Does Cognitive–Behavioral Therapy (CBT) for Insomnia Improve Sleep Outcomes in Individuals With Traumatic Brain Injury (TBI)? A Scoping Review

BACKGROUND: Sleep disturbances following a traumatic brain injury (TBI) are common and can persist for months to years’ post-injury. Insomnia is the most indorsed sleep disturbance in individuals with a chronic TBI. Insomnia occurs when there is a reduced sleep drive, improper sleep scheduling, and/or conditioned arousal. Cognitive behavioral therapy (CBT) to treat sleep disturbances and insomnia in particular (CBT-I) have been used to improve sleep outcomes in the general population and in individuals with Parkinson’s disease and multiple sclerosis. CBT-I has been shown to be more effective in improving insomnia symptoms than sleep medication and has a long-term effect of up to 10 years. However, it is unclear if CBT or CBT-I is efficacious in individuals with a traumatic brain injury.

PURPOSE: This scoping review was performed to evaluate the use of CBT or CBT-I in people with a traumatic brain injury who also endorse insomnia.

METHODS: Scoping review literature searches were done in June 2019. Search terms used were: Traumatic brain injury, TBI, cognitive behavioral therapy, CBT, cognitive behavioral therapy for insomnia, CBT-I, sleep, and insomnia. A total of 861 articles were found. After reviewing the abstracts, 14 articles were pulled for full text review. One reviewer (RL) screened the article abstracts and performed the full-text review. Quality appraisal was conducted to assess the risk for potential bias and quality of included articles.

RESULTS: Five articles matched the search terms and were included in this scoping review. Two articles were randomized control studies and three were case studies. The review indicates that individuals with TBI who participated in CBT or CBT-I experienced increased self-report sleep efficiency and sleep quality and reduced insomnia symptoms. Participants also reported reduced comorbid symptoms including anxiety, depression, and pain.

CONCLUSION: This scoping review provides evidence that treatment of insomnia following a TBI can improve sleep outcomes and reduce comorbid symptoms. More robust studies are needed to determine if CBT or CBT-I is an effective treatment for insomnia in individuals with TBI.

IMPACT STATEMENT: This report contributes important information for occupational therapy to inform practitioners about how a traumatic brain injury affects someone’s sleep. The intervention of cognitive behavioral therapy addressing insomnia directly impacts the occupation of sleep by aiding and coaching individuals in obtaining a restorative sleep which supports healthy and active engagement in other occupations.

References

Ouellet, M. C., & Morin, C. M. (2004). Cognitive behavioral therapy for insomnia associated with traumatic brain injury: a single-case study. Arch Phys Med Rehabil, 85(8), 1298-1302. doi:10.1016/j.apmr.2003.11.036

Ouellet, M. C., & Morin, C. M. (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. doi:10.1016/j.apmr.2007.09.006

Nguyen, S., McKay, A., Wong, D., Rajaratnam, S. M., Spitz, G., Williams, G., . . . Ponsford, J. L. (2017). Cognitive Behavior Therapy to Treat Sleep Disturbance and Fatigue After Traumatic Brain Injury: A Pilot Randomized Controlled Trial. Arch Phys Med Rehabil, 98(8), 1508-1517.e1502. doi:10.1016/j.apmr.2017.02.031

Lu, W., Krellman, J. W., & Dijkers, M. P. (2016). Can Cognitive Behavioral Therapy for Insomnia also treat fatigue, pain, and mood symptoms in individuals with traumatic brain injury? - A multiple case report. NeuroRehabilitation, 38(1), 59-69. doi:10.3233/nre-151296