one female, aged 41 to 70 years (median = 54 years). All participants were white; one was living with a partner and children, two with children only and four were living alone. Participants’ qualifications ranged from upper secondary to postgraduate. One participant was returning to work at the time of the study whilst the rest had no plans for return to work. Four participants sustained a TBI (two due to accident, one due to assault, one due to fall) and three an ABI (one due to brain tumour, one due to ischemic stroke and one due to anoxia). Time since injury was 2 to 32 years (median = 4 years). All participants reported being hospitalised following their brain injury and five participants received post-brain injury rehabilitation (Table 1). All participants reported experiencing at least five common consequences of brain injury other than sleep problems (e.g., sensory, memory, mood disturbances). Comorbid physical conditions were present in three participants, two disclosed previously treated mental health disorders. All were taking at least one, but some as many as six different types of prescribed medication.

Table 1

Participant demographic and injury characteristics.
	Age	Sex	Type of BI	Time since BI (years)	Hospitalisation after BI	Rehabilitation after BI
P1	49	M	TBI	3	Y	Y
P2	70	M	ABI	4	Y	N
P3	57	M	TBI	32	Y	Y
P5	41	F	TBI	2	Y	N
P7	54	M	ABI	3	Y	Y
P8	42	M	ABI	5	Y	Y
P9	55	M	TBI	10.5	Y	Y
Note. ABI = acquired brain injury; BI = brain injury; F = female; M = male; N = no; P = participant; TBI = traumatic brain injury; Y = yes,

Sleep diary completion

Compliance with daily sleep diary completion was high. A mean number of 48.71 (SD = 12.54) sleep diary entries were extracted per participant (range = 28 to 63 days). This range was a result of additional sleep diaries being available for those who had completed follow-ups and those who had treatment spread over a longer period due to pausing or rescheduling a session.

Treatment acceptability and credibility

Item-by-item mean scores for the Likert-scale questions on the Treatment Acceptability and Credibility Questionnaire ranged from 6.29 to 6.71 out of 7, indicating high subjective satisfaction with the treatment form, procedures, content and effectiveness. The answers provided to the three subsequent open-ended questions were also indicative of high satisfaction with the delivered intervention. Specifically, only one participant identified a treatment component they particularly struggled with (P9 − no naps) and all participants gave informative examples of treatment components they liked (e.g., clear sleep schedules − P2, P8).

BBTI Efficacy

Sleep Outcomes

Sleep diaries

Mean total wake time (TWT), sleep efficiency (SE) and sleep quality (SQ) were recorded for all participants throughout the duration of the study. Visual analyses of changes in mean sleep parameters were performed on a case-by-case basis and is shown in Table 2.

Table 2

Sleep diary parameters at pre- and post-treatment and at 1-, 2- and 3-month follow-ups.
		TWT					SE					SQ
		Pre	Post	FU1	FU2	FU3	Pre	Post	FU1	FU2	FU3	Pre	Post	FU1	FU2	FU3
TBI	P1	35.36	19.29	19.29	15.71	38.57	74.32	81.85	84.00	81.76	79.10	2.00	2.00	2.00	2.00	2.00
	P3	100.72	28.58	34.29	30.00	-	65.88	86.50	84.26	90.83	-	1.64	1.93	1.71	1.79	-
	P5	49.28	51.42	-	-	-	85.16	83.16	-	-	-	1.00	0.83	-	-	-
	P9	10.00	10.00	10.00	10.00	-	97.15	97.06	97.32	97.37	-	0.93	1.00	1.57	2.00	-
ABI	P2	180.00	34.28	25.00	26.66	32.14	35.63	82.18	85.73	75.51	87.72	1.39	2.14	2.18	2.14	2.14
	P7	170.72	109.29	10.00	4.29	-	92.49	74.36	96.23	95.43	-	0.14	1.36	2.50	2.71	-
	P8	73.34	50.36	-	-	-	65.87	86.47	-	-	-	1.79	2.93	-	-	-
Note. TWT in minutes, SE in %, SQ scored on a 0–4 scale, with higher scores indicating better sleep quality. Pre = pre-treatment; Post = post-treatment; FU1/2/3 = 1/2/3-month follow-up. TWT = Total Wake Time; SE = Sleep Efficiency; SQ = Sleep Quality.

