Diagnosis and Treatment of Sleep Apnea in Women Veterans

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Sleep disordered breathing (SDB) is associated with significant adverse health consequences including cardiovascular disease, motor vehicle accidents, daytime functional impairments and mortality risk. Although SDB is more common among men than women, it still impacts 17% of women in the general population. [Our preliminary evidence suggests it is even more common among women Veterans who receive VA care.] The recommended first-line therapy for most patients with SDB is positive airway pressure therapy (PAP). Published studies show that women have lower PAP adherence than men, particularly in the US, yet we are not aware of data comparing men and women Veterans. Because women Veterans experience significant sleep disturbance and other consequences of sleep disorders, adjusting to PAP therapy may be quite difficult. To date, studies have not tested interventions specifically designed to improve PAP adherence among women, accounting for important sleep-related and social factors. Since 2010 we have been studying sleep disorders among women Veterans, initially focusing on insomnia disorder. Through this work we discovered that a significant segment of women served by VA also are high risk for sleep disordered breathing (SDB; also referred to as sleep apnea), particularly if they report poor sleep. In treating insomnia, we found that the initial discomfort created by traditional cognitive-behavioral therapy for insomnia (e.g. initial sleep restriction) is difficult for many women Veterans to tolerate. We developed and are now testing an insomnia intervention based on Acceptance and Commitment Therapy (ACT), called “Acceptance and the Behavioral Changes to Treat Insomnia” or “ABC-I”. Within ACT, treatment focuses on a patient's values and reasons for implementing behavioral changes, and teaches the patient strategies for tolerating temporary discomfort in pursuit of goals consistent with one's values. We now propose to use these same therapeutic approach, adopted from ACT, to address unique challenges faced by women Veterans in adjusting to PAP therapy. This study is a randomized controlled trial (RCT) to test the efficacy of a program combining patient education with ACT-based techniques in improving adherence to PAP therapy, called “ABC-SA” or “Acceptance and the Behavioral Changes to treat Sleep Apnea.” This 6-session intervention will address initial discomfort, link treatment to the patient’s values and incorporate methods for accepting the changes that are required to treat SDB. Main study outcomes will be assessed 3 months after PAP initiation, and PAP adherence will be tracked remotely for 12 months. The 6-session “control” intervention will account for the contact with a study interventionist and will be modeled after usual care. The objectives of this proposal are: (1) to test the efficacy of the ABC-SA program in improving PAP adherence, compared to a control program modeled after usual care, for women Veterans with SDB; (2) to test the efficacy the ABC-SA program for improving objectively-measured and patient-reported sleep quality, compared to the control program; and (3), to test the efficacy the ABC-SA program for improving quality of life and symptoms of depression, compared to the control program. Data will be analyzed using “intention to treat” principles, using appropriate statistical methods for clinical trials.