Scholars@Duke
Christi S Ulmer

Christi S Ulmer

Associate Professor Emeritus in Psychiatry and Behavioral Sciences
Psychiatry & Behavioral Sciences, Behavioral Medicine & Neurosciences
christi.ulmer@duke.edu
HSR&D (152), 508 Fulton Street, Durham, NC 27705

Scholarly Works - Journal articles

Development and Evaluation of Sleep Disorder Decision Aids for Veterans With Mild Traumatic Brain Injury.

Journal article J Head Trauma Rehabil · May 2026 OBJECTIVE: First, to summarize the design of novel decision aid prototypes aimed at facilitating shared decision-making for Veterans with co-morbid mild traumatic brain injury (mTBI) and sleep disorders (insomnia, obstructive sleep apnea [OSA]) in the Vete ... Full text Link to item Cite

Qualitative Investigation of Primary Care Provider Perspectives on the Assessment and Treatment of Insomnia.

Journal article J Clin Psychol Med Settings · March 2026 Although common, insomnia is often undertreated and underrecognized in primary care settings. Few studies have examined primary care provider (PCP) perspectives to better understand the context of insomnia assessment and treatment. The purpose of the curre ... Full text Open Access Link to item Cite

Guideline-Concordant Cognitive Behavioral Therapy for Insomnia in the Veterans Health Administration Polytrauma/Traumatic Brain Injury System of Care.

Journal article Behav Sleep Med · 2026 OBJECTIVES: Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment over medication. However, its use among Veterans in the Polytrauma/Traumatic Brain Injury System of Care (PSC) - a high-riskgroup for insomnia and medicat ... Full text Link to item Cite

Sleep research, quality and implementation priorities in the Veterans Health Administration: a white paper.

Journal article J Clin Sleep Med · October 1, 2025 UNLABELLED: The Veterans Affairs (VA) seeks to improve the quality of life and long-term health outcomes for veterans facing unique sleep challenges related to their military service. The prevalence and burden of sleep disorders among military service memb ... Full text Link to item Cite

Implementing brief behavioral treatment for insomnia in Department of Veterans Affairs Primary Care Mental Health Integration clinics: Reach outcomes from a hybrid type 3 effectiveness-implementation trial.

Journal article Psychol Serv · August 2025 Chronic insomnia is one of the most common health problems among veterans and can significantly impact health, function, and quality of life. Brief behavioral treatment for insomnia (BBTI), an adaptation of cognitive behavioral therapy for insomnia (CBT-I) ... Full text Link to item Cite

Insomnia and Chronic Pain Mediate the Relationship Between Traumatic Brain Injury and Reduced Positive Airway Pressure Adherence Among Veterans.

Journal article J Head Trauma Rehabil · May 2025 OBJECTIVE: To examine whether co-morbid insomnia, post-traumatic stress disorder (PTSD), depression, and chronic pain mediate the relationship between traumatic brain injury (TBI) and positive airway pressure (PAP) treatment adherence. SETTING: One Veteran ... Full text Link to item Cite

Decisional Needs of Veterans With Mild Traumatic Brain Injury Initiating Treatment for Insomnia Disorder and Obstructive Sleep Apnea.

Journal article J Head Trauma Rehabil · March 2025 OBJECTIVE: We sought to elicit key informant (KI) perspectives regarding decisional needs of Veterans with mild traumatic brain injury (mTBI) who are initiating insomnia disorder and obstructive sleep apnea (OSA) treatment within the Veterans Health Admini ... Full text Link to item Cite

Nurse-Supported Self-Directed Cognitive Behavioral Therapy for Insomnia: A Randomized Clinical Trial.

Journal article JAMA Intern Med · November 1, 2024 IMPORTANCE: Cognitive behavioral therapy for insomnia (CBTi) is the standard of care for treating insomnia disorder, but access is limited. Alternative approaches are needed to expand access to the standard of care. OBJECTIVE: To examine the effectiveness ... Full text Link to item Cite

Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury.

Journal article J Clin Sleep Med · May 1, 2024 STUDY OBJECTIVES: We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Adm ... Full text Link to item Cite

Cognitive behavior therapy for insomnia for untreated hypertension with comorbid insomnia disorder: The SLEEPRIGHT clinical trial.

