The human skull is a bony fortress protecting the brain, a precious cargo weighing only about 3 pounds. No matter how formidable the fortress, though, violent blows after a misstep from a ladder, a slip in the shower, a battlefield blast, a car crash, or a ringing hit in a sports contest can rattle, shake, bounce, twist and injure the brain.

Millions of Americans each year suffer traumatic brain injuries (TBIs) from these kinds of assaults. People with TBIs may struggle to think, move, control their emotions or cope with pain. These problems can be worsened by long nightly battles with insomnia. That fight can complicate their recovery significantly.

Individuals with TBIs are roughly three times more likely to suffer from sleep conditions than members of the general population, said Dr. Lisa Brenner, a PhD professor of Physical Medicine and Rehabilitation, Psychiatry, and Neurology at the University of Colorado School of Medicine. Insomnia can scramble daily life for anyone, but chronic sleeplessness can be particularly challenging for those with TBIs, Brenner said.

“Many things travel together with brain injuries,” Brenner said. “If you have a traumatic brain injury, your thinking and cognition can obviously be disrupted,” Brenner said. “If you are not sleeping well, it can further exacerbate people’s cognitive problems.”

Other severe problems associated with TBIs may worsen if insomnia is added to the mix. For example, about half of people with TBIs also have depression, Brenner noted. In addition, a 2023 study she co-authored concluded that soldiers who suffered “military-related TBIs” had higher rates of “new-onset mental health conditions” and were at increased suicide risk. The paper called for “evidence-based interventions” to address the connections between TBIs and mental health disorders.

TBI and insomnia: A new virtual treatment approach 

Brenner now leads a study, dubbed CU-REST, that tests the effectiveness of computerized cognitive behavioral therapy (CBT) to treat insomnia among those with moderate to severe TBIs. Online CBT to treat insomnia has been well-studied in the general population and shown to be “a win” for patients, Brenner said. She wants to see if that success can extend to the more vulnerable TBI patient population, and just as importantly, improve their access to insomnia treatment.

“There is a lack of mental health therapists and evidence-based treatments, especially if you don’t live in an urban area,” she said. “It may be hard to locate providers. It may be hard to afford it. It may be hard to get there. If people can negotiate an online evidence-based program, they can seek the treatment at a time and place that works for them, and at a pace that works for them.”

The study is funded by the Colorado Department of Human Services Office of Adult, Aging and Disability Services Mindsource Brain Injury Network and is open to people throughout Colorado — including patients from UCHealth outpatient clinics. It focuses on people between the ages of 18 and 60 who sustained moderate to severe TBIs more than a year ago and experience insomnia. It is not for those who have sports-related or other concussions, Brenner said.

“The injuries are those that more frequently impact functioning for a longer period of time,” she said.

Half the trial participants receive “enhanced treatment as usual,” defined “as any (insomnia) treatment in which they routinely engage.”

The other half receive the six-week intervention, which consists of six sessions of CBT therapy for insomnia and four “check-ins”  to provide data on their progress with the therapy. (Learn more about how cognitive behavioral therapy works.)

The impact of the two approaches, if any, will be measured by comparing results of a test called the Insomnia Severity Index, taken at the beginning and at the end of the study. Study participants are equipped with secure email and video, and Brenner’s team gets data collection assistance from REDCap, a web-based system supported by the Colorado Clinical and Translational Sciences Institute (CCTSI) on the University of Colorado Anschutz Medical Campus.

Assistance for TBI study participants

The study team provides orientation to the materials and general support for participants throughout the six weeks, Brenner said. For example, the intervention requires participants to maintain “sleep diaries” that record when they went to bed and woke up, periods of wakefulness, the quality of their sleep, and so on. This kind of self-reporting is notoriously difficult for people, Brenner said, so the team works with enrollees to help them fill out the diaries.

In addition, the participants receive a wearable device that provides an objective measure of their nightly activity and sleep patterns.

In addition to the six CBT self-guided units and sleep diaries, the online intervention includes:

• Worksheets
• Videos
• Information about sleep disorders and sleep apnea, and ways to improve sleep behavior.

Brenner noted that the online CBT program could help to break down resistance some people have to mental health therapy because of stigma or a lack of understanding of its potential benefits.

“It explains CBT, what it does, how it works, why it works, and what you are going to do,” she said. “I think it really does help patients realize that, ‘wow, this is like a workout program, but it’s a workout program for my brain.’ People who do all the steps can change their sleep patterns. They’ve got the skills they need.”

She added that evidence strongly suggests that CBT treatment for insomnia also helps people to ease their symptoms of depression.

“What we’ve found is that if you start treating one symptom, all the (patients’) symptoms go down,” Brenner said.

Possible online help for depression and suicide risk

The CU-REST study is not Brenner’s first foray into probing the effectiveness of online CBT treatment. Her previous work examined the strategy as a way to help Veterans with suicidal ideation and depression. Both studies produced promising results. Her work generally points to online treatment as one way to provide resources to people with mental health challenges as they navigate a frequently strained system.

“We have a mental health crisis in this country,” she said. “Even if everybody wanted to come to therapy, there are literally not enough therapists to treat them all. I just feel like there is a lot more we could be doing to help humans do more to help themselves. To me, it’s really important to [raise] their mental health literacy and empower them to treat things that they can for themselves online.”

Brenner stressed that people should not avoid seeing psychotherapists, particularly in times of crisis. “But I want people to have different options,” she said. “And especially if you are not interested [in seeing a therapist], or you can’t afford it, or you can’t get there, we have to have different ways.”

The CU-REST study has an enrollment target of 100 patients. Brenner said that thus far, 65 have completed the online program and five more are currently enrolled. For more information, contact Morgan Nance at 303-319-5551.