Treatments of Sleep Disturbances in Military Veterans

Transcription

1 Rewriting Nighttime Stories from the House of Hades: Treatments of Sleep Disturbances in Military Veterans Anne Germain, PhD Associate Professor of Psychiatry University of Pittsburgh School of Medicine April 14 th, 2011

2 Disclosure Grant Support: US Department of Defense CDMRP DMRDP National Institutes of Health NIMH NIA NHLBI Consultant Concurrent Technologies Corporation, Inc.

3 Hades: the Unseen God of the underworld (not of death) Stern but just Wearing the Helm of Darkness, destroyed the enemy weapons the night before the war against the Titans Also referred to as the Wealthy, the Rich Hades with Cerberus Hagrid & Fluffy

4 Overview I. Sleep disturbances in military veterans II. Sleep and sleep in military operations /deployment Definition and prevalence of insomnia Definition and prevalence of nightmares Clinical relevance of sleep disturbances III. (Cognitive) behavioral treatments of sleep disturbances For nightmares For insomnia IV. Conclusions

5 Sleep: a fundamental brain function A neurobiological two-state process REM and NREM sleep Regulates psychological (and physical) health; Essential for survival / sustaining homeostasis; Emotion regulation and executive functions Cardiovascular & respiration functions Immune and endocrine functions Tissue repair and growth Can (temporarily) adapt to demands and conditions: Like (mal)nutrition, chronic sleep deficiency will compromise health and performance, and lead to organ (brain) failure.

6 Sleep during deployment Irregular sleep-wake schedule Sleep deprivation Unusual sleep environment Long work hours Shift work Jet lag Environmental disturbances Attacks, sounds, smells, light, temperature > 100F; sand Worry over family at home Combat/trauma exposure

7 Sleep during Military Deployment Peterson et al., Mil Med 2008 N = 156 Air Force members 83 % men, M age: 29.2 years 40% have Sleep Efficiency < 85% 42% have Sleep Latency > 30 minutes 26% have Wake Time After Sleep Onset > 30 minutes 13.5% have Total Sleep Time < 4.5 hours

8 Sleep disturbances in Active Duty Military Personnel Sleep disturbances are the 2 nd common reasons for referral to mental health services in active duty personnel. Bliese et al, UD Army Medical Reports Unit Europe

9 Insomnia in OEF/OIF Returnees McLay et al., Mil Med 2010

10 Insomnia in OEF/OIF Returnees McLay et al., Mil Med month post-deployment PTSD severity based on baseline report of insomnia

11 Sleep disturbances in military Focus on: veterans 1. Nightmares 2. Insomnia

12 General criteria for nightmares International Classification of Sleep Disorders, 2 nd edition, 2005 A. Recurrent episodes of awakenings from (REM) sleep with recall of intensely disturbing dream mentations, usually involving fear or anxiety, but also anger, sadness, disgust, and other dysphoric emotions. B. Full alertness on awakening, with little confusion or disorientation; recall of sleep mentation is immediate and clear. C. At least one of the following associated features is present: Delayed return to sleep after the episodes Occurrence of episodes in the latter half of the habitual sleep period.

13 Prevalence of Nightmares Civilian Population Estimates: 4-8% of the general adult population endorse distressing nightmares Unknown is these are trauma-related or not Nightmares are common: norm is 1/month Military population estimates: 50% to 100% of those with PTSD Prevalent in those with depression / elevated suicidality Unknown in other samples of veterans

14 Nightmares and Insomnia in Vietnam Veterans Neylan et al., Am J Psychiatry, Nightmares p <.0001 PTSD combat veterans n=233 Difficulty falling asleep p <.0001 Difficulty staying asleep p <.001 Other veterans n=411 Non-PTSD combat veterans n=934 Civilians n=385

15 General criteria for insomnia International Classification of Sleep Disorders, 2 nd edition, 2005 A. A complaint of: Difficulty initiating sleep Difficulty maintaining sleep Early morning awakening Non-restorative sleep B. Despite adequate opportunity for sleep (not sleep deprivation) B. At least one daytime impairment: Fatigue, malaise, daytime sleepiness; Attention, concentration, or memory impairment; Social/vocational dysfunction or poor school performance; Mood disturbance/irritability, motivation and energy reduction, concerns about sleep Proneness for errors/accidents at work or while driving; Tension headaches and/or GI symptoms in response to sleep loss

16 Prevalence of Insomnia Civilian Population Estimates: 9-15% of the general (civilian) population have Primary Insomnia. But many more have comorbid Insomnia.