Journal article J Clin Hypertens (Greenwich) · April 2024 Insomnia and poor sleep are associated with an increased risk of developing cardiovascular disease (CVD) and its precursors, including hypertension. In 2022, the American Heart Association (AHA) added inadequate sleep to its list of health behaviors that i ... Full text Link to item Cite

Barriers in Access to and Delivery of Behavioral Sleep Treatments

Journal article Current Sleep Medicine Reports · March 1, 2024 Purpose of Review: Sleep disorders are prevalent among the U.S. population. Despite the increasing recognition of evidence-based behavioral sleep interventions as an essential component of sleep disorders treatment, many patients do not receive this care. ... Full text Cite

Correction to: Barriers in Access to and Delivery of Behavioral Sleep Treatments (Current Sleep Medicine Reports, (2023), 10, 1, (70-80), 10.1007/s40675-023-00270-9)

Journal article Current Sleep Medicine Reports · March 1, 2024 The original version of this article unfortunately contained a mistake. The following statement should be included under the Ethics Declarations section. This material is the result of work supported with resources and the use of facilities at the Durham V ... Full text Cite

Pilot RCT Testing A Mailing About Sleeping Pills and Cognitive Behavioral Therapy for Insomnia: Impact on Benzodiazepines and Z-Drugs.

Journal article Clin Gerontol · 2024 OBJECTIVES: The aim is to pilot a low-touch program for reducing benzodiazepine receptor agonist (BZRA; benzodiazepines, z-drugs) prescriptions among older veterans. METHODS: Pilot randomized controlled trial consists of 2,009 veterans aged ≥ 65 years who ... Full text Link to item Cite

Factors Influencing Adherence to Insomnia and Obstructive Sleep Apnea Treatments among Veterans with Mild Traumatic Brain Injury.

Journal article Behav Sleep Med · 2024 OBJECTIVE: To understand factors influencing adherence to recommended treatment for insomnia and obstructive sleep apnea (OSA) among Veterans with mild traumatic brain injury (mTBI). METHOD: Semi-structured interviews (n = 49) with 29 clinical stakeholders ... Full text Link to item Cite

Mindful Night-to-Day: A Pilot Feasibility Trial of a Mindfulness-Based Insomnia and Symptom Management Intervention for Patients with Hematologic Cancer.

Journal article Behav Sleep Med · 2024 OBJECTIVES: Patients with hematologic cancer experience severe symptoms (i.e. insomnia, fatigue, pain, distress). Few interventions addressing insomnia and other symptoms exist for this population. Mindfulness-Based Therapy for Insomnia (MBTI) may be appro ... Full text Link to item Cite

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration.

Journal article Sleep Health · December 2023 OBJECTIVE: To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients. METHODS: Cognitive behavioral therapy for insomnia was identified from the text of psychot ... Full text Link to item Cite

The Use of Evaluation Panels During the Development of a Digital Intervention for Veterans Based on Cognitive Behavioral Therapy for Insomnia: Qualitative Evaluation Study.

Journal article JMIR Form Res · March 6, 2023 BACKGROUND: Individuals enrolling in the Veterans Health Administration frequently report symptoms consistent with insomnia disorder. Cognitive behavioral therapy for insomnia (CBT-I) is a gold standard treatment for insomnia disorder. While the Veterans H ... Full text Open Access Link to item Cite

Provider-supported self-management cognitive behavioral therapy for insomnia (Tele-Self CBTi): Protocol for a randomized controlled trial.

Journal article Contemp Clin Trials · February 2023 BACKGROUND: Cognitive Behavioral Therapy for Insomnia (CBTi) is recommended as first-line treatment for insomnia, yet patient access to CBTi is limited. Self-help CBTi could increase patient access. Self-help CBTI with provider sup]port is more effective a ... Full text Open Access Link to item Cite

Probable trauma associated sleep disorder in post-9/11 US Veterans.

Journal article Sleep Adv · 2023 STUDY OBJECTIVES: The purpose of this study was to (1) estimate trauma associated sleep disorder (TASD) prevalence among post-9/11 era veterans and to describe differences in service and comorbid mental health clinical characteristics among individuals wit ... Full text Open Access Link to item Cite

Maintaining Implementation through Dynamic Adaptations (MIDAS): protocol for a cluster-randomized trial of implementation strategies to optimize and sustain use of evidence-based practices in Veteran Health Administration (VHA) patients.

Journal article Implement Sci Commun · May 14, 2022 BACKGROUND: The adoption and sustainment of evidence-based practices (EBPs) is a challenge within many healthcare systems, especially in settings that have already strived but failed to achieve longer-term goals. The Veterans Affairs (VA) Maintaining Imple ... Full text Open Access Link to item Cite

Sleep disturbance and pain in U.S. adults over 50: evidence for reciprocal, longitudinal effects.

