JMIR Publications

ABSTRACT

Background:

Symptoms of insomnia, nightmares and trauma are highly prevalent in wildfire survivors. However, there are significant barriers to accessing evidence-based treatments for these conditions, leading to poor mental health outcomes for many wildfire survivors

Objective:

This pilot trial evaluated the feasibility of a four-week, digital, self-paced intervention combining cognitive behavioral therapy for insomnia (CBTi), and exposure, relaxation, and rescripting therapy for nightmares (ERRT) in wildfire survivors from Australia, Canada, and the United States of America.

Methods:

Study participants were recruited between May and December 2023 through social media platforms, workshops, conferences, and radio interviews. To be eligible, participants had to meet at least one of the following criteria: a score of ≥ 8 on the Insomnia Severity Index (ISI), and/or a score of ≥ 3 on the Nightmare Disorder Index (NDI), and/or a score of ≥ 31 on the PTSD Checklist – Civilian Version (PCL-5). Thirty wildfire survivors were allocated to either the treatment group (n=16) or the waitlist control group (n=14) in a sequential manner. Participants' ages ranged from 18 to 79 years, with a mean age of 52.50 years (SD = 16.26). The cohort consisted of 19 females (63.3%) and 11 males (36.7%). Participants also completed self-report secondary outcome measures, including the Generalized Anxiety Disorder Questionnaire (GAD-7), the Patient Health Questionnaire (PHQ-9), and the Pittsburgh Sleep Quality Index (PSQI), via the HealthZone digital platform. Participants were informed about the purpose, allocation, and the structure of the study. Assessments were conducted at baseline, post-treatment, and 3-months follow-up, with the waitlist group providing an additional assessment at pre-treatment, after 4 weeks of waiting, and prior to crossing over to treatment. The study employed two analyses including Intention-To-Treat analysis (ITT) as a principal analysis, and Per Protocol (PP) analysis as a secondary analysis.

Results:

Mixed-effects linear regression models and difference-in-difference analyses were utilized to assess the intervention's effects. The ITT revealed significant improvements over time (main effect of time) with a 1.64 point reduction (P=.001) on the NDI and 10.64 points reduction (P=.009) on the PCL-5 at post-intervention. No significant changes were observed in insomnia symptoms. On the secondary measures, there was an interaction effect of condition x time with a 2.22 point reduction (P<.001) on the PSQI and a main effect of time with a 6.48 point reduction (P<.001) on the PHQ-9. No significant changes were detected on the GAD-7. The PP analysis yielded comparable results for both the primary and the 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. Clinical Trial: Clinical trial name: Sleep Best-i: An online cognitive-behavioral intervention for the treatment of insomnia and nightmares in wildfire survivors Trial ID: ACTRN12623000415606 URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385054 Registry: Australian New Zealand Clinical Trial Registry