Improving Sleep and Functioning in Veterans with Posttraumatic Stress Disorder

睡眠障碍是退伍军人创伤后应激障碍最常见的症状 （PTSD），失眠的患病率超过90%，阻塞性睡眠呼吸暂停（OSA）的患病率约为70%。 除了精神压力驱动的痛苦，创伤后应激障碍，OSA和失眠是有问题的，因为它们的影响， 身体健康、功能结果和生活质量。虽然有有效的治疗OSA 和失眠，目前对这些疾病的治疗还没有适应大量的需要， 经历创伤后应激障碍的退伍军人这种调整是必要的，以针对特别是 这对这群退伍军人是不利的。例如，PTSD患者的气道正压通气较低， 治疗（PAP）的依从性高于那些没有PTSD的人，这是重要的，因为增加PAP的依从性 不仅与减少噩梦有关，而且与改善PTSD症状有关。此外，本发明还提供了一种方法， 尽管对失眠症的行为治疗已经在PTSD患者中进行了研究，结果很有希望， 已知如何解决合并OSA和失眠，因为OSA患者通常被排除在外， 从失眠症试验中，尽管高水平的合并症。此外，失眠本身与 降低PAP粘附性。目前，还没有综合的方法来治疗退伍军人与这些 合并症，并且现有治疗在不同治疗诊所之间通常不协调 因此可能比所需的时间更长。拟议的项目允许评估一个 在PTSD的背景下，同时解决OSA和失眠的治疗， 为有这些问题的退伍军人提供治疗。 拟议的CDA-2包括一项初步随机对照试验，评价疗效、可行性， 呼吸暂停和呼吸困难缓解（AIR）的可接受性，这是一种行为干预， 心理教育，动机访谈，失眠的认知行为疗法，以及PAP 脱敏。该试验将比较AIR（n = 40）与睡眠教育（对照条件; n = 40）， 患有阻塞性睡眠呼吸暂停综合症、失眠症和创伤后应激障碍的退伍军人。治疗将部分亲自进行（第1-2节）， 部分通过远程医疗（第3-6节），以加强退伍军人的参与和扩大获得护理。功能 结果将是治疗后的生活质量（主要结果）和睡眠相关功能， 月随访（目标1）。我们还将测量失眠和PTSD症状以及PAP的变化 坚持。将使用主观和客观睡眠测量评估失眠症状。目的2 将包括对AIR的可接受性和可行性的多方面评估。退伍军人将完成自我- 报告问卷和后续访谈，以评估对治疗的满意度，无论是在内容方面 和递送方法（即，面对面和远程保健）。我们还将衡量治疗辍学率和出勤率 在第一次PAP后续任命，以评估参与护理。最后，我们将进行一次探索性的 分析治疗结果的调节因素（目标3），如基线睡眠呼吸暂停严重程度或并发 药物使用，以促进对方案的调整或确定替代方案适用的亚群 可以推荐治疗。 拟议的项目可能对越来越多的患有创伤后应激障碍的退伍军人产生很大影响， 睡眠障碍，以及他们的供应商谁缺乏明确的指导方针，如何提供行为治疗 治疗创伤后应激障碍患者的睡眠障碍此外，通过同时治疗这些病症， 改善退伍军人的功能和减少服务利用率。这种干预与 VHA的使命是提供卓越的医疗保健。此外，拟议的干预措施符合 VHA的愿景是提供以患者为中心的循证护理， 在一体化的环境中合作。

Sleep disturbance is the most common symptom among Veterans with posttraumatic stress disorder (PTSD), with prevalence rates of over 90% for insomnia and around 70% for obstructive sleep apnea (OSA). Beyond symptom-driven distress, PTSD, OSA, and insomnia are problematic because of their effects on physical health, functional outcomes, and quality of life. While there are effective treatments available for OSA and insomnia, current treatments for these disorders have not been adapted to the needs of the large number of Veterans experiencing PTSD. This adaptation is necessary to target the problems that are particularly detrimental to this group of Veterans. For example, patients with PTSD have lower positive airway pressure therapy (PAP) adherence than those without PTSD, which is significant because increased adherence to PAP is associated not only with reduced nightmares but also with improved PTSD symptoms overall. In addition, though behavioral treatments for insomnia have been studied in those with PTSD with promising results, little is known about how to address comorbid OSA and insomnia because patients with OSA are typically excluded from insomnia trials in spite of high levels of comorbidity. Moreover, insomnia itself is associated with decreased PAP adherence. Currently, there is no integrated approach to treating Veterans with these comorbidities concurrently, and existing treatment is often not coordinated between different treatment clinics and consequently may be more prolonged than needed. The proposed project allows for the evaluation of a treatment that addresses OSA and insomnia in tandem and within the context of PTSD, which can serve to consolidate treatment for Veterans with these issues. The proposed CDA-2 consists of a pilot randomized controlled trial evaluating the efficacy, feasibility, and acceptability of Apnea and Insomnia Relief (AIR), a behavioral intervention that combines elements of psychoeducation, motivational interviewing, cognitive behavioral therapy for insomnia, and PAP desensitization. The trial will compare AIR (n = 40) with sleep education (control condition; n = 40) among Veterans with OSA, insomnia, and PTSD. Treatment will be administered partially in person (sessions 1-2) and partially via telehealth (sessions 3-6) to enhance Veteran engagement and broaden access to care. Functional outcomes will be quality of life (primary outcome) and sleep-related functioning at post-treatment and three- month follow-up (Aim 1). We will also measure change in insomnia and PTSD symptoms as well as PAP adherence. Insomnia symptoms will be assessed using subjective and objective sleep measurement. Aim 2 will consist of a multifaceted assessment of the acceptability and feasibility of AIR. Veterans will complete self- report questionnaires and a follow-up interview to assess satisfaction with treatment, both in terms of content and method of delivery (i.e., in-person and telehealth). We will also measure treatment dropout and attendance at the first PAP follow-up appointment to evaluate engagement in care. Finally, we will conduct an exploratory analysis of moderators of treatment outcome (Aim 3), such as baseline sleep apnea severity or concurrent medication use, to facilitate adjustments to the protocol or identify subpopulations for whom an alternative treatment may be recommended. The proposed project could be highly impactful for the increasing number of Veterans with PTSD and sleep disturbance, as well as their providers who lack clear guidelines for how to provide behavioral treatment for sleep disorders in patients with PTSD. Moreover, by treating these disorders concurrently, there may be an improvement in Veterans’ functioning and a reduction in service utilization. This intervention is consistent with the VHA mission of providing exceptional healthcare. Additionally, the proposed intervention is in alignment with the VHA vision of providing patient centered and evidence based care delivered by engaged and collaborative teams in an integrated environment.