Journal article Sleep Med · October 2021 OBJECTIVE: To examine the relationship between sleep disturbance and pain over a 14-year period. METHODS: This study used data from the 2002-2016 waves of the Health and Retirement Study (HRS), an observational study of U.S. adults over age 50 (n = 17,756) ... Full text Link to item Cite

Prevalence of insomnia disorder and sleep apnea in a sample of veterans at risk for cardiovascular disease.

Journal article J Clin Sleep Med · July 1, 2021 STUDY OBJECTIVES: The objectives of this study were to examine the proportion of study participants screening positive for insomnia disorder and/or sleep apnea in veterans engaged in routine health care and known to be at risk for cardiovascular disease an ... Full text Open Access Link to item Cite

Prevalence rates and correlates of insomnia disorder in post-9/11 veterans enrolling in VA healthcare.

Journal article Sleep · December 14, 2020 STUDY OBJECTIVES: Post-9/11 veterans are particularly vulnerable to insomnia disorder. Having accurate prevalence rates of insomnia disorder in this relatively young, diverse population, is vital to determine the resources needed to identify and treat inso ... Full text Link to item Cite

The Veterans Administration and Department of Defense clinical practice guidelines for the diagnosis and management of sleep disorders: what does this mean for the practice of sleep medicine?

Journal article J Clin Sleep Med · August 15, 2020 In 2017 the Veterans Administration (VA) and Department of Defense (DOD) launched development of clinical practice guidelines (CPGs) for the diagnosis and treatment of sleep disorders, with the goal of informing and improving patient care. The guideline de ... Full text Link to item Cite

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines.

Journal article Ann Intern Med · March 3, 2020 DESCRIPTION: In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep ... Full text Link to item Cite

Roles of Guilt Cognitions in Trauma-Related Sleep Disturbance in Military Veterans With Posttraumatic Stress Disorder.

Journal article Behav Sleep Med · 2019 Objective/Background: Despite a well-established role of guilt cognitions in the maintenance and treatment of posttraumatic stress disorder (PTSD), relationships of guilt cognitions to nightmares are not well understood. This study investigated the ways in ... Full text Link to item Cite

Posttraumatic stress disorder diagnosis is associated with reduced parasympathetic activity during sleep in US veterans and military service members of the Iraq and Afghanistan wars.

Journal article Sleep · December 1, 2018 STUDY OBJECTIVES: To determine whether high-frequency heart rate variability (HF-HRV) during sleep differs between those with and without posttraumatic stress disorder (PTSD) as a function of sleep type (non-rapid eye movement [NREM] vs. rapid eye movement ... Full text Link to item Cite

Work stressors, depressive symptoms and sleep quality among US Navy members: a parallel process latent growth modelling approach across deployment.

Journal article J Sleep Res · June 2018 The present study examined whether work stressors contribute to sleep problems and depressive symptoms over the course of deployment (i.e. pre-deployment, post-deployment and 6-month reintegration) among US Navy members. Specifically, we examined whether d ... Full text Link to item Cite

Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review.

Journal article J Gen Intern Med · June 2018 The American College of Physicians (ACP) recently identified cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment for insomnia. Although CBT-I improves sleep outcomes and reduces the risks associated with reliance on hypnotics, pat ... Full text Link to item Cite

Prevalence of and characteristics associated with insomnia and obstructive sleep apnea among veterans with knee and hip osteoarthritis.

Journal article BMC Musculoskelet Disord · March 9, 2018 BACKGROUND: Few studies have examined patterns of specific sleep problems among individuals with osteoarthritis (OA). The primary objective of this study was to examine prevalence of symptoms of insomnia and obstructive sleep apnea (OSA) among Veterans wit ... Full text Open Access Link to item Cite

Insomnia in United States military veterans: An integrated theoretical model.

Journal article Clin Psychol Rev · February 2018 Marked by difficulty falling or staying asleep and/or poor sleep leading to daytime dysfunction, insomnia contributes to functional impairment, poor health, and increased healthcare utilization when left untreated. As many as two-thirds of Iraq and Afghani ... Full text Link to item Cite

Sleep, resilience, and psychological distress in United States military Veterans.

Journal article Mil Psychol · 2018 Sleep problems are prevalent among Veterans. Left untreated, such problems may elevate psychological distress and increase risk of subsequent mental health disorders. Psychological resilience may buffer against negative psychological outcomes, yet the rela ... Full text Link to item Cite

Sleep quality in returning veterans: The influence of mild traumatic brain injury.

Journal article Rehabil Psychol · November 2017 OBJECTIVE: Sleep disturbance is a key behavioral health concern among Iraq and Afghanistan era veterans and is a frequent complaint among veterans with a history of mild traumatic brain injury (mTBI). Currently, it is unclear whether sleep disturbance is a ... Full text Link to item Cite

Self-Reported Pain in Male and Female Iraq/Afghanistan-Era Veterans: Associations with Psychiatric Symptoms and Functioning.

