{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T18:56:00Z","timestamp":1791399360024,"version":"4.3.3"},"reference-count":43,"publisher":"American Medical Association (AMA)","issue":"7","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>Many military service members and veterans report insomnia after sustaining traumatic brain injury (TBI). Limitations of first-line treatment, cognitive-behavioral therapy for insomnia (CBT-I), include availability of qualified clinicians, low completion rates, and cost.<\/jats:p><\/jats:sec>Objective<\/jats:title>To investigate the feasibility and efficacy of internet-guided CBT-I (eCBT-I) in military service members and veterans with insomnia and a history of TBI.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This randomized clinical trial of fully remote internet-based interventions and evaluations was conducted from September 1, 2020, to June 30, 2021, with 3 months of follow-up. Participants included a volunteer sample of military service members and veterans aged 18 to 64 years with a history of mild TBI\/concussion and at least moderately severe insomnia defined as an insomnia severity index (ISI) score of greater than 14 and Pittsburgh Sleep Quality Index of greater than 4. Self-reported race, ethnicity, and educational level were generally representative of the US military. Data were analyzed from October 21, 2021, to April 29, 2024.<\/jats:p><\/jats:sec>Intervention<\/jats:title>Internet-based CBT-I delivered over 6 weekly lesson modules with assigned homework activities.<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>The prespecified primary outcome measure was change in ISI score over time. Prespecified secondary outcome measures included self-reported measures of depression symptoms, posttraumatic stress disorder (PTSD) symptoms, sleep quality, migraine impact, and fatigue.<\/jats:p><\/jats:sec>Results<\/jats:title>Of 204 people screened, 125 were randomized 3:1 to eCBT-I vs online sleep education, and 106 completed baseline evaluations (83 men [78.3%]; mean [SD] age, 42 [12] years). Of these, 22 participants (20.8%) were Hispanic or Latino and 78 (73.6%) were White. Fifty participants completed postintervention evaluations, and 41 completed the 3-month follow-up. Baseline mean (SD) ISI scores were 19.7\u2009(4.0) in those randomized to eCBT-I and 18.9\u2009(5.0) in those randomized to sleep education. After intervention, mean (SD) ISI scores were 13.7\u2009(5.6) in those randomized to eCBT-I and 16.6\u2009(5.7) in those randomized to sleep education. The difference in the extent of reduction in ISI scores between groups was 3.5 (95% CI,\u22126.5 to \u22120.4 [P<\/jats:italic>\u2009=\u2009.03]; Cohen d<\/jats:italic>, \u22120.32 [95% CI, \u22120.70 to \u22120.04]). In the eCBT-I group, the extent of insomnia improvement correlated with the extent of depressive symptom improvement (Spearman \u03c1\u2009=\u20090.68 [P<\/jats:italic>\u2009&amp;lt;\u2009.001]), PTSD symptoms (\u03c1\u2009=\u20090.36 [P<\/jats:italic>\u2009=\u2009.04]), sleep quality (\u03c1\u2009=\u20090.54 [P<\/jats:italic>\u2009=\u2009.001]), and fatigue impact (\u03c1\u2009=\u2009\u22120.58 [P<\/jats:italic>\u2009&amp;lt;\u2009.001]) but not migraine-related disability.<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>The findings of this randomized clinical trial suggest that fully remote eCBT-I was moderately feasible and effective for self-reported insomnia and depression symptoms in military service members and veterans with a history of TBI. There is great potential benefit for eCBT-I due to low availability and cost of qualified CBT-I clinicians, although optimization of completion rates remains a challenge. Future studies may use home-based objective sleep assessments and should increase study retention.<\/jats:p><\/jats:sec>Trial Registration<\/jats:title>ClinicalTrials.gov Identifier: NCT04377009<\/jats:ext-link><\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2024.20090","type":"journal-article","created":{"date-parts":[[2024,7,9]],"date-time":"2024-07-09T15:31:37Z","timestamp":1720539097000},"page":"e2420090","source":"Crossref","is-referenced-by-count":27,"title":["Internet-Guided Cognitive Behavioral Therapy for Insomnia Among Patients With Traumatic Brain Injury"],"prefix":"10.1001","volume":"7","author":[{"given":"Molly E.","family":"Malarkey","sequence":"first","affiliation":[{"name":"The Henry M. 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