17 Prevalence of DSM-IV insomnias General Population (Ohayon, J Psychiatr Res, 1997) Expert computer system to drive interview assessment Total n= % have insomnia complaint % have insomnia 5 for >1 month with distress or daytime impairment 0 % (n=714)

18 % of subjects Insomnia and mood disorders: Which comes first? Ohayon and Roth, J Psychiatr Res, Insomnia first Concurrent Mood D/O first New onset mood disorder Recurrent mood disorder

19 Insomnia: Primary or Comorbid, but NOT Secondary Primary Insomnia: In the absence of another medical or psychiatric condition Comorbid Insomnia: NIH Consensus Conference 2005: Manifestations and Management of Chronic Insomnia in Adults: Although most cases of insomnia occur in association stress-related anxiety and mood disorders, the limited understanding of mechanistic pathways in chronic insomnia precludes drawing firm conclusions about the nature of these associations or the direction of causality.

20 Prevalence of Insomnia Civilian population estimates: 9-15% of the general civilian population Military population estimates: 62% of Vietnam veterans 6% to 30% of Gulf War veterans Other combat/deployment theaters? ~ 70% OEF/OIF veterans High-risk population

21 Sleep Disturbance in Gulf War Veterans Kroenke et al, J Occup Environ Med Roy et al, Psychosom Med, 1998

22 Sleep Disturbances in OEF/OIF Veterans Wright et al, Mil Med, 2008 Structured Clinical Interview Guide of Post Deployment Psychological Screening: Includes sleep module Based on DSM-IV criteria for primary insomnia N = 367 returnees 9% meet diagnostic criteria for primary insomnia > 70% say they would like help for sleep problems Socially acceptable post-deployment difficulty

23 Mean Score Sleep Quality in Returnees with PTSD vs. Primary Insomniacs & Good Sleepers 15 OEF/OIF PI GS Sleep Quality Nocturnal Behaviors Germain et al., ACBT Convention, 2008

24 Sleep Disturbances in OEF/OIF Veterans Hoge et al, NEJM, 2008 N = 2525 Army Infantry OIF returnees Sleep Disturbances Fatigue Injury with Loss of Consciousness Injury with Altered Mental Status 53.8% 53.2% 44.9% 39.7% Other injury 37.2% 34.6% No Injury 24.1 % 25.2%

25 Clinical relevance of sleep complaints in military personnel

26 Clinical Relevance of Sleep Complaints Subjective sleep complaints and objective sleep disruption following trauma exposure or under chronic stress conditions predict PTSD symptoms. Koren et al., Am J Psychiatry, 2002 Mellman et al., Am J Psychiatry, 2002 Mellman et al., Biol Psychiatry, 2004 Harvey & Bryant, JCCP,1998; 1999 Kauffman & Campbell, unpublished data 2009 Trauma Sleep Disturbances Sleep Preservation or Restoration PTSD Resilience/ Recovery?

27 Odds Ratios Clinical Relevance of Sleep Complaints Sleep disruption is a risk factor for poor psychological outcomes following trauma ** No Psych Hx ( n =324) With Psych Hx (n = 898) ** ** ** ** ** * ** PTSD MDD Substance Any ** p <.001 * p <.05 Bryant et al.,,sleep, 2010

28 Clinical Relevance of Sleep Complaints Sleep disruption is a risk factor of poor psychological outcomes, even without trauma Incidence (%) over 3.5 years * * Insomnia n=240 Depression Anxiety Alcohol Drug No Insomnia n=739 * 95% C.I. for Odds Ratio excludes 1.0 * Breslau, Biol Psychiatry, 1996

29 PSQI global score Clinical Relevance of Sleep Complaints Sleep disturbances are positive related to suicidality and suicidal attempts. Suicidal n = 22 Non-suicidal n = SADS suicide subscale vs. PSQI global score: r = 0.59, p < Ağargün, J Psychiat Res, 1997

30 Clinical Relevance of Sleep Complaints Sleep disturbances interfere with (PTSD) treatment outcomes (remission) =.56 (remission) =.34 Marks et al., Psych Res, 2010

31 Clinical Relevance of Sleep Complaints Hoge et al., NEJM, 2004 Fear of stigma is minimal with sleep disturbances. Army Pre- OIF (n = 2530) Army post- OIF (n = 1962) Army post- OEF (n = 894) Marine Post- OIF (n = 815) PTSD 5.0 % 12.9 % 6.2 % 12.2 % Anxiety 6.4 % 7.9 % 7.4 % 6.6 % Depression 5.3 % 7.9 % 6.9 % 7.1 % Any D/O 9.3 % 17.1 % 11.2 % 15.6 % Alcohol misuse 12.5 % 20.6 % 18.2 % 29.4 %

32 Treatment of Sleep Disturbances for Military Veterans

33 The 3-P model of Insomnia adapted for sleep disturbances in military veterans Spielmann, 1986 Predisposition Factors: e.g.: personality traits, genetics, vulnerable biology Precipitating Factors e.g.: stressor, psychiatric episode, disease Perpetuating Factors e.g.: behaviors, environmental disturbances

34 Factors that maintain nightmares and insomnia after military deployment High levels of vigilance Intrusive memories avoidance Irregular sleep-wake schedule Reduced sense of safety during sleep/at night Shift work Nightmares/bad dreams Social aspects of sleep Family / work tensions Untreated injuries Alcohol misuse Learned behaviors that continue after service Modifiable risk factors of poor health and treatment outcomes?

