Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study

Abstract

Background Sleep disorders frequently occur in posttraumatic stress disorder (PTSD) patients. Chronic insomnia is a common feature of and criteria for the diagnosis of PTSD. Another sleep disorder, obstructive sleep apnea (OSA), also occurs frequently in PTSD, and emerging research indicates OSA fuels chronic insomnia. Scant research has investigated the impact of OSA treatment on insomnia outcomes (Insomnia Severity Index, ISI) in trauma survivors. Methods OSA patients with moderately severe posttraumatic stress symptoms were studied in a retrospective chart review. Ninety-six patients who failed CPAP therapy due to expiratory pressure intolerance or complex sleep apnea or both underwent manual titration with advanced PAP modes [autobilevel (ABPAP); adaptive servo-ventilation (ASV)], which were subsequently prescribed. PAP use measured by objective data downloads divided the sample into three groups: compliant regular users (C-RU): n = 68; subthreshold users (SC-RU): n = 12; and noncompliant users (NC-MU): n = 16. The average follow-up was 11.89 ± 12.22 months. Baseline and posttreatment ISI scores were analyzed to assess residual insomnia symptoms as well as cure rates. Results The C-RU group showed significant improvements in insomnia with very large effects compared to those in the NC-MU reference group ( P = 0. 019). Insomnia severity significantly decreased in all three groups with large effects (C-RU, P = 0. 001; SC-RU, P = 0. 027; NC-MU, P = 0. 007). Hours of weekly PAP use and insomnia severity were inversely correlated ( P = 0. 001, r = − 0.321). However, residual insomnia symptoms based on established ISI cut-offs were quite common, even among the C-RU group. Post hoc analysis showed that several categories of sedating medications reported at baseline (hypnotics, anti-epileptic, opiates) as well as actual use of any sedating medication (prescription or nonprescription) were associated with smaller insomnia improvements than those in patients not using any sedating agents. Conclusions In a retrospective, nonrandomized analysis of a select sample of sleep clinic patients with OSA and PTSD symptoms, advanced PAP therapy was associated with significant improvement in insomnia severity for both compliant and partial users. However, residual insomnia symptoms persisted, indicating that PAP therapy provides only limited treatment. RCTs are warranted to assess the effect of ABPAP and ASV modes of therapy on adherence and sleep outcomes, and their potential impact on posttraumatic stress symptoms. Treatment arms that combine PAP with CBT-I would be expected to yield the greatest potency.

Beirut Blast: Post-Traumatic Stress Disorder, Depression, & Post-Traumatic Growth After 6 Months

“…[67] Socially, people having been diagnosed with PTSD showed a higher social dysfunction, including loss of valuable relationships and disrupted family connections. [68] This indicates well that a supportive social network is a very important predictor of the development of PTSD in people with genetic susceptibility who have undergone a certain traumatic event.…”

Testing for Sleep-Disordered Breathing in Psychiatric Practice

“…11 Research followed, demonstrating how advanced PAP technology rescues CPAP failure cases, improves outcomes, and increases adherence. [12][13][14] Recently, a randomized controlled trial proved ASV significantly and clinically superior to CPAP in treating chronic insomnia, yielding nearly thrice as many insomnia "cures," based on Insomnia Severity Index (ISI) scores (mean exit ISI with ASV = 5.89 vs CPAP = 10.19; ISI "cure" cutoff = 8; P = .01). 8 Although the total sample was small (n = 40), limiting significance findings, large effect sizes for ASV were demonstrated within-group compared to small-medium effects for CPAP on 3 validated scales measuring fatigue, quality of life, and daytime impairment, plausible outcomes consistent with growing evidence that independent sleep disorders therapy improves mental health.…”

The influence of sleep on fear extinction in trauma-related disorders

“…Although the contribution of primary sleep disorders preceding the occurrence of trauma requires knowledge of prior medical histories, clinical studies of such sleep disorders occurring co-morbidly with PTSD strongly suggest they increase vulnerability to PTSD. For example, OSA is associated with higher severity of PTSD symptoms ( Mayer et al., 2021 ; Miles et al., 2022 ), worsened insomnia symptoms ( Krakow et al., 2019 ) and poorer PTSD treatment outcome ( Reist et al., 2017 ; Taylor et al., 2020 ) whereas treatment of OSA is associated with an improved PTSD therapeutic outcome ( Hurwitz and Khawaja, 2010 ; Krakow et al., 2000 , 2019 ). Similarly, pre-treatment insomnia is associated with lesser treatment gains ( Sullan et al., 2021 ) and residual sleep symptoms have been shown to predict poorer response to prolonged exposure therapy (PE) ( Brownlow et al., 2016 ; Lopez et al., 2017 ; Taylor et al., 2020 ).…”