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: 10020798
• 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/10020798
• 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; actigraphy; alternative treatment; base; career; collaborative approach; common symptom; comorbidity; comparison intervention; desensitization; effective therapy; evidence base; experience; follow up assessment; follow-up; functional disability; functional outcomes; improved; innovation; motivational enhancement therapy; patient oriented; physical conditioning; post-traumatic symptoms; pressure; primary outcome; programs; psychoeducation; rehabilitation research; research and development; response; satisfaction; secondary outcome; service utilization; 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.

睡眠障碍是创伤后应激障碍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）约为70％。 除了症状驱动的困扰，PTSD，OSA和失眠是有问题的，因为它们对 身体健康，功能结果和生活质量。虽然有有效的OSA治疗 和失眠，目前对这些疾病的治疗尚未适应大量的需求 经历PTSD的退伍军人。这种适应是针对特别针对的问题所必需的 对这群退伍军人有害。例如，PTSD患者的气道压力较低 与没有PTSD的治疗（PAP）依从性相比，这很重要，因为增加了对PAP的依从性 不仅与噩梦减少有关，而且与PTSD症状的改善有关。此外， 尽管失眠的行为治疗已经在患有PTSD的患者中研究了，但很少 知道如何解决合并症OSA和失眠，因为OSA患者通常被排除 尽管合并症很高，但从失眠试验中进行。而且，失眠本身与 PAP依从性降低。目前，没有综合方法来治疗退伍军人 合并症同时进行，现有治疗通常不协调 因此，可能比所需的要长。拟议的项目允许评估 解决串联和PTSD背景下的OSA和失眠的治疗 通过这些问题巩固对退伍军人的治疗。 提出的CDA-2由一个试验随机对照试验组成，该试验评估了效率，可行性， 以及呼吸暂停和失眠的可接受性（空气），一种行为干预措施，结合了元素 心理教育，动机访谈，失眠的认知行为疗法和PAP 脱敏。试验将将空气（n = 40）与睡眠教育（控制条件; n = 40）进行比较 有OSA，失眠和PTSD的退伍军人。治疗将以亲自管理（会议1-2）和 部分通过远程医疗（第3-6节）来增强退伍军人的参与度并扩大获得护理的机会。功能 结局将是生活质量（主要结果）和与睡眠相关的功能，在治疗后和三个 一个月随访（AIM 1）。我们还将衡量失眠和PTSD症状以及PAP的变化 坚持。失眠符号将使用主观和客观的睡眠测量评估。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 报告问卷调查和后续访谈，以评估对治疗的满意度 和交付方法（即面对面和远程医疗）。我们还将测量治疗辍学和出勤 在第一个PAP后续约会中，以评估参与护理。最后，我们将进行探索 分析治疗结果的主持人（AIM 3），例如基线睡眠呼吸暂停或并发 使用药物，以方便调整协议或确定替代方案的亚群 可以建议治疗。 拟议的项目可能对使用PTSD和PTSD的退伍军人和 睡眠障碍以及他们缺乏如何提供行为治疗准则的提供者 用于PTSD患者的睡眠障碍。而且，通过同时治疗这些疾病，可能会有一个 退伍军人功能的改善和服务利用率的降低。这种干预与 VHA的任务是提供卓越的医疗保健。此外，提议的干预措施是对齐的 具有VHA的愿景，即通过参与和 在集成环境中的协作团队。