Changes in Subjective-Objective Sleep Discrepancies Among Participants With Post-acute Moderate-to-Severe Traumatic Brain Injury Following Computerized Cognitive Behavioral Therapy for Insomnia

J Head Trauma Rehabil. 2026 Jul 8. doi: 10.1097/HTR.0000000000001196. Online ahead of print.

ABSTRACT

OBJECTIVE: Evaluate changes in subjective-objective sleep discrepancies among participants with insomnia and a history of moderate-to-severe traumatic brain injury (TBI) following computerized cognitive behavioral therapy for insomnia (cCBT-I).

SETTING: An outpatient setting at a Department of Veterans Affairs medical center.

PARTICIPANTS: United States veterans between the ages of 18 and 60 years with current insomnia and a history of moderate-to-severe TBI (N = 36).

DESIGN: A secondary analysis of intervention-arm data from a randomized controlled trial. Participants completed an online cCBT-I program called SleepEZ. The program was primarily self-guided, with adjunctive assistance provided by a study clinician.

MAIN MEASURES: Subjective sleep outcomes were measured using the Consensus Sleep Diary, which were collected nightly throughout the entire intervention. Objective sleep outcomes were measured using wrist-based actigraphy, which were collected during the initial and final weeks of the program. Subjective-objective sleep discrepancies were calculated for total sleep time (TST), sleep onset latency (SOL), waking after sleep onset (WASO), early morning awakening (EMA), and sleep efficiency. Measure agreement was estimated with Bland-Altman plots. Changes in subjective-objective sleep discrepancies were estimated through multilevel modeling.

RESULTS: Poor agreement was observed for all 4 sleep outcomes. At baseline, participants overreported SOL and EMA on sleep diaries. However, WASO was greatly underreported, resulting in higher TST values calculated using sleep diaries compared with actigraphy. Following cCBT-I, overreporting of SOL decreased and sleep efficiency discrepancies grew larger, driven by improvements in subjective, but not objective, sleep measures.

CONCLUSION: The concurrent use of subjective and objective measures is recommended to fully capture sleep health when treating insomnia after moderate-to-severe TBI. Further research is needed to elucidate mechanisms contributing to subjective-objective sleep discrepancies-potentially including specific aspects of cognitive impairment, striatal hyperactivity, or sleep pressure homeostasis-which may inform novel targets for post-TBI insomnia treatments among those with more severe injuries.

PMID:42441739 | DOI:10.1097/HTR.0000000000001196