Impact of an internet-based insomnia intervention on suicidal ideation and associated correlates in veterans at elevated suicide risk

Abstract

Improving public health approaches to suicide prevention requires scalable evidence-based interventions that can be easily disseminated. Given empirical data supporting the association between insomnia and suicide risk, internet-delivered insomnia interventions are promising candidates to meet this need. The purpose of this study was to examine whether an unguided internet-delivered cognitive-behavioral therapy for insomnia (iCBT-I) improved insomnia severity, suicidal ideation (SI), and suicide risk correlates (depression, post-traumatic stress disorder, anxiety, hostility, belongingness, hopelessness, agitation, irritability, concentration) in a sample of veterans. Secondary data analysis of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans (n = 50) with clinically significant insomnia and elevated SI drawn from a larger randomized controlled trial (RCT) of an iCBT-I, Sleep Healthy Using the Internet (SHUTi). Two-sample t-tests or Wilcoxon rank sum tests were used to evaluate between-group differences (SHUTi vs. Insomnia Education Website control) in symptom improvement from baseline to post-intervention. SHUTi participants experienced a significant improvement in insomnia severity (P < .001; d = -1.08) and a non-significant with small (subthreshold medium) effect size reduction of SI (P = .17, d = 0.40), compared to control participants. Significant improvement in hopelessness was observed (medium effect size), with non-significant small to medium effect size reductions in most remaining suicide risk correlates. Self-administered iCBT-I was associated with improvements in insomnia severity in veterans at elevated risk for suicide. These preliminary findings suggest that SI and suicide risk correlates may improve following an iCBT-I intervention, demonstrating the need for future well-powered iCBT-I RCTs targeted for populations at elevated suicide risk.

Keywords: insomnia; internet intervention; sleep treatment; suicide; technology; veteran.

Figure 1

Bar plots showing the average score and standard error (SE) bar for: (A) ISI, (B) ASIQ, (C) CDE Hopelessness, (D) BDI-II, (E) PCL-5, (F) CDE Hostility at baseline and post-intervention assessment for SHUTi and IEW. ASIQ, Adult Suicidal Ideation Questionnaire; BDI-II, Beck Depression Inventory, second edition; CDE, Military Suicide Research Consortium Common Data Elements; IEW, Insomnia Education Website; ISI, Insomnia Severity Index; PCL-5, PTSD Checklist for DSM-5; SHUTi, Sleep Healthy Using the Internet.