The Effect of Sleep Disorders, Sedating Medications, and Depression on Cognitive Processing Therapy Outcomes: A Fuzzy Set Qualitative Comparative Analysis

Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial

STUDY OBJECTIVES

Sleep disturbances are common in military personnel with posttraumatic stress disorder (PTSD) and may persist following treatment. This study examined service members seeking treatment for PTSD, reporting insomnia symptoms, nightmares, excessive daytime sleepiness, and potential obstructive sleep apnea at baseline and the impact of sleep disturbances on a course of PTSD treatment.

METHODS

In this secondary analysis, sleep was evaluated in 223 service members who participated in a randomized clinical trial comparing Cognitive Processing Therapy for PTSD delivered in individual or group formats. Sleep assessments included the Insomnia Severity Index, the Trauma-Related Nightmare Survey, and Epworth Sleepiness Scale administered at baseline and 2 weeks posttreatment.

RESULTS

Following PTSD treatment, there were significant improvements for insomnia symptoms (MΔ = -1.49; d = -0.27), nightmares (MΔ = -0.35; d = -0.27), and excessive daytime sleepiness (MΔ = -0.91; d = -0.16). However, mean scores remained in clinical ranges at posttreatment. Participants with baseline insomnia symptoms had worse PTSD severity throughout treatment. Participants with baseline excessive daytime sleepiness or probable obstructive sleep apnea had greater PTSD severity reductions when treated with Cognitive Processing Therapy individually vs. in a group. Those with insomnia symptoms, nightmare disorder, and sleep apnea had greater depressive symptoms throughout treatment.

CONCLUSIONS

Insomnia symptoms, nightmares, and excessive daytime sleepiness were high at baseline in service members seeking treatment for PTSD. While sleep symptoms improved with PTSD treatment, these sleep disorders were related to worse treatment outcomes with regards to symptoms of PTSD and depression. Individual Cognitive Processing Therapy is recommended over group Cognitive Processing Therapy for patients with either excessive daytime sleepiness or probable obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Group vs. Individual Cognitive Processing Therapy for Combat-related PTSD; URL: https://clinicaltrials.gov/ct2/show/NCT02173561; Identifier: NCT02173561.

CITATION

Puriksma KE, Taylor DJ, Wachen JS, et al. Self-reported sleep problems in active-duty US Army personnel receiving posttraumatic stress disorder treatment in group or individual formats: secondary analysis of a randomized clinical trial. J Clin Sleep Med. 2023;19(8):1389-1398.

Acute sleep interventions as an avenue for treatment of trauma-associated disorders

Scientific evidence that acute, posttrauma sleep disturbances (eg, nightmares and insomnia) can contribute significantly to the pathogenesis of trauma-induced disorders is compelling. Sleep disturbances precipitating from trauma are uniquely predictive of daytime posttrauma symptom occurrence and severity, as well as subsequent onset of mental health disorders, including post-traumatic stress disorder. Conversely, adequate sleep during the acute posttrauma period is associated with reduced likelihood of adverse mental health outcomes. These findings, which are broadly consistent with what is known about the role of sleep in the regulation of emotion, suggest that the acute posttrauma period constitutes a "window of opportunity" during which treatment of sleep disturbances may be especially effective for preventing or mitigating progression of aberrant psychophysiological processes. At this point, the weight of the scientific evidence supporting this possibility warrants initiation of clinical trials to confirm the benefits of targeted prophylactic sleep enhancement, and to establish treatment guidelines as appropriate.

CITATION

Swift KM, Thomas CL, Balkin TJ, Lowery-Gionta EG, Matson LM. Acute sleep interventions as an avenue for treatment of trauma-associated disorders. J Clin Sleep Med. 2022;18(9):2291-2312.

The prevalence rate of smoking among Veterans: A forgotten epidemic

LAY SUMMARY

The purpose of this study was to learn more about the smoking habits of U.S. Veterans compared with the rest of the population and to find the best ways to help Veterans quit smoking. This study found that Veterans tend to smoke more than the general population and that some groups of Veterans smoke more than others. When helping Veterans to quit smoking, health care providers should use approaches that are based on evidence, such as cognitive behavioral therapy, cognitive processing therapy, mindfulness-based stress reduction, and biofeedback in addition to the traditional 3A cessation model (ask, advise, refer).