Sleep questionnaires

A substantial pre- to post-treatment change in self-reported sleep measures was present following BBTI for most participants, with the exception of P5 (Table 4). PSQI scores showed a general decrease, with six of the seven participants scoring 8 or less post-treatment, indicative of good sleep quality. This was generally well-maintained at follow-up. Further, SCI scores showed an increase across all participants, indicating improvement in insomnia symptoms, with five of the seven participants no longer meeting the threshold for an insomnia disorder post-treatment. These gains were either maintained or improved at follow-up.

Mood

Co-occurring changes in HADS-A scores were present, with one participant showing a reduction in anxiety symptoms from mild to normal level, one from moderate to normal level, one from moderate to mild level and one from severe to moderate level post-treatment. There were also modest improvements in HADS-D scores for some participants, with one participant showing a reduction from moderate to normal level, two from moderate to mild level, and one from mild to normal level of depression. Improvements in subjective mood measures were mostly well-maintained, and a few participants showed further reductions in anxiety and depression scores, particularly at 1- and 2-month follow-ups (Table 4).

Table 4

PSQI, SCI, HADS scores at pre- and post-treatment and at 1-, 2- and 3-month follow-ups.
		Sleep										Mood
		PSQI					SCI					HADS-A					HADS-D
		Pre	Post	FU1	FU2	FU3	Pre	Post	FU1	FU2	FU3	Pre	Post	FU1	FU2	FU3	Pre	Post	FU1	FU2	FU3
TBI	P1	10	6	6	5	8	20	31	31	31	30	2	2	2	2	1	10	5	8	8	10
	P3	9	4	6	3	-	9	28	24	30	-	2	1	6	1	-	6	1	6	0	-
	P5	8	8	-	-	-	12	13	-	-	-	13	7	-	-	-	11	9	-	-	-
	P9	11	6	4	4	-	6	18	28	29	-	9	6	5	1	-	10	10	8	7	-
ABI	P2	14	5	3	5	4	6	27	30	27	29	12	10	5	7	10	10	9	6	7	8
	P7	10	9	3	3	-	4	13	32	29	-	6	3	4	3	-	11	9	4	4	-
	P8	14	6	-	-	-	4	25	-	-	-	16	12	-	-	-	11	7	-	-	-

Note: Pre = pre-treatment; Post = post-treatment; FU1/2/3 = 1/2/3-month follow-up. TWT = Total Wake Time; SE = Sleep Efficiency; SQ = Sleep Quality. PSQI = Pittsburgh Sleep Quality Index; SCI = Sleep Condition Indicator; HADS-A/D = Hospital Anxiety and Depression Scale, Anxiety/Depression subscale.

Clinically significant change in sleep

Using the predetermined criteria, five out of seven participants (P1, P2, P3, P8, P9) showed a clinically significant improvement post-treatment. This change was retained by P1, P2, P3 and P9 at all available follow-ups (Table 5). For P8 no follow-up data were available.

Further, for a response to the intervention at least two of the following criteria needed to be met: at least a 3-point improvement on PSQI, at least a 5-point improvement on SCI, 10% improvement in two out of three sleep diary parameters (TWT, SE, SQ) as compared to pre-treatment. P7 met the criteria for response post-treatment and reached the criteria for clinically significant improvement at all available follow-ups.

