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Liu J, Zang C, Yi M, Zhang Y. Clinical Characteristics and Treatment Efficacy for Co-Morbid Insomnia and Sleep Apnea (COMISA): Evidence from Qualitative and Quantitative Analysis. Behav Sleep Med 2024; 22:611-635. [PMID: 38519143 DOI: 10.1080/15402002.2024.2324361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2024]
Abstract
OBJECTIVES A multitude of physical and mental challenges are being faced in the population with Co-morbid Insomnia and Sleep Apnea (COMISA). Unfortunately, research about clinical characteristics and management of COMISA based on quantitative evidence is lacking. METHOD Standard procedures for literature retrieval, selection and quality assessment, data extraction, analysis, and interpretation were conducted step by step. For studying the sleep characteristics, common complications and widely recognized treatment options for COMISA, Weighted Mean Difference (WMD) and Odds Ratio (OR) were applied to assess the mean and risk differences between compared groups. Outcomes included sleep health parameters and secondary impairments in physical and mental well-being. RESULTS COMISA showed worse sleep quality than OSA only by PSQI (WMD = 3.38 point) and heavier sleep fragmentation (WMD = 11.46 min) than insomnia only. Besides, COMISA patients showed a higher risk for depression (OR [95%CI] = 5.03[2.31, 10.93]) and PTSD (OR [95%CI] = 3.96[1.85, 8.46]) in comparison with OSA alone. Compared to insomnia alone, COMISA patients suffered from more than two times higher risk of cardiovascular diseases, hypertension, and diabetes. In treating COMISA patients, combining CBTI with PAP treatment can enhance the improvement of insomnia severity (ISI, WMD [95%CI] =-3.26[-4.51, -2.00] point) and sleep efficiency (WMD [95%CI] = 6.39[1.97, 10.81] %) compared to PAP alone. CONCLUSIONS Impaired sleep domains in COMISA cover sleep quality and sleep structure. Also, COMISA has a higher risk for cardiometabolic diseases and mental disorders. Combining CBTI with PAP can be a recommended treatment to relieve sleep impairments for COMISA.
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Affiliation(s)
- Jie Liu
- Department of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Chenyang Zang
- Department of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
- Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Minhan Yi
- School of Life Sciences, Central South University, Changsha, Hunan, China
| | - Yuan Zhang
- Department of Respiratory Medicine, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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Titone MK, Hunt C, Bismark A, Nokes B, Lee E, Ramanathan D, Park J, Colvonen P. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med 2023; 19:2043-2051. [PMID: 37539643 PMCID: PMC10692930 DOI: 10.5664/jcsm.10746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
STUDY OBJECTIVES Intranasal administration of esketamine is Food and Drug Administration-approved for treatment-resistant depression. In a recent retrospective case series, we show that it has promise in reducing symptoms of posttraumatic stress disorder (PTSD) as well. Untreated obstructive sleep apnea (OSA) is prevalent among veterans with PTSD and has been shown to interfere with other PTSD treatments. In the current study, we examined whether OSA impacts esketamine's effectiveness in reducing symptoms of PTSD or depression. METHODS Participants were 60 veterans with a diagnosis of major depressive disorder and PTSD who received intranasal esketamine treatment at the San Diego Veterans Affairs (VA) Medical Center. We used growth-curve modeling to examine changes in depression and PTSD symptoms following esketamine treatments and, in the subset of individuals screened for OSA (n = 24, all prescribed positive airway pressure therapy), examined the impacts of OSA severity on these trajectories. RESULTS We first showed that both PTSD and depressive symptoms significantly decreased over the course of esketamine treatment. In the subset of veterans screened for OSA, individuals with lower OSA severity reported the greatest reduction in PTSD symptoms, while veterans with the most severe OSA reported the least reduction in PTSD symptoms. Depression response was not affected by severity of OSA in this analysis. CONCLUSIONS Veterans with PTSD and depression tend to benefit from esketamine treatment, but OSA may interfere with esketamine effectiveness. Comorbid OSA should be assessed for and treated to maximize esketamine's benefits in PTSD. CITATION Titone MK, Hunt C, Bismark A, et al. The effect of obstructive sleep apnea severity on PTSD symptoms during the course of esketamine treatment: a retrospective clinical study. J Clin Sleep Med. 2023;19(12):2043-2051.
