Traumatic Brain Injuries (TBIs), primarily because of blast exposure, were the “signature wound” associated with Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF) (Cifu et al., 2010). Since 2000, there have been 468,424 TBIs sustained by service members (SMs), which include significant increases in injuries during OEF and OIF, resulting in a surge in demand for adequate acute and extended follow up medical services (Swanson et al., 2017; Health.mil, 2023). TBIs, particularly mild traumatic brain injuries (mTBIs), resulting from blast related injuries, have been found to be associated with a multitude of medical (e.g., headaches, obstructive sleep apnea) and psychiatric concerns (e.g., PTSD, insomnia) (Cifu et al., 2010; Collen et al., 2012; Mysliwiec et al., 2013).

Insomnia is one of the most frequently co-occurring conditions associated with TBIs, impacting ~30–50% of these patients (Mathias and Alvaro, 2012; Dietch and Furst, 2020). Insomnia is conceptualized as a “dissatisfaction with sleep quantity and quality” during sleep initiation and sleep maintenance (American Psychiatric Association, 2022). The prevalence of insomnia is higher for military populations who have sustained TBIs compared to those who have not (Epstein et al., 2012; Mosti et al., 2019). In addition, insomnia associated with TBIs negatively impacts medical recovery and decreases the likelihood of SMs returning to full duty (Mollayeva et al., 2020). Further, insomnia is associated with poorer recovery from comorbid behavioral health conditions (e.g., PTSD) and impairments in cognitive functioning (e.g., reaction time) (Troxel et al., 2015). Although there is a critical need for effective treatments to improve sleep in TBI clinics, many TBI treatment programs servicing MHS beneficiaries (i.e., SMs, family members, retirees, veterans) do not focus on sleep as a primary treatment target (Gilbert et al., 2015).

Cognitive behavioral therapy for insomnia (CBTi) is recognized as an effective treatment for chronic insomnia (Kuhn et al., 2016). Research indicates that between 70 and 80% of patients with insomnia experience sustained benefits from CBTi and ~50% experience clinical remission ((Dietch and Furst, 2020). Further, CBTi has been found to improve sleep among specific populations including SMs (Taylor et al., 2017; Lee et al., 2021). CBTi is a manualized treatment and typically includes the following: sleep education, sleep hygiene, relaxation training, sleep restriction, stimulus control, and cognitive restructuring (Ouellet and Morin, 2004).

While TBIs may often result in patients experiencing symptoms of insomnia, the effectiveness of CBTi within TBI clinics are relatively unknown as few such studies have been conducted to examine its use with this population (Ludwig et al., 2020). Ludwig et al. (2020) conducted a comprehensive review of studies that evaluated the use of CBTi among individuals with a TBI. Most studies that were included in their evaluation (3 of 4) were case studies or case series that found that CBTi improved reported sleep behaviors or symptoms comorbid with insomnia (Ouellet and Morin, 2004, 2007; Lu et al., 2016). Theadom et al. (2018) conducted a pilot randomized controlled study comparing online programs, specifically CBT skills for sleep to an educational program, in which the CBT program demonstrated greater improvements in self-reported sleep quality compared to the educational program. Therefore, although promising, the implementation of CBTi as part of routine care in TBI programs should be further evaluated to better understand its effectiveness with this population.

Although CBTi has been found to be an effective treatment for sleep problems among military personnel (Taylor et al., 2017; Lee et al., 2021), special considerations may need to be taken into account for patients being treated in TBI clinics (Gallagher et al., 2016). Research suggests sleep difficulties may have greater impact on cognitive functioning among those with TBI (Bloomfield et al., 2010). In addition, cognitive dysfunction such as deficits in working memory, episodic memory, attention, and executive function may present as barriers to effective CBTi implementation with individuals who have sustained TBIs (Dietch and Furst, 2020). For example, CBTi is a treatment that uses skills that involve memory and executive functioning (e.g., remembering to attend appointments, the completion of take-home tasks, and following directions). Currently, it is unclear whether cognitive deficits would adversely impact treatment for patients who sustained TBIs. Adaptations to CBTi delivery for patients being seen in TBI clinics may be needed to optimize treatments (Dietch and Furst, 2020). For example, preliminary evidence suggests smartphone apps may help to improve behavioral treatment adherence and understanding of treatment materials among patients who have sustained moderate-to-severe TBIs (Rabinowitz et al., 2022).

Smartphone apps offer certain advantages to improve treatment adherence and treatment effectiveness by providing patients with a highly convenient way to access treatment materials and complete at-home assignments independently (Cavanagh et al., 2020). Specifically, research has found that smartphone apps have been effective in helping patients make positive behavioral changes such as adhering to specific medical treatment regimens, making healthy lifestyle choices, and increasing self-efficacy (Lunde et al., 2018; Kazemi et al., 2022). To address sleep difficulties among MHS beneficiaries, the Veteran's Affairs (VA), Stanford University, and Department of Defense (DOD) developed CBTi Coach to support patient adherence to clinical treatment by utilizing features such as a sleep diary tracker, reminders, and checklists (Koffel et al., 2018). CBTi Coach promotes daily interactions and sleep diary completion through key features such as checklists and reminders (Kuhn et al., 2016). Despite having several promising features to improve treatment adherence and sleep in general, little is known as to how effective a CBTi program, which utilizes CBTi Coach, would be for MHS beneficiaries seeking care within TBI clinics.

