Improving Sleep and Functioning in Veterans with Posttraumatic Stress Disorder

改善患有创伤后应激障碍的退伍军人的睡眠和功能

• 批准号: 10508495
• 负责人: lizabeth goldstein
• 金额: --
• 依托单位: VETERANS AFFAIRS MED CTR SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-10-01 至 2024-09-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10508495
• 关键词: Address; Adherence; Aftercare; Agreement; Apnea; Applications Grants; Appointment; Area; Behavior Therapy; Behavioral; Caring; Clinic; Cognitive Therapy; Data; Devices; Diagnosis; Disease; Distress; Dropout; Education; Elements; Environment; Evaluation; Feedback; Goals; Grant Review; Guidelines; Health; Health Services Accessibility; Healthcare; Healthcare Systems; Improve Access; Intervention; Interview; Knowledge; Measures; Mental Health; Methods; Mission; Monitor; Nightmare; Obstructive Sleep Apnea; Outcome; Participant; Patient Self-Report; Patients; Persons; Pharmaceutical Preparations; Polysomnography; Post-Traumatic Stress Disorders; Prevalence; Protocols documentation; Provider; Quality of Care; Quality of life; Questionnaires; Randomized Controlled Trials; Reporting; Research; Severities; Sleep; Sleep Apnea Syndromes; Sleep Disorders; Sleep disturbances; Sleeplessness; Symptoms; Techniques; Trauma; Treatment outcome; Veterans; Vision; acceptability and feasibility; actigraphy; alternative treatment; base; career; collaborative approach; common symptom; comorbidity; comparison intervention; desensitization; effective therapy; efficacy evaluation; evidence base; experience; follow up assessment; follow-up; functional disability; functional outcomes; improved; innovation; motivational enhancement therapy; patient oriented; physical conditioning; positive airway pressure; post-traumatic symptoms; primary outcome; programs; psychoeducation; rehabilitation research; research and development; response; satisfaction; secondary outcome; service utilization; sleep difficulty; telehealth; therapy adherence; trend; trial comparing

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.

睡眠障碍是患有创伤后应激障碍的退伍军人中最常见的症状 (PTSD)，失眠症的患病率超过 90%，阻塞性睡眠呼吸暂停 (OSA) 的患病率约为 70%。 除了症状驱动的痛苦之外，创伤后应激障碍 (PTSD)、阻塞性睡眠呼吸暂停 (OSA) 和失眠也存在问题，因为它们会影响 身体健康、功能结果和生活质量。虽然 OSA 有有效的治疗方法 和失眠，目前对这些疾病的治疗方法尚未适应大量患者的需求 患有创伤后应激障碍 (PTSD) 的退伍军人。这种调整对于解决特别突出的问题是必要的。 对这群退伍军人来说是不利的。例如，患有 PTSD 的患者气道正压较低 治疗 (PAP) 依从性高于没有 PTSD 的人，这一点很重要，因为对 PAP 的依从性增加 不仅与减少噩梦有关，而且与总体上改善 PTSD 症状有关。此外， 尽管针对创伤后应激障碍 (PTSD) 患者的失眠行为治疗研究取得了可喜的结果，但很少有 了解如何解决 OSA 和失眠共病，因为 OSA 患者通常被排除在外 尽管合并症水平很高，但仍来自失眠试验。此外，失眠本身也与 PAP 依从性下降。目前，还没有综合方法来治疗退伍军人的这些疾病 合并症同时存在，并且不同治疗诊所之间的现有治疗往往不协调 因此可能会比需要的时间更长。拟议的项目允许评估 在 PTSD 背景下同时解决 OSA 和失眠问题的治疗方法，可有助于 巩固对有这些问题的退伍军人的治疗。 拟议的 CDA-2 包括一项试点随机对照试验，评估有效性、可行性、 呼吸暂停和失眠缓解 (AIR) 的可接受性和可接受性，这是一种结合了以下要素的行为干预措施 心理教育、动机访谈、失眠认知行为疗法和 PAP 脱敏。该试验将 AIR (n = 40) 与睡眠教育（对照条件；n = 40）进行比较 患有 OSA、失眠和创伤后应激障碍 (PTSD) 的退伍军人。部分治疗将亲自进行（第 1-2 节），并且 部分通过远程医疗（第 3-6 场）来提高退伍军人的参与度并扩大获得护理的机会。功能性 结果将是治疗后的生活质量（主要结果）和睡眠相关功能，以及三个- 一个月的随访（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来评估失眠症状。目标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 报告调查问卷和后续访谈，以评估对治疗的满意度，包括内容 和交付方式（即现场和远程医疗）。我们还将衡量治疗退出率和出勤率 在第一次 PAP 随访预约时评估护理参与度。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），例如基线睡眠呼吸暂停严重程度或并发情况 药物使用，以促进方案的调整或确定替代方案的亚人群 可能会建议治疗。 拟议的项目可能会对越来越多患有创伤后应激障碍 (PTSD) 的退伍军人产生巨大影响 睡眠障碍，以及缺乏如何提供行为治疗的明确指南的提供者 用于治疗 PTSD 患者的睡眠障碍。此外，通过同时治疗这些疾病，可能会 改善退伍军人的功能并减少服务利用率。这种干预符合 VHA 的使命是提供卓越的医疗保健。此外，拟议的干预措施是一致的 VHA 的愿景是提供以患者为中心和基于证据的护理，由积极参与和 集成环境中的协作团队。