Journal article Pain Med · September 1, 2017 OBJECTIVE: To examine pain symptoms and co-occurring psychiatric and functional indices in male and female Iraq/Afghanistan-era veterans. DESIGN: Self-reported data collection and interviews of Iraq/Afghanistan-era veterans who participated in a multisite ... Full text Link to item Cite

Veterans Affairs Primary Care Provider Perceptions of Insomnia Treatment.

Journal article J Clin Sleep Med · August 15, 2017 STUDY OBJECTIVES: Insomnia is a widespread issue among United States adults and rates of insomnia among veterans are even higher than the general population. Prior research examining primary care provider (PCP) perspectives on insomnia treatment found that ... Full text Open Access Link to item Cite

Circadian Contrasts in Heart Rate Variability Associated With Posttraumatic Stress Disorder Symptoms in a Young Adult Cohort.

Journal article J Trauma Stress · October 2016 Prior research has demonstrated that individuals exposed to trauma have shown impaired autonomic function. We sought to determine if heart rate variability (HRV), a marker of impaired autonomic function, differed across periods of wake, rest, and sleep as ... Full text Link to item Cite

Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women.

Journal article Gerontologist · February 2016 PURPOSE OF THE STUDY: To compare the prevalence and cardiometabolic health impact of sleep disturbance among postmenopausal Veteran and non-Veteran participants in the Women's Health Initiative (WHI). DESIGN AND METHODS: The prevalence of five categories o ... Full text Link to item Cite

A Collaborative Paradigm for Improving Management of Sleep Disorders in Primary Care: A Randomized Clinical Trial.

Journal article Sleep · January 1, 2016 OBJECTIVES: To test a collaborative care model for interfacing sleep specialists with primary care providers to enhance patients' sleep disorders management. METHODS: This study used a randomized, parallel group, clinical intervention trial design. A total ... Full text Link to item Cite

A Comparison of Sleep Difficulties among Iraq/Afghanistan Theater Veterans with and without Mental Health Diagnoses.

Journal article J Clin Sleep Med · September 15, 2015 STUDY OBJECTIVES: Sleep disturbance is among the most common complaints of veterans and military personnel who deployed to the conflicts in Iraq and Afghanistan. A growing body of research has examined cross-sectional and longitudinal relationships between ... Full text Link to item Cite

Associations between sleep difficulties and risk factors for cardiovascular disease in veterans and active duty military personnel of the Iraq and Afghanistan conflicts.

Journal article J Behav Med · June 2015 Recent evidence suggests that sleep disturbance may play an important role in the development of cardiovascular disease (CVD). Despite the prevalence of sleep complaints among service members of recent military conflicts, few studies have examined associat ... Full text Open Access Link to item Cite

Behavioral health mediators of the link between posttraumatic stress disorder and dyslipidemia.

Journal article J Psychosom Res · July 2014 OBJECTIVES: Posttraumatic stress disorder (PTSD) has been linked to dyslipidemia, which is a major risk factor for coronary artery disease. Although this link is thought to reflect response to heightened stress, behavioral health risks, including smoking, ... Full text Link to item Cite

Impact of combat deployment and posttraumatic stress disorder on newly reported coronary heart disease among US active duty and reserve forces.

Journal article Circulation · May 6, 2014 BACKGROUND: The recent conflicts in Iraq and Afghanistan have exposed thousands of service members to intense stress, and as a result, many have developed posttraumatic stress disorder (PTSD). The role of military deployment experiences and PTSD in coronar ... Full text Link to item Cite

The Association of Sleep Duration, Mental Health, and Health Risk Behaviors among U.S. Afghanistan/Iraq Era Veterans.

Journal article Sleep · July 1, 2013 STUDY OBJECTIVES: Short and long sleep duration have been linked with higher rates of comorbid medical and mental health issues, as well as increased mortality. The current study examined the association between sleep duration, mental health problems, and ... Full text Link to item Cite

Predeployment Sleep Duration and Insomnia Symptoms as Risk Factors for New-Onset Mental Health Disorders Following Military Deployment.

Journal article Sleep · July 1, 2013 STUDY OBJECTIVES: To evaluate predeployment sleep duration and insomnia symptoms in relation to the development of mental health symptoms. DESIGN: Longitudinal cohort study. SETTING: The Millennium Cohort Study survey is administered via a secure website o ... Full text Link to item Cite

Sensitivity and specificity of polysomnographic criteria for defining insomnia.

