In the JournalsPerspective

Obstructive sleep apnea worsens symptoms, QOL in patients with PTSD

Patients with combat-related PTSD who also had obstructive sleep apnea demonstrated worsened sleep-related symptoms and quality of life compared with patients without sleep apnea and healthy controls, according to study results.

Patients with PTSD and obstructive sleep apnea also displayed a limited adherence and response to positive airway pressure therapy, according to the researchers.

“In our population, we found that either PTSD or obstructive sleep apnea (OSA) were associated with worsened symptoms of sleepiness, fatigue and sleep-related quality of life (QoL) in comparison to normal subjects,” Christopher J. Lettieri, MD, a pulmonary and critical care medicine consultant to the U.S. Army Surgeon General, and colleagues wrote. “The presence of both OSA and PTSD lead to greater impairments than either condition alone.”

Lettieri and colleagues conducted a case-controlled observational study of active duty service members who received outpatient care for combat-related PTSD at Walter Reed Army Medical Center between 2008 and 2012 to analyze the impact OSA had on symptoms and QoL in patients with PTSD.

The analysis included 200 consecutive patients with PTSD and evaluated for OSA, 50 consecutive aged-matched patients with OSA but without PTSD and 50 aged-matched healthy controls.

Almost all (96.9%) of the patients with PTSD reported subjective sleep complaints such as daytime sleepiness and poor quality sleep.

Less than half of the patients with PTSD (41.2%) experienced reduced sleep efficiency and 31.2% of patients had prolonged sleep latency during polysomnography. Patients also had a mean total arousal index of 19.7 arousals per hour.

Patients with OSA and PTSD (n = 113) had the highest Epworth Sleepiness Scale (ESS) values compared with patients with PTSD alone (n = 87) and the healthy controls (12.5 vs. 9.5; P = .002 and 12.5 vs. 4.5; P < .001).

QoL — measured by the functional outcomes of sleep questionnaire — appeared significantly lower in patients with both PTSD and OSA (14.7) than in patients with PTSD alone (18, P = .001), OSA alone (18.7) and healthy controls (19.4, P < .001 for both).

The researchers then reassessed the patients 4 weeks after the start of positive airway pressure (PAP) therapy to evaluate adherence and response to therapy.

Patients with OSA used PAP 77.9% of nights whereas patients with both OSA and PTSD used the therapy on 53.3% of the nights (P < .001).

The patients with both disorders had a reduced treatment response to the therapy compared with patients with just OSA. ESS value dropped below 10 in 85.7% of PAP adherent and 54.5% of non-adherent patients with just OSA. However the ESS value dropped below 10 in 72.1% of adherent and 21.4% of non-adherent patients with both PTSD and OSA (P < .001).

“Although PAP can significantly improve QoL in this population, benefits are limited by poor adherence in an already compromised population,” the researchers wrote. “These results further advocate for a careful and individualized approach to therapy among patients with PTSD.” – by Ryan McDonald

Disclosure: The researchers report no relevant financial disclosures.

Patients with combat-related PTSD who also had obstructive sleep apnea demonstrated worsened sleep-related symptoms and quality of life compared with patients without sleep apnea and healthy controls, according to study results.

Patients with PTSD and obstructive sleep apnea also displayed a limited adherence and response to positive airway pressure therapy, according to the researchers.

“In our population, we found that either PTSD or obstructive sleep apnea (OSA) were associated with worsened symptoms of sleepiness, fatigue and sleep-related quality of life (QoL) in comparison to normal subjects,” Christopher J. Lettieri, MD, a pulmonary and critical care medicine consultant to the U.S. Army Surgeon General, and colleagues wrote. “The presence of both OSA and PTSD lead to greater impairments than either condition alone.”

Lettieri and colleagues conducted a case-controlled observational study of active duty service members who received outpatient care for combat-related PTSD at Walter Reed Army Medical Center between 2008 and 2012 to analyze the impact OSA had on symptoms and QoL in patients with PTSD.

The analysis included 200 consecutive patients with PTSD and evaluated for OSA, 50 consecutive aged-matched patients with OSA but without PTSD and 50 aged-matched healthy controls.

Almost all (96.9%) of the patients with PTSD reported subjective sleep complaints such as daytime sleepiness and poor quality sleep.

Less than half of the patients with PTSD (41.2%) experienced reduced sleep efficiency and 31.2% of patients had prolonged sleep latency during polysomnography. Patients also had a mean total arousal index of 19.7 arousals per hour.

Patients with OSA and PTSD (n = 113) had the highest Epworth Sleepiness Scale (ESS) values compared with patients with PTSD alone (n = 87) and the healthy controls (12.5 vs. 9.5; P = .002 and 12.5 vs. 4.5; P < .001).

QoL — measured by the functional outcomes of sleep questionnaire — appeared significantly lower in patients with both PTSD and OSA (14.7) than in patients with PTSD alone (18, P = .001), OSA alone (18.7) and healthy controls (19.4, P < .001 for both).

The researchers then reassessed the patients 4 weeks after the start of positive airway pressure (PAP) therapy to evaluate adherence and response to therapy.

Patients with OSA used PAP 77.9% of nights whereas patients with both OSA and PTSD used the therapy on 53.3% of the nights (P < .001).

The patients with both disorders had a reduced treatment response to the therapy compared with patients with just OSA. ESS value dropped below 10 in 85.7% of PAP adherent and 54.5% of non-adherent patients with just OSA. However the ESS value dropped below 10 in 72.1% of adherent and 21.4% of non-adherent patients with both PTSD and OSA (P < .001).

“Although PAP can significantly improve QoL in this population, benefits are limited by poor adherence in an already compromised population,” the researchers wrote. “These results further advocate for a careful and individualized approach to therapy among patients with PTSD.” – by Ryan McDonald

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    Philip Gehrman

    Philip Gehrman

    The results of this study have important implications for the clinical management of military service members with PTSD. In recent years there has been growing recognition that the sleep problems that often are part of PTSD need to be a focus of clinical attention because they typically do not resolve with PTSD-focused treatment. Most of the attention has been paid to insomnia and, to a lesser extent, nightmares, but this study suggests that sleep apnea should also be considered.

    It is not surprising that patients with both sleep apnea and PTSD had poorer functioning than those with either condition alone. This also suggests that the daytime impairment in PTSD may frequently be due, in part, to comorbid sleep apnea. Given that sleep apnea has a proven treatment (PAP therapy) screening for sleep disorders should be routine for this population. Providers who treat patients with military personnel with PTSD should make it a priority to at least ask their patients about sleep problems and ideally would use brief, validated screening measures such as those used in this study.

    • Philip Gehrman, PhD, CBSM
    • Assistant Professor, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine

    Disclosures: Gehrman reports no relevant financial disclosures.