Improving Cognitive Rehabilitation Outcomes for Veterans with mTBI+PTSD

SUMMARY/ABSTRACT Significance to VA: Improving rehabilitation outcomes for Veterans with comorbid posttraumatic stress disorder (PTSD) and history of mild traumatic brain injury (mTBI) is an urgent need. These conditions frequently co-occur and are associated with worse cognitive performance, mental health, everyday functioning, community integration, quality of life, and response to evidence-based psychotherapies than in PTSD or mTBI alone. Additional comorbidities, such as depression and sleep disturbance, are common and further contribute to poor outcomes. Innovation and Impact: Our proposed study addresses the significant gap in services and evidence-based treatments for Veterans with mTBI+PTSD. Cognitive rehabilitation treatments emphasizing cognitive strategy training, such as Compensatory Cognitive Training (CCT), are associated with improvements in cognitive functioning, functional capacity, and quality of life in Veterans with mTBI and mTBI+PTSD. However, CCT is an intensive cognitive intervention requiring highly motivated, fully engaged participants. Concomitant depression and sleep disturbance, in addition to contributing directly to cognitive impairment, may reduce the ability of participants to engage in the treatment and learn and practice the strategies taught. Thus, novel intervention combinations directly targeting depression and sleep disturbance may improve treatment effects. Morning bright light therapy (MBLT) has well documented effects on both mood and sleep. We thus propose to enhance CCT by adding MBLT to target depression and sleep disturbance in Veterans with mTBI+PTSD. Our combined expertise in VA behavioral trials, cognitive rehabilitation, TBI, PTSD, neurology, sleep medicine, and biostatistics has led to the development of this proposal and this comprehensive, Whole Health-congruent approach. Our pilot data demonstrate the feasibility and acceptability of CCT+MBLT, as well as the efficacy of CCT and MBLT for Veterans with mTBI, PTSD, and mTBI+PTSD. Specific Aims: We aim to determine (1) whether CCT+MBLT is more efficacious than CCT+sham for improving cognition, functioning, and secondary outcomes such as PTSD and postconcussive symptom severity and quality of life; (2) whether improved rehabilitation outcomes are mediated by improvements in mood and sleep; and (3) whether there are factors that moderate outcomes. Methodology: Our proposed randomized controlled trial will compare CCT+MBLT with CCT+sham in a representative sample of 144 post- 9/11 Veterans with mTBI+PTSD at two VA sites (San Diego and Portland). Assessments will be conducted at baseline, mid-treatment (5 weeks), post-treatment (10 weeks), and three-month follow-up. Path to Translation/Implementation: Our study has the potential to yield a manualized, empirically validated, pragmatic, Veteran-centered intervention that meets the needs of Veterans with mTBI+PTSD across the United States. Thus, the project is a low-risk/high-reward proposal with clear relevance to the mission of VA Rehabilitation Research, Development and Translation. If found to be efficacious, our study team will work with VA Central Office leaders toward national dissemination and scale-up of CCT+MBLT for Veterans with mTBI+PTSD. Project Number: 1I01RD000714-01A1 | Fiscal Year: 2026 | NIH Institute/Center: Veterans Affairs (VA) | Principal Investigator: Elizabeth Twamley (+1 co-PI) | Institution: VA SAN DIEGO HEALTHCARE SYSTEM, SAN DIEGO, CA | Activity Code: I01 | Study Section: Brain Health and Injury[RRD1] View on NIH RePORTER: https://reporter.nih.gov/project-details/11240842