Table 5

Clinical significance of outcomes at post-treatment and at 1-, 2- and 3-month follow-ups.
		PSQI score < 8				SCI score ≥ 16				TWT ≤ 30 min, SE ≥ 85%, SQ ≥ 2*				Reported no current sleep problems**				Clinically Significant Improvement Post-treatment
		Post	FU1	FU2	FU3	Post	FU1	FU2	FU3	Post	FU1	FU2	FU3	Post	FU1	FU2	FU3	Clinically Significant Improvement Post-treatment
T B I	P1	YES	YES	YES	NO	YES	YES	YES	YES	YES	YES	YES	NO	YES	YES	YES	YES	YES
	P3	YES	YES	YES	-	YES	YES	YES	-	YES	NO	YES	-	unsure	unsure	YES	-	YES
	P5	NO	-	-	-	NO	-	-	-	NO	-	-	-	NO	-	-	-	NO
	P9	YES	YES	YES	-	YES	YES	YES	-	YES	YES	YES	-	NO	NO	YES	-	YES
A B I	P2	YES	YES	YES	YES	YES	YES	YES	YES	NO	YES	YES	YES	NO	YES	YES	YES	YES
	P7	NO	YES	YES	-	NO	YES	YES	-	NO	YES	YES	-	NO	YES	YES	-	NO
	P8	YES	-	-	-	YES	-	-	-	YES	-	-	-	NO	-	-	-	YES

Note

*At least two out of three need to be met. **A “no” answer to the question “Do you currently have problems with your sleep?” in the Semi-structured Sleep Interview.

Case Study

In order to give a comprehensive illustration of the effects of the intervention, we included the following case study. Participant 2 (P2) was a 70-year-old male, retired and living alone, with upper secondary qualification. He had no diagnosed physical or mental illnesses, but was regularly taking simvastatin, amlodipine and occasionally co-codamol. He sustained a moderate-severe ABI due to a tumour that was surgically removed four years prior to his participation in the study. He had spent five weeks in hospital but was not offered rehabilitation post-surgery.

P2’s primary complaint was difficulty falling asleep, which affected him seven nights a week. He experienced some night awakenings and did not feel refreshed after a typical night. He perceived his poor sleep to significantly impact his daytime functioning. He disclosed sometimes taking naps and using a laptop in bed. The individualised treatment recommendations included reducing time in bed from nearly 13 hours per night to seven, as well as eliminating daytime napping and use of the laptop in bed.

His PSQI scores decreased from 14 to 5, indicative of good sleep quality post-treatment. Further, his SCI score increased from 6 to 27, indicating no presence of insomnia symptoms after treatment. Co-occurring changes in HADS-A scores (12 to 10) were present, reflecting a non-clinically significant reduction in anxiety symptoms with a change in symptom severity classification from moderate to mild. HADS-D score changed minimally and remained mild post-treatment. Improvements in subjective sleep measures were maintained, while anxiety and depression scores showed further reductions, particularly at 1- and 2-month follow-ups.

Using the criteria for visual analysis of time series plots suggested by Kazdin (35), it was noted that for all three parameters, change was discontinuous rather than gradual, with a clearly perceptible decreasing trend in TWT, and increasing trends in SE and SQ. Overall, improvements remained well-maintained at all 1-, 2- and 3-month follow-ups, despite the one very poor night of sleep visible at 2-month follow-up due to alcohol consumption. Further, a clear reduction in inter-night variability was observed for all three parameters towards the end of the study period. Changes in sleep diary parameters throughout the study are depicted in Figs. 2, 3 and 4 respectively.

This is the first study with a case series design to demonstrate the feasibility and efficacy of Brief Behavioural Treatment for Insomnia for individuals after brain injury on sleep outcomes for all participants, including sleep quality with change evident for the majority of participants on questionnaire measures with accompanying improvement in mood.

More specifically, regarding the feasibility of BBTI in this sample, most participants tolerated the intervention well. The drop-out rate from the start of intervention to post-intervention was 22.22%, which is comparable with other intervention studies conducted in this population (36) as well as BBTI investigations in other groups (20). Further, seven of the nine participants who commenced the intervention attended all sessions and completed all sleep diaries. Moreover, the feedback given in the Treatment Acceptability and Credibility Questionnaire pointed to very high satisfaction with all treatment components, exceeding the already positive ratings BBTI received in other populations (24).

