TBM TBM page 1169 of 1177 ORIGINAL RESEARCH Implications Practice: Cognitive behavioral therapy for in- somnia is effective when delivered in a small number (four) of brief duration (30 min) sessions to primary care patients endorsing suicidal ideation. Policy: Health care systems may consider brief behavioral interventions for insomnia to address the underutilization of nonpharmacologic inter- ventions for insomnia and to expand interven- tions available for insomnia patients who endorse suicidal thoughts, but are not at imminent risk. Research: Future research should be conducted in large and varied populations to assess gener- alizability of brief insomnia intervention effects. 1 VISN 2 Center of Excellence for Suicide Prevention, Canandaigua VA Medical Center, Canandaigua, NY, USA 2 Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, USA 3 Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY, USA 4 Department of Psychology, Syracuse University, Syracuse, NY, USA Abstract Insomnia co-occurs frequently with major depressive disorder (MDD) and posttraumatic stress disorder (PTSD); all three conditions are prevalent among primary care patients and associated with suicidal ideation (SI). The purpose of the article was to test the efects of a brief cognitive behavioral therapy for insomnia (bCBTi) and the feasibility of delivering it to primary care patients with SI and insomnia in addition to either MDD and/or PTSD. Fifty-four patients were randomized to receive either bCBTi or treatment-as-usual for MDD and/ or PTSD. The primary outcome was SI intensity as measured by the Columbia-Suicide Severity Rating Scale; secondary clinical outcomes were measured by the Insomnia Severity Index, Patient Health Questionnaire for depression, and PTSD Symptom Checklist. Efect sizes controlling for baseline values and sample size were calculated for each clinical outcome comparing pre–post diferences between the two conditions with Hedge’s g. The efect size of bCBTi on SI intensity was small (0.26). Efects were large on insomnia (1.91) and depression (1.16) with no efect for PTSD. There was a marginally signifcant (p = .069) efect of insomnia severity mediating the intervention’s efect on SI. Findings from this proof-of-concept trial support the feasibility of delivering bCBTi in primary care and its capacity to improve mood and sleep in patients endorsing SI. The results do not support bCBTi as a stand-alone intervention to reduce SI, but this or other insomnia interventions may be considered as components of suicide prevention strategies. Keywords Depression, Insomnia, Posttraumatic stress disorder, Primary care, Suicide, Veteran INTRODUCTION Insomnia and suicidal thoughts and behaviors In 2007, a pivotal review drew increased attention to the association of suicidal thoughts and behaviors to sleep disturbance [1]. A seminal meta-analysis has since borne out the increased relative risk of suicide outcomes posed by sleep disturbance in general, as well as for insomnia and nightmares specifically [2]. A second meta-analysis, including only studies of pa- tients with psychiatric diagnoses, observed similar associations of sleep disturbance with suicidal behav- iors [3]. Sleep disturbance has also been shown to precede suicide in veterans [4] and suicide attempts in military service members [5]. Despite this recent evidence, intervention work undertaken to deter- mine whether improving sleep disturbance has an effect on suicidal thoughts and behaviors is limited. Instead, clinical research in suicide prevention has understandably focused on risk factors more com- monly associated with suicide (e.g., depression). There is a strong etiological link between behav- ioral health conditions and suicide [6,7]. In a study of over 3 million patients receiving care in the U.S. Veterans Health Administration, those with a psy- chiatric diagnosis were more than twice as likely to die by suicide as those without such diagnoses [8]. Bipolar disorder, substance use disorders, depres- sion, posttraumatic stress disorder (PTSD), other anxiety disorders, and schizophrenia were all asso- ciated with greater risk of suicide. In psychological autopsy studies, ~ 90% of suicide decedents had one or more behavioral health conditions during their last weeks of life [9]. Moreover, approximately half of suicide decedents in a national cohort study had a history of one or more psychiatric conditions [10]. Major depression, for instance, is a potent risk factor for eventual suicide [10, 11] and PTSD has been Brief CBT for insomnia delivered in primary care to patients endorsing suicidal ideation: a proof-of-concept randomized clinical trial Wilfred R. Pigeon, 1–3, Jennifer S. Funderburk, 2–4 Wendi Cross, 1,2 Todd M. Bishop, 1–3 Hugh F. Crean 1,2 Corresponding to: Wilfred R. Pigeon, Wilfred.Pigeon2@ va.gov Cite this as: TBM 2019;9:1169–1177 doi: 10.1093/tbm/ibz108 Published by Oxford University Press on behalf of the Society of Behavioral Medicine 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US. Downloaded from https://academic.oup.com/tbm/article/9/6/1169/5528205 by guest on 04 May 2021