This commentary evaluates the feasibility of delivering Cognitive Behavioral Therapy for Nightmares (CBT-N) in non-traditional settings — specifically the VA Primary Care Mental Health Integration (PCMHI) clinic and, separately, via telehealth to acute trauma patients discharged from emergency departments within 72 hours of trauma.
PCMHI clinicians perceived greater veteran benefit from CBT-N vs. other VA mental health settings, but 57% cited time constraints as a barrier to feasibility. In a pilot RCT (n=34 randomized), 85.1% of acute trauma ED patients expressed interest in nightmare therapy, 76.5% initiated telehealth treatment, and 100% rated video sessions as 'very easy' to attend; 71.4% said in-person attendance would have been difficult.
- The PCMHI findings (Bolstad et al.) rely on clinician-perceived outcomes, not objective or patient-reported measures. - The authors' own pilot RCT has a very small sample (n=34) and is ongoing, so preventive effects on PTSD are not yet established. - The commentary cannot determine whether better PCMHI outcomes reflect early intervention or lower baseline severity.
Clinicians in primary care and emergency settings should proactively screen for nightmares using the 'DARC' criteria (Dreams causing Awakenings, partially Remembered, causing Clinically significant impairment) and consider offering CBT-N or referring patients — especially in the acute post-trauma period when interest and telehealth engagement are high.
