CBT-I on Alcohol Treatment Outcomes Among Veterans

Alcohol use disorders (AUDs) are prevalent among Veterans and result in significant physical
and psychological burden. Among those who receive treatment for AUDs, 1 in 3 relapses to
problematic drinking within one year of treatment. Thus, additional strategies are needed to
enhance alcohol treatment outcomes. One promising approach involves providing concurrent
treatment for a common complaint - difficulty falling or staying asleep. Up to 74% of
Veterans seeking treatment for AUD report co-occurring symptoms of insomnia. Given the
negative impact of insomnia on attention and emotion regulation, insomnia symptoms may
decrease patients' abilities to attend to alcohol treatment and manage negative emotions that
lead to craving and relapse. Moreover, approximately 50% of individuals with AUDs report
using alcohol to help them sleep, making relapse more likely for those with no other tools or
skills to help them sleep. Indeed, sleep disturbance has been identified as a risk factor for
relapse among individuals in alcohol treatment. Thus, effective treatment of sleep problems
may enhance alcohol treatment. Cognitive Behavioral Therapy for Insomnia (CBT-I) has been
effective in reducing insomnia severity in individuals with AUDs; however, no investigations
have examined the efficacy of CBT-I delivered concurrently with AUD treatment to determine
its impact on treatment outcomes. This R21 aims to examine the feasibility, acceptability,
and initial efficacy of a CBT-I supplement to outpatient alcohol treatment. A randomized
pilot trial with 80 Veterans who meet diagnostic criteria for AUD and Insomnia Disorder will
be conducted. Participants will be randomly assigned to receive Cognitive Behavioral Therapy
for Insomnia (CBT-I) or minimal treatment (educational handout only; EDU) in addition to
alcohol treatment as usual. Outcomes will be assessed at the end of the active intervention
period (6 weeks) and 6 weeks post-intervention. Outcomes of interest include
recruitment/retention rates, treatment satisfaction, insomnia severity, total wake time,
sleep quality, use of alcohol or other drugs as a sleep aid, percentage of abstinent days,
percentage of heavy drinking days, alcohol-related problems, attention (vigilance), working
memory, treatment-related learning, negative affect, and emotion regulation. Analyses will
focus on size of treatment effects. Results will inform an R01 application to examine the
efficacy, cost-effectiveness, and potential mechanisms of CBT-I in preventing or delaying
relapse to problematic drinking among Veterans with insomnia and AUDs. This study will
provide initial evidence that treatment of insomnia not only improves sleep but also allows
participants to derive greater benefit from outpatient alcohol treatment.

Inclusion Criteria:

- Participation in the Addictions Treatment Program at the Truman VA (Columbia, MO)

- DSM-5 criteria for moderate to severe Alcohol Use Disorder

- DSM-5 episodic criterion (duration at least 1 month) for Insomnia Disorder

Exclusion Criteria:

- unable to provide informed consent

- cognitive impartment

- continuous sobriety for 2+ months at baseline

- contraindications for CBT-I (lifetime history of mania or seizure disorder)

- sleep disorder requiring more than behavioral treatment for insomnia

- severe psychiatric disorder that requires immediate clinical attention

- initiation of a sleep medication in the past six (6) weeks.