Cognitive Processing Therapy for Posttraumatic Stress Disorder Is Associated with Negligible Change in Subjective and Objective Sleep

Background: Patients receiving Cognitive Processing Therapy (CPT), an evidence based therapy for posttraumatic stress disorder (PTSD), report improved sleep quality. However, the majority of studies have examined residual sleep disturbance via self-report surveys or separate items on PTSD measures. This study examined whether CPT delivered to veterans in a VA setting improved sleep indices using state-of-the-art objective and subjective insomnia measures. Participants: Participants were war veterans with a current PTSD diagnosis scheduled to begin outpatient individual or group CPT at two Veteran's Affairs (VA) locations (n = 37). Methods: Sleep symptom severity was assessed using the recommended research consensus insomnia assessment, the consensus daily sleep diary and actigraphy. PTSD symptomatology pre- and post-treatment were assessed using the Clinician Administered PTSD Scale. Results: A small to moderate benefit was observed for the change in PTSD symptoms across treatment (ES_RMC = .43). Effect sizes for changes on daily sleep diary and actigraphy variables after CPT were found to be negligible (Range ES_RMC = - .16 to .17). Sleep indices remained at symptomatic clinical levels post-treatment. Discussion: These findings support previous research demonstrating a need for independent clinical attention to address insomnia either before, during, or after PTSD treatment.

Pathways to Help-Seeking Among Black Male Trauma Survivors: A Fuzzy Set Qualitative Comparative Analysis

Many Black men suffer symptoms of traumatic stress in the aftermath of traumatic injury, and they also often carry social concerns, including experiences of discrimination and stigma, and a lack of financial resources. The objective of the present study was to understand how traumatic symptoms and social factors combine in complex ways toward the outcome of psychological help-seeking. We analyzed qualitative and quantitative data from 32 injured Black men admitted to a Level 1 trauma center. Qualitative interviews explored their attitudes toward seeking professional psychological help. We analyzed quantitative data, collected using validated instruments, on posttraumatic stress and depression symptoms, financial worry, and discrimination/stigma. Fuzzy set qualitative comparative analysis (fsQCA) was conducted by calibrating each condition to fuzzy set membership scores based on our knowledge of the causal conditions and the cases. We then constructed truth tables for QCA analysis using fsQCA software. Three causal pathways for psychological help-seeking were identified: Two pathways showed that severe trauma symptoms in the absence of financial worry were sufficient for seeking help, whereas the third showed that financial worry and discrimination in the absence of trauma symptoms were sufficient for help-seeking. We identified two causal pathways for negated help-seeking, in which low posttraumatic symptom severity and low levels of discrimination or financial worry were sufficient for not seeking psychological help. The QCA analysis revealed multiple pathways for psychological help-seeking among Black men who suffer trauma. These findings highlight the need for further research to understand complex pathways toward psychological help-seeking in this population.

Influence of sleep disorders on anxiety and depression and quality of life in elderly patients with chronic functional constipation

BACKGROUND

With the changes of dietary structure and lifestyles, the incidence of chronic constipation is gradually increasing. Sleep disorders increase gastrointestinal symptoms and are a risk factor for anxiety and depression. The purpose of this study was to explore the influence of sleep disorders on anxiety and depression and quality of life in elderly patients with chronic functional constipation, so as to provide an objective basis for the treatment of elderly patients with chronic functional constipation.

AIM

To investigate the effects of sleep disorders on anxiety and depression and quality of life in elderly patients with chronic functional constipation.

METHODS

A total of 126 elderly patients with chronic functional constipation admitted to our hospital from March 2017 to September 2019 were selected as the study subjects. They were divided into a sleep disorder group and a normal sleep group according to whether they had a sleep disorder. All patients underwent assessments using the constipation scoring system (CSS), patient assessment of constipation-symptoms (PAS-SYM) questionnaire, sleep quality assessment, self-rating anxiety scale (SAS), self-rating depression scale (SDS), and a quality of life scale.

RESULTS

In the sleep disorder group, the CSS score was 19.63 ± 3.36, the PAS-SYM score was 1.59 ± 0.52, the SAS score was 58.92 ± 6.72, and the SDS score was 57.74 ± 6.38, all of which were significantly higher than those of the normal sleep group (P < 0.05). The scores of social function, emotional score, physical role, physical health, mental health, and total health in the sleep disorder group were 71.56 ± 3.38, 75.89 ± 2.95, 76.86 ± 2.92, 80.25 ± 3.35, 78.36 ± 3.65, and 76.19 ± 2.56, respectively, all of which were significantly lower than those of the normal sleep group (P < 0.05). CSS scores, PAS-SYM scores, and total scores were positively correlated with SAS and SDS scores (P < 0.05). The scores of the six dimensions in SF-36 were negatively correlated with SAS and SDS scores (P < 0.05).

