Digital Cognitive Behavioral Therapy–Based Treatment for Insomnia, Nightmares, and Posttraumatic Stress Disorder Symptoms in Survivors of Wildfires: Pilot Randomized Feasibility Trial

Abstract

Background: Symptoms of insomnia, nightmares, and trauma are highly prevalent. However, there are significant barriers to accessing evidence-based treatments for these conditions, leading to poor mental health outcomes. Objective: This pilot trial evaluated the feasibility of a 4-week, digital self-paced intervention combining cognitive behavioral therapy for insomnia and exposure, relaxation, and rescripting therapy for nightmares in survivors of wildfires from Australia, Canada, and the United States. Methods: Study participants were recruited between May 2023 and December 2023 through social media platforms, workshops, conferences, and radio interviews. Participants had to meet at least one of the following criteria: a score of ≥8 on the Insomnia Severity Index, a score of ≥3 on the Nightmare Disorder Index, or a score of ≥31 on the PTSD Checklist for DSM-5. In total, 30 survivors of wildfires were allocated to either the treatment group (n=16, 53%) or the waitlist control group (n=14, 47%) in a sequential manner. Participants’ ages ranged from 18 to 79 years, with a mean age of 52.50 (SD 16.26) years. The cohort consisted of 63% (19/30) female and 37% (11/30) male participants. Participants also completed self-report secondary outcome measures, including the Generalized Anxiety Disorder–7, the Patient Health Questionnaire–9, and the Pittsburgh Sleep Quality Index, via the HealthZone digital platform. Assessments were conducted at baseline, the posttreatment time point, and the 3-month follow-up, with the waitlist group undergoing an additional assessment at the pretreatment time point, after 4 weeks of waiting and before crossing over to treatment. This study used intention-to-treat analysis as a primary analysis and per-protocol analysis as a secondary analysis. Results: Mixed-effects linear regression models and difference-in-differences analyses were used to assess the intervention’s effects. The intention-to-treat analysis revealed significant improvements over time (main effect of time), with a 1.64-point reduction (P=.001) on the Nightmare Disorder Index and 10.64-point reduction (P=.009) on the PTSD Checklist for DSM-5 at the postintervention time point. No significant changes were observed in insomnia symptoms. On the secondary measures, there was an interaction effect of condition × time, with a 2.22-point reduction (P<.001) on the Pittsburgh Sleep Quality Index, and a main effect of time, with a 6.48-point reduction (P<.001) on the Patient Health Questionnaire–9. No changes were detected on the Generalized Anxiety Disorder–7. The per-protocol analysis yielded comparable results for both the primary and secondary measures. Conclusions: The findings of this pilot trial demonstrated a reduction in nightmares and trauma symptoms. Future research studies should aim at evaluating the intervention in a more definitive trial with a larger sample size. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12623000415606; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385054