As far as the preliminary efficacy of BBTI in this sample is concerned, five out of seven participants demonstrated clinically significant sleep improvement post-treatment, one participant showed (clinically nonsignificant) response and one participant showed nonresponse, according to the predetermined clinical change criteria. While no universal standard for classifying insomnia treatment response exists (37), other BBTI studies used criteria similar to ours and reported relatively comparable ratios (38). The proportion of participants with brain injury and insomnia demonstrating a clinically significant response to CBT-I reported in Ouellet and Morin (22) (73%) was comparable to our results. This indicates that for people with brain injury a shorter and more easily disseminated intervention, such as the BBTI, may be a good alternative to the better-established CBT-I in terms of efficacy.

Participants in the clinically significant improvement category presented markedly improved changes in both sleep and insomnia questionnaire measures (PSQI and SCI) as well as sleep diary parameters (TWT, SE, SQ). Moreover, the inter-night variability in these parameters, which is typical of insomnia (39) was reduced in most cases. Sleep diary parameter changes were mostly gradual (except for P2) and appeared within one or two weeks after starting the intervention. As this is the same time frame for improvement noted in Ouellet and Morin (22) it is possible that observable positive effects by the second week of treatment may serve as a reliable predictor of the ultimate treatment response. Furthermore, where follow-up data were available, sleep-related improvements were well-maintained, or indeed further augmented, which provides evidence for the durable effects of BBTI already established by previous research (23), however the sample size is too small, in the context of case series methodology, for firm conclusions to be drawn.

Sleep-related improvements were in most cases accompanied by a decline in self-reported anxiety and depression symptoms, mirroring the findings of Fuller et al. (40). The general association of insomnia with mental health complaints is well-documented, yet its directionality remains unclear (41). Consequently, it is difficult to ascertain whether in the present study sleep improvements led to anxiety and depression reductions or reductions in anxiety and depression brought about improvements in sleep or whether each operated relatively independently. This latter option tentatively emerges as most likely, considering the two participants who did not show clinically significant sleep improvements (P5, P7) both presented anxiety and depression symptom reductions.

While these findings are promising overall, the characteristics of the selected design (particularly the lack of a control group) do not permit establishing with certainty that improvements arose due to the administered insomnia treatment. Several alternative explanations must be considered (42). First, if we assumed sleep disturbances spontaneously improved as brain recovery progressed, then the passing of time since injury could have led to the alleviation of reported sleep complaints. Yet, based on the participants’ self-report, spontaneous improvements of sleep disturbances since the injury ranged from non-existent to minimal and the insomnia symptoms had been present for a median of four years. It is thus implausible that the observed marked change occurring over the course of a few weeks could be solely due to the passing of time. Future studies should consider including a control group or implement single case experimental design methodology to increase confidence of any observed changes being due to the effects of the intervention.

Second, while face-to-face client-therapist contact was limited to once per week, participants received daily text reminders which contained some personalised elements. Thus, the virtually daily study contact could have induced the symptom improvements, rather than the BBT-I itself. However, self-reported adherence to particular treatment recommendations typically preceded observed effects. Further, participant 5 who complained of insomnia despite already practicing most of the BBTI recommendations and emphasized liking the regular contact did not show improvement on sleep parameters merely through contact with the therapist. Therefore, despite constituting an important active element to any talking therapy, it is unlikely that contact via text messaging could solely account for the observed treatment effects.

Two participants did not show clinically significant treatment improvements. For P7 (demonstrating “response”), modest positive effects appeared towards the end of the treatment course. P7 presented with further improvements in the weeks following the end of the treatment, reaching the criteria for clinically significant improvement at 1-month and 2-month follow-ups. Notably, for P7 the timing of the treatment coincided with several adverse life events, which may have masked the benefits of the intervention at that time, with these benefits fully appearing when some time since the adverse events has passed.

