Veterans’ Study Dealt With Sleep Disruption in AUD
COLUMBIA, MO — Patients seeking treatment for insomnia are urged to abstain from alcohol, which is known to disrupt sleep. Sleep disturbances often continue, however, even in those who are abstinent, which decreases the likelihood of treatment completion and increases the risk of relapse.
Now, a new veterans’ study has established that cognitive behavioral therapy (CBT) is effective in first-line treatment for insomnia among alcohol-use disorder patients, regardless of whether they abstain from alcohol.
“We wanted to test the feasibility and efficacy of CBT with individuals early in their treatment for alcohol-use disorder,” said lead researcher Mary Beth Miller, PhD, assistant professor of psychiatry at the University of Missouri. “The typical standard of care is to wait to provide CBT for insomnia to patients with alcohol-use disorder until they are abstinent from alcohol for four weeks. We wanted to see if CBT could improve insomnia symptoms and reduce alcohol-related harm before abstinence from alcohol use was established.”
Essentially, the study published in JAMA Psychiatry found that long-term abstinence might not be required to derive benefit from CBT-I.1
The study team recruited 67 patients from the Harry S. Truman VA hospital in Columbia, MO. Participants in the randomized clinical trial were in a VA addiction treatment program there, and all met criteria for insomnia and alcohol-use disorder. The veterans, who had a median age of 46.3 years and were 91% male, were randomly assigned in 2019 and 2022 to five weekly sessions of CBT or one single session of sleep-hygiene treatment—where a study therapist recommended bedtime routine changes, such as limiting caffeine.
Background information in the study noted that 3 out of 4 adults in treatment for alcohol-use disorder (AUD) report symptoms of insomnia. Yet, the first-line treatment for insomnia (CBT-I) is often delayed until abstinence is established.
Defined as primary outcomes were:
- posttreatment insomnia severity (assessed using the Insomnia Severity Index);
- follow-up frequency of any drinking and heavy drinking (four drinks for women, more than five drinks for men);
- number of days via Timeline Followback) and
- alcohol-related problems (Short Inventory of Problems).
The researchers tested posttreatment insomnia severity as a mediator of CBT-I effects on alcohol-use outcomes at the 6-week follow-up.
Results indicated that, relative to sleep hygiene, CBT-I participants reported greater decreases in insomnia severity at posttreatment (group × time interaction: -3.70; 95% CI, -6.79 to -0.61) and follow-up (-3.34; 95% CI, -6.46 to -0.23) and greater improvements in sleep efficiency (posttreatment, 8.31; 95% CI, 1.35 to 15.26; follow-up, 18.03; 95% CI, 10.46 to 25.60). “They also reported greater decreases in alcohol problems at follow-up (group × time interaction: -0.84; 95% CI, -1.66 to -0.02), and this effect was mediated by posttreatment change in insomnia severity,” according to the report. “No group differences emerged for abstinence or heavy-drinking frequency.”
The researchers concluded that, in this randomized clinical trial, CBT-I outperformed sleep hygiene in reducing insomnia symptoms and alcohol-related problems over time. It had no effect on frequency of heavy drinking, however.
“CBT-I should be considered a first-line treatment for insomnia, regardless of abstinence,” the study concluded.
CBT was determined to out-perform sleep hygiene in reducing insomnia severity, which reduced participants’ alcohol use, cravings and negative behaviors associated with alcohol consumption over time.
“CBT not only reduced insomnia symptoms among adults in early alcohol recovery—it also reduced the problems they experienced from drinking,” Miller said. “We shouldn’t wait until people are abstinent to provide evidence-based treatment. We should give them the treatment they need when they’re open to it.”
- Miller MB, Carpenter RW, Freeman LK, et al. Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial. JAMA Psychiatry. Published online June 21, 2023. doi:10.1001/jamapsychiatry.2023.1971
