Improving Sleep and Functioning in Veterans with Posttraumatic Stress Disorder

睡眠障碍是患有创伤后应激障碍的退伍军人最常见的症状 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%。 除了症状驱动的痛苦之外，创伤后应激障碍、阻塞性睡眠呼吸暂停和失眠也是有问题的，因为它们对 身体健康、功能结果和生活质量。虽然有治疗阻塞性睡眠呼吸暂停综合症的有效方法 和失眠，目前对这些疾病的治疗还不能适应大量患者的需要 经历创伤后应激障碍的退伍军人。这一适应是必要的，以针对特别是 对这群退伍军人不利。例如，创伤后应激障碍患者的气道正压较低 治疗(PAP)的依从性比没有创伤后应激障碍的人更高，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，而且与整体创伤后应激障碍症状的改善有关。此外, 尽管行为疗法在创伤后应激障碍患者中的研究取得了令人振奋的结果，但几乎没有 知道如何解决OSA和失眠的并存问题，因为OSA患者通常被排除在外 来自失眠试验，尽管共病水平很高。此外，失眠本身与 降低了PAP的粘附性。目前，还没有综合的方法来治疗退伍军人 同时并存，不同治疗诊所之间的现有治疗往往不协调 因此可能比所需的时间更长。拟议的项目允许对一项 在创伤后应激障碍的背景下同时解决阻塞性睡眠呼吸暂停综合症和失眠的治疗，这可以起到以下作用 加强对有这些问题的退伍军人的治疗。 建议的CDA-2由一项试验性随机对照试验组成，评估其疗效、可行性、 和可接受的呼吸暂停和失眠缓解(AIR)，这是一种行为干预，结合了 心理教育、动机访谈、失眠认知行为疗法和PAP 脱敏。这项试验将空气(n=40)与睡眠教育(控制条件；n=40)进行比较 患有阻塞性睡眠呼吸暂停综合症、失眠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期)和 部分通过远程保健(会议3-6)，以加强退伍军人的参与度和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)和与睡眠相关的功能，以及三 1个月随访(目标1)。我们还将测量失眠和创伤后应激障碍症状以及PAP的变化 坚持不懈。失眠症状将通过主观和客观的睡眠测量进行评估。目标2 将包括对空气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，两者的内容都是 和交付方法(即面对面和远程健康)。我们还将测量治疗辍学率和出勤率。 在第一次PAP后续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)，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的亚群 可以推荐进行治疗。 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和 睡眠障碍，以及他们的提供者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，通过同时治疗这些疾病，可能会有一种 退伍军人功能的改善和服务利用率的降低。这一干预措施符合 VHA的使命是提供卓越的医疗保健。此外，拟议的干预措施也是一致的 VHA的愿景是提供以患者为中心的循证护理，由敬业和 集成环境中的协作团队。

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.