Only P5 showed “nonresponse” to treatment, albeit presenting a high motivation to change and being one of the only participants with significant family support. In this case, it is plausible that BBT-I failed to produce sleep improvements as the participant was already instinctively practicing most of the core treatment elements. Their total sleep time was already short and any further restriction would have violated the recommended safe minimum. As discussed by Buchanan et al. (24) and in accordance with stepped-care model of insomnia (43), there may be a small subset of clients for whom short and purely behavioural therapy is not sufficient and such clients should be considered for the longer CBT-I delivered by a sleep specialist.

Limitations

Several limitations to the present study must be considered, such as lack of access to medical records. All information regarding brain injury characteristics was obtained through self-report, which could have contained important distortions, especially considering any post-brain-injury memory problems (44). Individuals with brain injury have been shown to overestimate their sleep difficulties when subjective reports were compared to objective data (28, 45). The current sample consisted of participants attending Headway support services hence it is possible that their insomnia symptoms did not impact their social engagement. Additionally, participants’ responses to HADS demonstrate low levels of depression. As depression is highly comorbid with insomnia(46) and has a high prevalence in those following a brain injury (47) future studies should explore whether participants with moderate to severe symptoms of depression may benefit from the intervention.

Future studies should include objective measures of sleep and circadian patterns, such as actigraphy or ambient recorded polysomnography. Lastly, longer follow-ups may have been more informative as to the long-term maintenance of the benefits achieved. Follow up data were not collected for a few participants due to difficulty to maintain contact.

Future directions, implications and conclusions

The promising findings of our study expand on the existing evidence base suggesting that brief, non-specialist-delivered and purely behavioural therapies can yield positive results in people with insomnia after brain injury. Further research is needed to investigate the use of this treatment for insomnia in people after ABI employing single case experimental design and randomised controlled trial protocols.

Acknowledgements

We wish to thank our study participants and staff members of Headway Glasgow for their support in the recruitment and data collection of the present study.