Journal article J Clin Sleep Med · May 15, 2013 STUDY OBJECTIVES: In recent years, polysomnography-based eligibility criteria have been increasingly used to identify candidates for insomnia research, and this has been particularly true of studies evaluating pharmacologic therapy for primary insomnia. Ho ... Full text Link to item Cite

Nocturnal blood pressure non-dipping, posttraumatic stress disorder, and sleep quality in women.

Journal article Behav Med · 2013 Women with posttraumatic stress disorder (PTSD) have poor sleep quality and increased risk of cardiovascular disease (CVD). Non-dipping of nocturnal blood pressure may be an explanatory factor for the relationship between sleep and CVD found in previous re ... Full text Link to item Cite

Improving sleep with mindfulness and acceptance: a metacognitive model of insomnia.

Journal article Behav Res Ther · November 2012 While there is an accumulating evidence to suggest that therapies using mindfulness and acceptance-based approaches have benefits for improving the symptoms of insomnia, it is unclear how these treatments work. The goal of this paper is to present a concep ... Full text Link to item Cite

Move over LOCF: principled methods for handling missing data in sleep disorder trials.

Journal article Sleep Med · February 2012 Missing data, e.g. patient attrition, are endemic in sleep disorder clinical trials. Common approaches for dealing with this situation include complete-case analysis (CCA) and last observation carried forward (LOCF). Although these methods are simple to im ... Full text Link to item Cite

REM sleep bout duration and frequency in PTSD

Journal article Journal of Aggression Maltreatment and Trauma · January 1, 2012 The few pharmacological treatments shown to be effective in reducing sleep disturbance in posttraumatic stress disorder (PTSD) might work through normalization of rapid eye movement (REM). However, evidence of REM sleep disturbance in PTSD has been inconsi ... Full text Cite

A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study.

Journal article J Clin Sleep Med · February 15, 2011 STUDY OBJECTIVES: A significant portion of US military personnel are returning from deployment with trauma-related sleep disturbance, and disrupted sleep has been proposed as a mechanism for the development of medical conditions in those with posttraumatic ... Link to item Cite

Mindfulness and acceptance are associated with exercise maintenance in YMCA exercisers.

Journal article Behav Res Ther · August 2010 Although most U.S. adults have initiated an exercise program at some time, only a fraction are able to maintain consistent exercise. Instead, research suggests that intermittent exercise is commonplace among U.S. adults, underscoring the importance of iden ... Full text Link to item Cite

Ethnic differences in continuous positive airway pressure (CPAP) adherence in veterans with and without psychiatric disorders.

Journal article Behav Sleep Med · 2010 Continuous positive airway pressure (CPAP) is a safe, effective treatment for sleep apnea, yet adherence is notoriously problematic. Vulnerable populations that may be at increased risk of sleep apnea include African Americans (AAs) and individuals with ps ... Full text Link to item Cite

Sleep disturbance and baroreceptor sensitivity in women with posttraumatic stress disorder.

Journal article J Trauma Stress · December 2009 In a previous study, women with posttraumatic stress disorder (PTSD) had greater objective sleep disturbance than those without PTSD. In a separate previous study, women with PTSD were also found to have lower baroreceptor sensitivity (BRS), an index of bl ... Full text Link to item Cite

Assessing depression symptoms in those with insomnia: an examination of the beck depression inventory second edition (BDI-II).

Journal article J Psychiatr Res · February 2009 BACKGROUND: Due to concerns about overlapping symptomatology between medical conditions and depression, the validity of the beck depression inventory (BDI-II) has been assessed in various medical populations. Although major depressive disorder (MDD) and pr ... Full text Link to item Cite

Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: results of a randomized clinical trial.

Journal article Arthritis Rheum · February 15, 2007 OBJECTIVE: Depressive symptoms are common among patients with fibromyalgia, and behavioral intervention has been recommended as a major treatment component for this illness. The objective of this study was to test the effects of the Mindfulness-Based Stres ... Full text Link to item Cite

Mindfulness meditation in clinical practice

Journal article Cognitive and Behavioral Practice · January 1, 2004 The practice of mindfulness is increasingly being integrated into contemporary clinical psychology. Based in Buddhist philosophy and subsequently integrated into Western health care in the contexts of psychotherapy and stress management, mindfulness medita ... Full text Cite

Cognitive aspects of chronic depression.

Journal article J Abnorm Psychol · February 2003 Previous research on chronic depression has focused on its link with other mood disorders and Axis II personality disorders. However, there are few data examining whether the cognitive perspective applies to this condition. In this cross-sectional study, 4 ... Link to item Cite