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The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans.Pilot randomized controlled trial consists of 2,009 veterans aged ≥ 65 years who received BZRA prescriptions from a Veterans Health Administration pharmacy (Colorado or Montana) during the prior 18 months. Active: Arm 1 was a mailed brochure about BZRA risks that also included information about a free, online cognitive behavioral therapy for the insomnia (CBTI) program. Arm 2 was a mailed brochure (same as arm 1) and telephone reinforcement call. Control: Arm 3 was a mailed brochure without insomnia treatment information. Active BZRA prescriptions at follow-up (6 and 12 months) were measured.In logistic regression analyses, the odds of BZRA prescription at 6- and 12-month follow-ups were not significantly different for arm 1 or 2 (active) versus arm 3 (control), including models adjusted for demographics and prescription characteristics (Although we observed no differences in active BZRA prescriptions, this pilot study provides guidance for conducting a future study, indicating a need for a more potent intervention. A full-scale trial testing an optimized program would provide conclusive results.Mailing information about BZRA risks and CBTI did not affect BZRA prescriptions.

Introduction Approximately half of all Veterans meet diagnostic criteria for Insomnia Disorder. Cognitive Behavioral Therapy for Insomnia (CBTi) is recommended as first-line treatment but access is limited. Self-help CBTi could increase patient access and is more effective with provider support. Self-help CBTi has not been evaluated in those with significant mental health morbidity or Veterans; a population having greater medical and mental health morbidity and more severe sleep difficulties than non-Veterans. Methods Treatment-seeking Veterans were randomly assigned to 6 sessions of Tele-Self CBTi or Health Education Control (HEC). Nurses without sleep medicine experience were trained to deliver Tele-Self CBTi; the combination of provider support plus professionally designed patient and provider CBTi treatment manuals developed through an iterative process integrating expert and patient feedback. Both arms received nurse phone contacts (≤20 minutes). Outcomes including insomnia severity, subjective and objective sleep parameters, fatigue and mood were assessed at baseline, post-treatment (8 weeks), and 6 months. Results Study participants (N=178) were 55 years of age (SD=13), mostly male (72%), with a mental health condition (83%), and about half African American (43%) and half Caucasian (49%). At post-treatment, Veterans randomized to Tele-Self CBTi realized greater reductions in insomnia severity (ISI estimated mean improvement 5.7 vs 2.0, p Conclusion A self-management CBTi requiring minimal provider resources was effective in reducing insomnia severity in veterans with considerable mental health co-morbidity. Tele-Self CBTi can help bridge the gap between unavailable resources and high demand for services and can serve as the entry level in stepped-care treatment for insomnia disorder. Future research is needed to identify characteristics of patients most likely to benefit from Tele-Self CBTi. Support (if any) Funding was provided by Veterans Affairs Office of Research and Development (CIN 13-410 and IIR 16-281).

Background: Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the Beck Depression Inventory (BDI-II) has been assessed in various medical populations. Although Major Depressive Disorder (MDD) and Primary Insomnia (PI) share some daytime symptoms, the BDI-II has not been evaluated for use with insomnia patients. Method Participants (N = 140) were screened for the presence of insomnia using the Duke Structured Clinical Interview for Sleep Disorders (DSISD), and evaluated for diagnosis of MDD using the Structured Clinical Interview for DSM-IV-TR (SCID). Participants’ mean BDI-II item responses were compared across two groups [insomnia with or without MDD) using multivariate analysis of variance (MANOVA), and the accuracy rates of suggested clinical cutoffs for the BDI-II were evaluated using a Receiver Operating Characteristic (ROC) curve analysis. Results The insomnia with depression group had significantly higher scores on several items; however, the groups did not differ on insomnia, fatigue, concentration problems, irritability, libido, increased appetite, and thoughts relating to suicide, self-criticism and punishment items. The ROC curve analysis revealed moderate accuracy for the BDI-II’s identification of depression in those with insomnia. The suggested BDI cutoff of ≥ 17 had 81% sensitivity and 79% specificity. Use of the mild cutoff for depression (≥14) had high sensitivity (91%) but poor specificity (66%). Conclusion Several items on the BDI-II might reflect sleep disturbance symptoms rather than depression per se. The recommended BDI-II cutoffs in this population have some support but a lower cutoff could result in an overclassification of depression in insomnia patients, a documented problem in the clinical literature. Understanding which items discriminate insomnia patients without depression may help address this nosological issue.