Sleep difficulties contribute to poor quality of life and frequently accompany mental health problems, including posttraumatic stress disorder (PTSD). Poor sleep is both a risk factor for development of PTSD, as well as being aggravated by PTSD symptoms. Two studies conducted by Phoenix Australia, one completed and one under development, provide practitioners who treat people with PTSD and accompanying mental health problems, with a greater understanding of the interrelationship between sleep and mental health, and insights into effective treatment approaches.
Sleep problems are common in the general population, with insomnia the most prevalent sleep disorder. Amongst veterans and first responders the rates of sleep disturbance can be as high as 90 per cent. Likely reasons for this include the unique aspects of these occupations such as the atypical working week, sleep deprivation during and following deployment, exposure to high levels of traumatic situations and stress, and a culture that reportedly perceives sleep as a luxury or weakness.
Poor quality sleep and sleep disorders affect quality of life and are intricately associated with mental ill-health, particularly mood disorders like bipolar illness, depression and anxiety. Fortunately, our knowledge of its impact on PTSD is growing. For people with existing mental health problems, having a sleep disorder results in poorer treatment outcomes. It makes sense then that practitioners who understand the interplay between sleep and mental health, and have the tools to address poor sleep, are able to improve treatment outcomes for their patients.
In a recently completed study, we examined the relationship between insomnia and PTSD symptoms in 693 Australian veterans being treated for PTSD. We asked them about their PTSD symptoms and the quality of their sleep on admission to treatment, at discharge, and three and nine months following treatment.
Our findings corroborated earlier research that there is a significant maintaining relationship between insomnia and PTSD symptoms following PTSD treatment. In particular, we noted that high levels of insomnia following treatment can exacerbate PTSD symptoms in both the short and long term, undermining gains made from treatment and raising the risk of PTSD relapse.
The study findings have implications for practitioners treating veterans with PTSD and sleep problems. The use of a sleep-focussed intervention to augment PTSD treatment is indicated if insomnia is an issue following treatment.
Cognitive behaviour therapy for Insomnia (CBT-I) is currently the first line treatment for chronic insomnia. It is a multicomponent treatment that includes education regarding the physiology of sleep, good sleep practices referred to as sleep hygiene, and it addresses some myths and unhelpful beliefs about sleep. The intervention also focusses on reducing anxieties around going to sleep, offers assistance with restricting opportunities to oversleep or disrupt sleep patterns, and promotes relaxation training.
Out of the work completed at Phoenix Australia, and with funding support from the Victorian Government Department of Premier and Cabinet, we are planning to test a newer treatment for insomnia called Transdiagnostic Sleep and Circadian Intervention (Trans-C). Trans-C incorporates aspects of all evidence-based psychological approaches to the treatment of sleep problems including CBT-I, but has the advantage of also improving mental health outcomes. It is a flexible, modular intervention delivered over four to ten sessions. Early research has shown promise.
In the proposed study, we hope to test the acceptability and effectiveness of Trans-C with veterans and first responders living in Victoria, and are aiming to deliver the intervention via a telehealth platform. Currently, people living in rural or remote areas have limited access to professional mental health services, and especially to practitioners with expertise in treating sleep disorders – these being mainly located in major metropolitan centres. The pilot in Victoria will help inform its wider use for veterans and first responders living remotely across the country.
Given that sleep problems are intricately connected with quality of life and our general wellbeing, it is not surprising that problem sleep can lead to ill-health and contribute to mental health disorders including PTSD. As such, there is a growing appreciation that it is vital that we increase our knowledge of new evidence-based treatments and seek ways to increase opportunities for improved access to these treatments. With high rates of sleep problems reported by veterans and first responders, new knowledge gained will be particularly beneficial to practitioners supporting these people and to people who live in rural and remote areas.