CONCLUSION

Sleep disorders, anxiety, and depression may be important factors affecting the clinical symptoms and quality of life of elderly patients with chronic functional constipation.

Analysis of correlation of sleep disturbance with anxiety, depression, and quality of life in elderly patients with chronic constipation based on "brain-gut axis" theory

BACKGROUND

Sleep disorders can increase the incidence of gastrointestinal symptoms, and a long-term decline in sleep quality is a risk factor for anxiety and depression. This study, based on the "brain-gut axis" theory, explored whether sleep disorder aggravates the clinical manifestations of elderly patients with chronic constipation and whether it affects their psychological mood and quality of life.

AIM

To explore the correlation of sleep disturbance with anxiety, depression, and quality of life in elderly patients with chronic constipation based on the "brain-gut axis" theory.

METHODS

One hundred and twenty-six elderly patients with chronic constipation who were hospitalized at our hospital from March 2017 to September 2019 were selected as the study subjects. The constipation scoring system (CSS), symptom self-rating questionnaire, sleep quality assessment, anxiety and depression scales, and quality of life scale were administered to all patients.

RESULTS

The sleep disorder group had a CSS score of 19.63 ± 3.36, patient assessment of constipation symptom (PAS-SYM) score of 1.59 ± 0.52, self-rating anxiety scale (SAS) score of 58.92 ± 6.72, and self-rating depression scale (SDS) score of 57.74 ± 6.38, which were significantly higher than those of the normal sleep group (P < 0.05). In the sleep disorder group, the scores of social function, mood, physical role, physical health, mental health, and overall health were 71.56 ± 3.38, 75.89 ± 2.95, 76.86 ± 2.92, 80.25 ± 3.35, 78.36 ± 3.65, and 76.19 ± 2.56, respectively, all of which were significantly lower than those of the normal sleep group (P < 0.05). CSS score, scores of all dimensions of PAC-SYM score, and PAC-SYM total score were positively correlated with SAS and SDS scores (P < 0.05). The scores of the six dimensions of SF-36 were negatively correlated with SAS and SDS scores (P < 0.05).

CONCLUSION

The brain-gut axis is the bridge between the gastrointestinal tract and the brain. Sleep disorders, anxiety, and depression may be important factors affecting the clinical symptoms of elderly patients with chronic constipation, and affect their quality of life.

Identification of effective parameters for anti-inflammatory concentration in València City's wastewater using fuzzy-set qualitative comparative analysis

The current literature about pharmaceutical and personal care compounds (PPCPs) focuses on identifying their concentration and toxicological risk both in surface water and in wastewater. However, the influence of urban areas (population ageing, income level, hospitals and others) has not yet been analysed. Knowing how a population (and its facilities) affects PPCPs' presence in wastewater is important to identify the conditions that are responsible for their presence. In this work, the influence of water consumption, population ageing, income level, hospitals and nursing homes on the anti-inflammatory concentration have been analysed. To fill the gap between the quantitative data on PPCPs' concentration and the qualitative reasoning of the influence of urban areas on the anti-inflammatory concentration, the use of fuzzy-set qualitative comparative analysis (fsQCA) is proposed. The fsQCA results are presented as recipes that show the different causal combinations of conditions that explain the presence of anti-inflammatories in wastewater. Using fsQCA for urban wastewater management with the aim of explaining the presence of anti-inflammatories in wastewater treatment plants (WWTPs) is a novelty in the literature. The results obtained here show the influence of water consumption (WATCON), hospitals (HOSP) and population ageing (POPAG) as the main conditions for the anti-inflammatory concentration in Valèncian wastewater. Specifically, these conditions are present in all the recipes obtained with consistency of 99%. Through the results obtained, it would be possible to identify that HOSP are the main facilities that discharge anti-inflammatories into urban wastewater. Hence, the necessity of preventive measures to avoid the anti-inflammatory discharge into water bodies has been showed. Furthermore, under a methodological point of view, this work highlights the eligibility of fsQCA as a wastewater cycle management tool.