Research on the effectiveness of CBTi Coach has been promising, albeit somewhat limited. Currently, only one pilot study has evaluated the effectiveness of CBTi Coach which found the app to be effective in decreasing reported symptoms of insomnia among veterans as a standalone treatment (Reilly et al., 2021). Further, Insomnia Coach, an app that functions as a fully automated and self-directed clinical program to address symptoms of insomnia was recently developed by the VA (Kuhn et al., 2019). Although interventions may be more accessible and convenient when using Insomnia Coach, treatment efficacy on the app is currently limited and face-to-face empirically based behavioral treatments remain as standard of care practices within the DOD (U.S. Department of Veterans Affairs and Department of Defense., 2019; Kuhn et al., 2022).

Therefore, our aim is to describe how an in-person CBTi protocol was implemented in the context of a multidisciplinary clinic for TBIs. Importantly, we will also describe how CBTi Coach can be utilized as a treatment aid to improve patient care. Further, we will provide initial pilot data on the utility of CBTi used in conjunction with CBTi Coach for MHS beneficiaries being seen in a TBI clinic. Observations on adherence to the CBTi treatment program are also discussed and recommendations for future research on CBTi for those who sustained TBIs are described.

This evaluation was reviewed and approved as a quality assurance/quality improvement project by the Tripler Army Medical Center quality assurance/quality improvement review board and the Deputy Commander for Quality and Safety at Tripler Army Medical Center. Data was collected during patients' treatment sessions and documented in their medical record as part of routine clinical care.

Overall, results from this project found that patients who were being evaluated for TBIs at a military TBI clinic and completed CBTi improved during and after treatment on several sleep treatment outcomes. Improvements in treatment were found for SOL, WASO, and self-reported symptoms of insomnia.

To our knowledge, these findings are the first to demonstrate the utility of CBTi used as part of routine care to address insomnia among MHS beneficiaries being seen for evaluation and/or treatment of TBIs. Results from the current project are consistent with findings from earlier case studies and a clinical program evaluation, which found CBTi improved sleep for both individuals who have sustained TBIs as well as SMs in general (Ouellet and Morin, 2007; Lee et al., 2021). Further, our findings are consistent with studies that have found technology based CBTi skills programs are effective in addressing sleep problems among individuals who have sustained TBIs (Theadom et al., 2018).

Importantly, this project is one of the first to report on the utilization of a smartphone app to aid in the implementation of CBTi among patients being seen for TBIs. Specifically, these analyses found that many patients had chosen to use CBTi Coach to complete their sleep diaries as opposed to completing these using a pencil-and-paper format. Further, 67% of patients (24 of 36 patients) completed sleep diaries at their one-month follow-up session, after completing CBTi with their provider. Patients in the current project who stopped completing their sleep diaries by their post-treatment session cited low motivation and lack of accountability as the reason. The completion of sleep diaries in CBTi is critical to treatment effectiveness, as research has found that homework completion (e.g., sleep diaries) predicts insomnia remission following CBTi (Dong et al., 2018). Although smartphone apps used to improve sleep have been available for over a decade, there has been little research on whether such apps improve CBTi treatment adherence and treatment outcome (Koffel et al., 2018).

A 48% attrition rate (33 out of 69 patients) at a 1-month follow-up for the current evaluation is consistent with other studies examining CBTi (Vincent and Lewycky, 2009). Vincent and Lewycky (2009) examined the effectiveness of CBTi in a clinical setting among patients with insomnia and determined that 41.5% dropped out of treatment by their 1-month follow up session. Similarly, another study found that 42% of a clinical sample of SMs being seen for CBTi completed fewer than four sessions of the program (Lee et al., 2021).

This project has several limitations that warrant mention. Most importantly, these findings are limited as this was not a formal research study and was instead approved as a performance improvement project to determine whether an evidence-based treatment program for sleep was feasible in the context of a multidisciplinary care for TBIs. Therefore, the project is limited in terms of study design and data collection. For example, a control group was not used in this project. Therefore, conclusions on the effectiveness of CBTi for patients being seen in TBI clinics is limited. Further, sleep diary data was not verified by a second reviewer as data was collected entirely as part of each patient's clinical care. Lastly, this project evaluated MHS beneficiaries as an entire group and therefore did not examine treatment effectiveness among separate beneficiary subgroups such as SMs, family members, or retirees. Thus, conclusions on how military personnel responded to CBTi are limited. Despite that, anecdotal accounts from TBI clinic leadership indicate that SMs comprise of ~90% of all patients being seen in the clinic at any point in time.

Overall, findings demonstrate that CBTi, integrated with the CBTi Coach app, may be a promising treatment to address insomnia for those seeking care in TBI clinics and warrant further evaluation on the effectiveness of this treatment for individuals who have sustained TBIs, particularly among SMs. If effective, smartphone assisted CBTi may become a standard of care in military TBI programs.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by the Tripler Army Medical Center Human Protections Exempt Determinations Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required from the participants or the participants' legal guardians/next of kin because Project was determined to be a quality improvement evaluation of a clinical program as part of routine clinical care and not a research study and only de-identified data was used.

JM: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Writing–original draft, Writing–review & editing. NK: Writing–original draft. ML: Formal analysis, Writing–original draft, Writing–review & editing. CC: Writing–review & editing. CG: Resources, Writing–review & editing.