Treatment of OSA with CPAP Is Associated with Improvement in PTSD Symptoms among Veterans

Abstract

Study Objectives: Posttraumatic stress disorder (PTSD) is common among veterans of the military, with sleep disturbance as a hallmark manifestation. A growing body of research has suggested a link between obstructive sleep apnea and PTSD, potentially due to obstructive sleep apnea (OSA) related sleep disruption, or via other mechanisms. We examined the hypothesis that treatment of OSA with positive airway pressure would reduce PTSD symptoms over 6 months. Methods: A prospective study of Veterans with confirmed PTSD and new diagnosis of OSA not yet using PAP therapy were recruited from a Veteran's Affairs sleep medicine clinic. All subjects were instructed to use PAP each night. Assessments were performed at 3 and 6 months. The primary outcome was a reduction in PTSD symptoms at 6 months. Results: Fifty-nine subjects were enrolled; 32 remained in the study at 6 months. A significant reduction in PTSD symptoms, measured by PCL-S score was observed over the course of the study (60.6 ± 2.7 versus 52.3 ± 3.2 points; p < 0.001). Improvement was also seen in measures of sleepiness, sleep quality, and daytime functioning, as well as depression and quality of life. Percentage of nights in which PAP was used, but not mean hours used per night, was predictive of improvement. I NTRO DUCTI O NPosttraumatic stress disorder (PTSD) is highly prevalent among veterans of the United States armed forces, afflicting 11% to 22% of those returning from Iraq and Afghanistan.1,2 Among Vietnam veterans, the lifetime prevalence approaches 31%, and despite 40 years having elapsed since combat exposure, PTSD remains in 10% of veterans of this era, reflecting the challenges for recovery.3 Patients with PTSD have a substantially reduced quality of life and increased mortality.4,5 Sleep disturbance is often called the "hallmark" of PTSD, 6 and formal DSM-5 criteria includes several sleep-related complaints, including recurrent distressing dreams and sleep disturbances. Sleep disturbance has been recognized as both an early predictor of development of PTSD, and a marker of disease severity.7-9 However, whether sleep disturbance is a reflection of disease, or a predisposing factor in development and continuance of PTSD is an ongoing subject of debate. Moreover, treatment of PTSD has been elusive, leading to a search for potential therapeutic targets in this condition. Sleep and Pediatrics, Carmel Medical Center, Haifa, A growing body of research has suggested an association between OSA and PTSD. Prevalence estimations for OSA in PTSD patients range from 52% to 69%, with some as high as 95%. [10][11][12] The odds of PTSD have been estimated at 2.7-fold higher in patients with sleep apnea. SCIENTIFIC INVESTIGATIONS13 While the nature of this interaction is unclear, it has been hypothesized that OSA-related sleep disruption contributes to PTSD, either by contributing to symptoms or more direct influences on disease pathogenesis. In general, untreated OSA might contribute to symptoms of depression and anxiety. 14,15 In PTSD patients, recurrent BRI...

Challenges in the Management of Sleep Apnea and PTSD: Is the Low Arousal Threshold an Unrealized Target?

“…1 Dr. Gupta's experiences parallel those described by the journal's recent article by Orr et al 2 and our prior studies on this topic. 3,4 Dr. Gupta raises an important question regarding the potential benefits of adjunctive pharmacotherapy for comorbid OSA and PTSD.…”

Advancing Treatment of Comorbid PTSD and OSA

“…Thus, although heightened arousal may lead to higher incidence of OSA, treatment of OSA is unlikely to fully eliminate hyperarousal, particularly during the daytime. This is evidenced by Orr et al 5 finding a modest reduction in PTSD symptoms among veterans using PAP. PAP should be considered a component of treatment in patients with PTSD/OSA, but should not be viewed as a magic bullet for curing PTSD.…”

A Randomized Crossover Trial Evaluating Continuous Positive Airway Pressure Versus Mandibular Advancement Device on Health Outcomes in Veterans With Posttraumatic Stress Disorder

“…8,40,41 In one of these studies involving 40 veterans with combat-related PTSD, a positive association was established between the reduction in PCL-M and the average of hours of CPAP use per night. 40 Similarly, Orr and colleagues 41 showed significant reduction in PTSD symptoms following 6 months of treatment with CPAP. In this study, we were able to show that the amelioration in PTSD severity extended also to OSA treatment with MAD.…”