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Affiliation(s)
- Madison K. Titone
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | | | | | - Brandon Nokes
- VA San Diego Healthcare System, San Diego, California
| | - Ellen Lee
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Dhakshin Ramanathan
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
| | - Jane Park
- VA San Diego Healthcare System, San Diego, California
| | - Peter Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
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Pruiksma KE, Taylor DJ, Wachen JS, Straud CL, Hale WJ, Mintz J, Young-McCaughan S, Peterson AL, Yarvis JS, Borah EV, Dondanville KA, Litz BT, Resick PA. 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; 19:1389-1398. [PMID: 36988304 PMCID: PMC10394372 DOI: 10.5664/jcsm.10584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/30/2023]
Abstract
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.
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Affiliation(s)
- Kristi E. Pruiksma
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
| | - Daniel J. Taylor
- Department of Psychology, University of Arizona, Tucson, Arizona
- Department of Psychology, University of North Texas, Denton, Texas
| | - Jennifer Schuster Wachen
- Women’s Health Sciences Division, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Casey L. Straud
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | - Willie J. Hale
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | - Jim Mintz
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Stacey Young-McCaughan
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
| | - Alan L. Peterson
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
| | - Jeffrey S. Yarvis
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- School of Social Work, Tulane University, New Orleans, Louisiana
| | - Elisa V. Borah
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- School of Social Work, University of Texas at Austin, Austin, Texas
| | - Katherine A. Dondanville
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Brett T. Litz
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
| | - Patricia A. Resick
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina
| | - on behalf of the STRONG STAR Consortium
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Research and Development Service, South Texas Veterans Health Care System, San Antonio, Texas
- Department of Psychology, University of Arizona, Tucson, Arizona
- Department of Psychology, University of North Texas, Denton, Texas
- Women’s Health Sciences Division, National Center for PTSD at VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
- Department of Psychology, University of Texas at San Antonio, San Antonio, Texas
- Department of Population Health Sciences, University of Texas Health Science Center at San Antonio, San Antonio, Texas
- Department of Behavioral Health, Carl R. Darnall Army Medical Center, Fort Hood, Texas
- School of Social Work, Tulane University, New Orleans, Louisiana
- School of Social Work, University of Texas at Austin, Austin, Texas
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts
- Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts
- Department of Psychiatry and Behavioral Sciences, Duke Health, Durham, North Carolina
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Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med 2023; 19:857-863. [PMID: 36692162 PMCID: PMC10152361 DOI: 10.5664/jcsm.10430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 01/25/2023]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is a common sleep disturbance in individuals with posttraumatic stress disorder (PTSD), with an emerging literature showing that treating OSA with positive airway pressure (PAP) therapy has a moderate effect on decreasing PTSD severity. Unfortunately, PAP adherence among individuals with PTSD is low. Our study examined how baseline PTSD cluster subscores predict 6-month PAP adherence and how PAP adherence predicts change in PTSD cluster subscores over time. METHODS We examined PTSD and PAP adherence in 41 veterans with PTSD newly diagnosed with OSA over 6 months of PAP use (mean age = 50.27 years; 73.7% White; 13.6% female). The Posttraumatic Stress Disorder Checklist-Specific (PCL-S) was used to examine PTSD and subscales (re-experiencing, avoidance, and hyperarousal). We used longitudinal analyses to examine PTSD subscores on PAP adherence and PAP adherence predicting changes in PTSD subscores at 6-month follow-up. RESULTS Among veterans with PTSD, higher levels of re-experiencing and hyperarousal, but not avoidance, predicted lower PAP use. Overall, the high-adherent group showed a 14.36-point decrease on the PCL-S, while the low-adherent group averaged just a 3.66-point decrease. More days of PAP use were associated with greater improvement in hyperarousal and avoidance subscores but not re-experiencing. CONCLUSIONS Our findings reaffirm the importance of PAP use among patients with comorbid PTSD and sleep apnea, as well as the difficulty in achieving adherent PAP use in this population. Directly addressing heightened re-experiencing and hyperarousal in PTSD may increase PAP adherence among veterans with PTSD and requires future research. CITATION Colvonen PJ, Goldstein LA, Sarmiento KF. Examining the bidirectional relationship between posttraumatic stress disorder symptom clusters and PAP adherence. J Clin Sleep Med. 2023;19(5):857-863.