Hilkens NA, Casolla B, Leung TW, Leeuw FE (2024) de. Stroke. The Lancet. ;403(10446):2820–36
Mathias JL, Alvaro PK (2012) Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med 13(7):898–905
American Psychiatric Association, American Psychiatric Association, editors (2013) Diagnostic and statistical manual of mental disorders: DSM-5, 5th edn. American Psychiatric Association, Washington, D.C, p 947
Baylan S, Griffiths S, Grant N, Broomfield NM, Evans JJ, Gardani M (2020) Incidence and prevalence of post-stroke insomnia: A systematic review and meta-analysis. Sleep Med Rev 49:101222
Montgomery MC, Baylan S, Gardani M (2022) Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis. Sleep Med Rev 61:101563
Ohayon MM (2002) Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev 6(2):97–111
Ponsford JL, Ziino C, Parcell DL, Shekleton JA, Roper M, Redman JR et al (2012) Fatigue and sleep disturbance following traumatic brain injury–their nature, causes, and potential treatments. J Head Trauma Rehabil 27(3):224–233
Gellerstedt L, Medin J, Karlsson MR (2014) Patients’ experiences of sleep in hospital: a qualitative interview study. J Res Nurs 19(3):176–188
Amato S, Anthony MK (2020) Hospital Environmental Effects on Sleep in Adults With Traumatic Brain Injury in Rehabilitation. Rehabil Nurs Off J Assoc Rehabil Nurses 45(6):340–347
Walker MP, Stickgold R (2006) Sleep, memory, and plasticity. Annu Rev Psychol 57:139–166
Fulk GD, Boyne P, Hauger M, Ghosh R, Romano S, Thomas J et al (2020) The Impact of Sleep Disorders on Functional Recovery and Participation Following Stroke: A Systematic Review and Meta-Analysis. Neurorehabil Neural Repair 34(11):1050–1061
Tang WK, Grace Lau C, Mok V, Ungvari GS, Wong KS (2015) Insomnia and health-related quality of life in stroke. Top Stroke Rehabil 22(3):201–207
Fleming MK, Smejka T, Henderson Slater D, van Gils V, Garratt E, Yilmaz Kara E et al (2020) Sleep Disruption After Brain Injury Is Associated With Worse Motor Outcomes and Slower Functional Recovery. Neurorehabil Neural Repair 34(7):661–671
Zunzunegui C, Gao B, Cam E, Hodor A, Bassetti CL (2011) Sleep Disturbance Impairs Stroke Recovery in the Rat. Sleep 34(9):1261–1269
Facchin L, Schöne C, Mensen A, Bandarabadi M, Pilotto F, Saxena S et al (2020) Slow Waves Promote Sleep-Dependent Plasticity and Functional Recovery after Stroke. J Neurosci Off J Soc Neurosci 40(45):8637–8651
Duss SB, Seiler A, Schmidt MH, Pace M, Adamantidis A, Müri RM et al (2017) The role of sleep in recovery following ischemic stroke: A review of human and animal data. Neurobiol Sleep Circadian Rhythms 2:94–105
Ford ME, Geurtsen GJ, Groet E, Rambaran Mishre RD, Van Bennekom CAM, Van Someren EJW (2023) A blended eHealth intervention for insomnia following acquired brain injury: a randomised controlled trial. J Sleep Res 32(1):e13629
Herron K, Farquharson L, Wroe A, Sterr A (2018) Development and Evaluation of a Cognitive Behavioural Intervention for Chronic Post-Stroke Insomnia. Behav Cogn Psychother 46(6):641–660
Koffel E, Bramoweth AD, Ulmer CS (2018) Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. J Gen Intern Med 33(6):955–962
McLaren DM, Evans J, Baylan S, Smith S, Gardani M (2023) The effectiveness of the behavioural components of cognitive behavioural therapy for insomnia in older adults: A systematic review. J Sleep Res 32(4):e13843
Troxel WM, Germain A, Buysse DJ (2012) Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med 10(4):266–279
Ouellet MC, Morin CM (2007) Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design. Arch Phys Med Rehabil 88(12):1581–1592
Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME et al (2011) Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med 171(10):887–895
Buchanan DT, McCurry SM, Eilers K, Applin S, Williams ET, Voss JG (2018) Brief Behavioral Treatment for Insomnia in Persons Living with HIV. Behav Sleep Med 16(3):244–258
Germain A, Richardson R, Stocker R, Mammen O, Hall M, Bramoweth AD et al (2014) Treatment for Insomnia in Combat-Exposed OEF/OIF/OND Military Veterans: Preliminary Randomized Controlled Trial. Behav Res Ther 61:78–88
Wang J, Wei Q, Wu X, Zhong Z, Li G (2016) Brief behavioral treatment for patients with treatment-resistant insomnia. Neuropsychiatr Dis Treat 12:1967–1975
Perlis ML, Benson-Jungquist C, Smith MT, Posner DA (2005) Cognitive behavioral treatment of insomnia: A session-by-session guide [Internet]. Springer New York; [cited 2024 May 28]. https://pure.johnshopkins.edu/en/publications/cognitive-behavioral-treatment-of-insomnia-a-session-by-session-g-3
