Insomnia and nightmares are central features of posttraumatic stress disorder (PTSD). However, often they are inadequately assessed and ineffectively resolved following gold-standard PTSD treatment. Here we: (a) evaluate effects of prolonged exposure (PE) on subjectively measured sleep and (b) present pilot results of an examination of whether adding sleep interventions (imagery rehearsal therapy [IRT] and cognitive-behavioral therapy for insomnia [CBT-I]) to PE improves treatment response, relative to PE alone, for night-and/or daytime PTSD symptoms among returning U.S. veterans and postdeployment personnel. Method: In a parallel-groups, randomized controlled trial, participants received 12 sessions of PE followed by IRT (5 weeks) and CBT-I (7 weeks) or PE followed by 12 weeks supportive care therapy (SCT). Results: PE did not improve sleep to a clinically meaningful degree, despite significant improvements in both Clinical Administered PTSD Scale and PTSD Checklist. Enhancing treatment with IRT/CBT-I led to greater improvements in insomnia (diary-recorded sleep efficiency) symptoms with large effect size, relative to SCT (p ϭ .068, d ϭ 1.07). There were large improvements in nightmare frequency relative SCT that did not reach statistical significance (p ϭ .11, d ϭ 0.90). Moreover, there was small improvement in daytime symptoms (Clinical Administered PTSD Scale) that did not reach statistical significance (p ϭ .54, d ϭ .31). Conclusion: The addition of targeted, validated sleep treatment improves effects of PE and improves nighttime symptoms. Thus, evidencebased sleep treatment should be considered in comprehensive PTSD treatment.

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Study Objectives: Sleep disturbance is common in those who experience trauma. In a sample of nontreatment-seeking refugees, we examined the associations between trauma exposure, postmigration stress, sleep symptoms, and posttraumatic psychological symptoms. Methods: Syrian and Iraqi refugees (n = 86; 51% female; mean age = 45 years) residing in Australia were recruited from the local community. Cross-sectional descriptive design, multinominal regression analyses, and mediation analyses were used. Participants completed measures in Arabic assessing premigration trauma exposure, postmigration stress, sleep symptoms, and mental health. They also completed 7 days of sleep diaries and actigraphy. Results: We identified 34.9% of the participants as normal sleepers, 32.6% as probably having insomnia, and 32.6% as likely having insomnia. Variables associated with greater sleep disturbance (McFadden's R 2 = 0.57) included greater trauma exposure, increased time of resettlement, greater postmigration stress, and greater presleep arousal. The association of premigration trauma exposure to current posttraumatic symptoms was mediated sequentially by postmigration stress and sleep symptoms. Conclusions: Our findings highlight the extent of sleep disturbance in refugees. We found evidence for an indirect pathway between trauma exposure and posttraumatic symptoms through premigration stress and sleep (particularly presleep arousal). In the current global refugee crisis, improving the existing system of care in countries experiencing increased migration is critical. Because sleep disturbance is a modifiable condition associated with mental health, targeting sleep could be an important component of psychological interventions for refugees.

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Background: High prevalence of sleep disturbance, which is associated with poor mental health, has been observed among non-treatment seeking refugees. However, no longitudinal research has investigated the chronicity of untreated sleep disturbance and its impact on refugees' mental health. Objective: This longitudinal study investigated associations between mental health (posttraumatic stress disorder, anxiety, depression), sleep symptoms (insomnia severity, pre-sleep arousal), and factors predicting mental health, over a 12-month period. Method: Syrian refugees (N = 69) from a cross-sectional study (Time 1) participated in the current 12-month (Time 2) follow-up study. Participants completed a series of questionnaires examining sleep, trauma exposure, post-migration living difficulties, and mental health at both time points. Results: When compared to Time 1, participants showed a significant increase in postmigration stress at Time 2. However, there was an improvement in their mental health and levels of sleep disturbance. Half of the participants met criteria for moderate (36%) or severe sleep disturbance (15%) at Time 2. Forty-two per cent of the participants had moderate to severe sleep disturbance at both Time 1 and Time 2. When predicting mental health at 12month follow-up, only pre-sleep arousal at Time 1 uniquely predicted mental health at Time 2. Mediation analysis indicated that change in pre-sleep arousal (from Time 1 to Time 2) significantly mediated the relationship between change in post-migration stress and change in mental health symptoms. Conclusions: This study demonstrated that sleep symptoms have an indirect and long-term impact on mental health among refugees. Understanding modifiable factors, such as sleep, mediating the relationship between trauma exposure and PTSD symptoms is important, as such factors can be targeted in psychological interventions for refugees. Investigación Longitudinal de la Relación entre la Exposición al Trauma, el Estrés Post-migratorio, las Alteraciones del Sueño, y la Salud Mental en Refugiados Sirios Antecedentes: Se ha observado en refugiados que no están en búsqueda de tratamiento una alta prevalencia de alteraciones del sueño, que se asocia con una salud mental pobre. Sin embargo, no existen estudios longitudinales que hayan investigado la cronicidad de las alteraciones del sueño no tratadas y su impacto en la salud mental de los refugiados. Objetivo: Este estudio longitudinal investigó las asociaciones entre salud mental (trastorno de estrés postraumático, ansiedad, depresión), síntomas del sueño (severidad del insomnio, activación previa al sueño), y factores predictores de salud mental, a lo largo de un periodo de 12 meses. Método: Refugiados sirios (N=69) de un estudio transversal (Momento 1) participó en el siguiente seguimiento a los 12 meses (Momento 2). Los participantes completaron una serie de cuestionarios examinando el sueño, la exposición al trauma, las dificultades vitales luego de la migración y la salud mental en ambos momentos de medición. Resu...