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Affiliation(s)
- Peter J. Colvonen
- VA San Diego Healthcare System, San Diego, California
- Department of Psychiatry, University of California, San Diego, San Diego, California
- VA Center of Excellence for Stress and Mental Health, San Diego, California
- National Center for PTSD, White River Junction, Vermont
| | - Lizabeth A. Goldstein
- San Francisco VA Health Care System, San Francisco, California
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California
| | - Kathleen F. Sarmiento
- San Francisco VA Health Care System, San Francisco, California
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Schmickl CN, Bosompra NO, DeYoung PN, Gilbertson D, Orr JE, Malhotra A, Grant I, Ancoli-Israel S, Young MK, Owens RL. Diagnostic performance of screening tools for the detection of obstructive sleep apnea in people living with HIV. J Clin Sleep Med 2022; 18:1797-1804. [PMID: 35383569 DOI: 10.5664/jcsm.9964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Many people living with HIV (PLWH) have undiagnosed obstructive sleep apnea (OSA), which may contribute to commonly reported fatigue and the high cardiovascular disease burden in this population. Our objective was to assess the utility of traditional OSA screening tools (STOP-BANG, Berlin Questionnaire (BQ), and Epworth Sleepiness Scale (ESS)) for detecting OSA in PLWH. METHODS Adult PLWH were recruited from sleep/HIV clinics and the community into a larger clinical trial which included completion of these questionnaires before in-laboratory polysomnography. Discriminatory performance of these screening tools was assessed using area under receiver operating characteristic curves (AUC). The reference standard for the primary analysis was OSA based on an AHI≥5/h using recommended "1A"-criteria (hypopnea with 3%-desaturation and/or arousal). Secondary analyses explored acceptable "1B"-criteria (hypopnea with 4%-desaturation) and/or higher AHI cut-offs (≥15/h). RESULTS 120 PLWH were included (mean-age: 50±11 years; body mass index: 27±4 kg/m2, 84% male) and OSA was diagnosed in 75% using 1A-criteria. In the primary analysis, the discriminatory performance of the three screening tools was low (AUCs 0.58 to 0.70) and similar across the tools (P≥0.14). In secondary analyses, STOP-BANG showed moderate-high discriminatory ability (AUCs 0.77-0.80) and performed significantly better (P≤0.008) than the BQ or ESS (AUCs 0.53-0.62). CONCLUSIONS OSA was highly prevalent in our cohort of PLWH. Although STOP-BANG could reasonably identify moderate-severe OSA, the tools were not reliable for mild disease. Specifically, the questionnaires perform poorly for PLWH with mild OSA manifesting with arousals, yet such people may be at risk of fatigue/sleepiness and impaired memory consolidation. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Obstructive Sleep Apnea Endotypes and Impact on Phenotypes of People Living With HIV (PLWH/OSA); Identifier: NCT03575143; URL: https://clinicaltrials.gov/ct2/show/NCT03575143.
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Affiliation(s)
| | | | | | | | - Jeremy E Orr
- University of California San Diego, La Jolla, California
| | - Atul Malhotra
- University of California San Diego, La Jolla, California
| | - Igor Grant
- University of California San Diego, La Jolla, California
| | | | | | - Robert L Owens
- University of California San Diego, La Jolla, California
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