Gardani M, Morfiri E, Thomson A, O’Neill B, McMillan TM (2015) Evaluation of Sleep Disorders in Patients With Severe Traumatic Brain Injury During Rehabilitation. Arch Phys Med Rehabil 96(9):1691–1697e3
Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL et al (2012) The Consensus Sleep Diary: Standardizing Prospective Sleep Self-Monitoring. Sleep 35(2):287–302
Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ (1989) The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 28(2):193–213
Fichtenberg NL, Putnam SH, Mann NR, Zafonte RD, Millard AE (2001) Insomnia Screening in Postacute Traumatic Brain Injury: Utility and Validity of the Pittsburgh Sleep Quality Index. Am J Phys Med Rehabil 80(5):339
Kaufmann CN, Orff HJ, Moore RC, Delano-Wood L, Depp CA, Schiehser DM (2019) Psychometric Characteristics of the Insomnia Severity Index in Veterans With History of Traumatic Brain Injury. Behav Sleep Med 17(1):12–18
Espie CA, Kyle SD, Hames P, Gardani M, Fleming L, Cape J (2014) The Sleep Condition Indicator: a clinical screening tool to evaluate insomnia disorder. BMJ Open 4(3):e004183
Zigmond AS, Snaith RP (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67(6):361–370
Kazdin AE (2019) Single-case experimental designs. Evaluating interventions in research and clinical practice. Behav Res Ther 117:3–17
Zollman FS, Larson EB, Wasek-Throm LK, Cyborski CM, Bode RK (2012) Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention study. J Head Trauma Rehabil 27(2):135–142
Riemann D, Espie CA, Altena E, Arnardottir ES, Baglioni C, Bassetti CLA et al (2023) The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res 32(6):e14035
Germain A, Moul DE, Franzen PL, Miewald JM, Reynolds CF, Monk TH et al (2006) Effects of a brief behavioral treatment for late-life insomnia: preliminary findings. J Clin Sleep Med JCSM Off Publ Am Acad Sleep Med 2(4):403–406
Suh S, Nowakowski S, Bernert RA, Ong JC, Siebern AT, Dowdle CL et al (2012) Clinical Significance of night-to-night sleep variability in insomnia. Sleep Med 13(5):469–475
Fuller JM, Wong KK, Hoyos C, Krass I, Saini B (2016) Dispensing good sleep health behaviours not pills–a cluster-randomized controlled trial to test the feasibility and efficacy of pharmacist-provided brief behavioural treatment for insomnia. J Sleep Res 25(1):104–115
Fernandez-Mendoza J, Vgontzas AN (2013) Insomnia and Its Impact on Physical and Mental Health. Curr Psychiatry Rep 15(12):418
Alan E, Kazdin - Research Design in Clinical Psychology-Pearson (2016) | PDF | Validity (Statistics) | Statistical Significance [Internet]. [cited 2024 May 28]. https://www.scribd.com/document/531855761/Alan-E-Kazdin-Research-Design-in-Clinical-Psychology-Pearson-2016
Baglioni C, Espie CA, Altena E, Gavriloff D, Jernelöv S, Holzinger B et al (2023) Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model. J Sleep Res 32(6):e14016
Maeshima S, Osawa A Memory Impairment Due to Stroke. In: Dehkharghani S, editor. Stroke [Internet]. Brisbane (AU): Exon Publications; 2021 [cited 2024 May 29]. http://www.ncbi.nlm.nih.gov/books/NBK571999/
Ouellet MC, Morin CM (2006) Subjective and objective measures of insomnia in the context of traumatic brain injury: a preliminary study. Sleep Med 7(6):486–497
Riemann D, Krone LB, Wulff K, Nissen C (2020) Sleep, insomnia, and depression. Neuropsychopharmacology 45(1):74–89
Garrelfs SF, Donker-Cools BHPM, Wind H, Frings-Dresen MHW (2015) Return-to-work in patients with acquired brain injury and psychiatric disorders as a comorbidity: A systematic review. Brain Inj 29(5):550–557

The authors declare no competing interests.

Download PDF

Version 1

posted

You are reading this latest preprint version

Preliminary Feasibility and Efficacy of a Brief Behavioural Treatment for Insomnia after Acquired Brain Injury: A Case Series

Status:

Version 1

Abstract

Figures

Introduction

Methods

Design and Ethics

Participants

BBTI Intervention

Questionnaire measures

Procedure

Results

BBTI Feasibility

Retention and attendance

Sleep diary completion

Treatment acceptability and credibility

BBTI Efficacy

Sleep Outcomes

Sleep diaries

Sleep questionnaires

Mood

Clinically significant change in sleep

Case Study

Discussion

Limitations

Future directions, implications and conclusions

Declarations

Acknowledgements

References

Additional Declarations

Status:

Version 1