35 Cognitive Behavioral Treatments for Sleep Disturbances A diverse set of behavioral prescriptions designed to improve the quality of nocturnal sleep Involve some change in the patient s behavior, using voluntary waking behavior to influence physiological controls of sleep-wake regulation Reduce sleep onset latency, nightmares, and nocturnal wakefulness, and increase sleep duration (?), sleep efficiency Regularize sleep timing, dream mentation, increase predictability of sleep and dreaming Can address dysfunctional beliefs and thoughts that contribute to insomnia and nightmares

36 Cognitive-Behavioral Treatments Technique Imagery Rehearsal Therapy (IRT) Stimulus control Sleep restriction Cognitive therapy Relaxation training Chronotherapy Aim Re-script and rehearse new dream scenarios to replace nightmares Strengthen bed/bedroom as sleep stimulus Restrict time in bed to improve sleep depth/consolidation Address maladaptive thoughts and beliefs Reduce physical/psychological arousal Change sleep timing to improve quality

37 CBT For Nightmares IRT Rationale: 1. Nightmares are a learned behavior. Involuntary cognitive behavior 2. With repetition, nightmares become automatic (involuntary) behaviors. 3. Nightmares can be reduced by replacing them with more desirable behavior (dream patterns/scenarios): How? By exercising our dreaming brain when we are awake

38 Notes on IRT It s not thinking; it s mentally imagery/imagining. Need to exercise the imagery parts of our brains to get rid of nightmares. Training occurs at optimal times, when we can do it best During the day, awake, several times per day When conditioned arousal is lower When frontal cortex is online and can control arousal and emotion centers It s more than positive/guided imagery: Self-directed, voluntary control is involved in practice of new dream scenario and reduction of nightmares.

39 Efficacy of IRT in civilians Krakow et al., JAMA 2001 Nights with Nightmares/ week NM / week PSQI Scores PSS Scores (PTSD)

40 IRT In Vietnam Veterans Forbes et al., J Trauma Stress, 2003 Sample N = 12 Vietnam veterans Who completed PTSD treatment program < 6 months. No control group controlled study IRR treatment 6 once-weekly 90-min group sessions Select and write a nightmare in detail, read it to the group, group contributes ideas for changes to the scenario Rehearse version mentally before going to bed nightly + relaxation

41 IRT In Vietnam Veterans Forbes et al., J Trauma Stress, Intake Post-IRR 3 months 12 monts Target NM Freq Target NM Intensity General NM Freq Genral NM Intensity 60% report complete cessation of nightmares at 12 months

42 Controlled RCT of IRT in Vietnam Veterans Cook et al., J Trauma Stress, veterans 53 IRT 58 Control Group format 6 weeks 90-min sessions NM Frequency / week IRT Control Baseline Post 1 month Post 6 months PTSD Severity (CAPS) IRT Sleep Quality (PSQI) IRT Control Baseline Post 1 month Post 6 months Control IRT: focused on worst combat nightmare Baseline Post 1 month

43 IRT in Combat Theater for Acute Nightmares Moore & Krakow, Am J Psych 2007 N = 11 soldiers Trauma exposure < 30 days 4 weekly 1 hour sessions 7 improved, 3 no change, one worse Decreased in NM decreased insomnia and PTSD symptoms H = 1.04 H = 1.37 H = 1.23

44 Efficacy of CBT for insomnia vs. pharmacotherapy Smith, Am J Psychiatry, 2002 Sleep latency (minutes): p<0.01 Wake after sleep onset (minutes) Pharmacotherapy Behavioral Therapy 10 Pharmacotherapy Behavioral Therapy Pretreatment Posttreatment n = 8 pharmacotherapy studies, n = 14 behavioral therapy studies

45 Barriers to dissemination of CBT-I 1. Training & expertise in behavioral sleep medicine are scarce CBT for insomnia is NOT sleep hygiene Active and mindful behavioral changes Motivational interviewing skills are required 2. The format of delivery is not clinic-friendly 6-8 weekly sessions of 45 minutes each Burdensome for patients and clinicians, even in group format Few PhD level clinicians around to do it

46 Brief Behavioral Treatment of Insomnia (BBTI) for military veterans (MH080696; PI: Germain) Developed for primary care & other nonspecialized clinics for older adults (> 60yo) (AG20677; PI: Buysse; Buysse et al., Arch Int Med) 1-session intervention combining stimulus control and sleep restriction + 1 in-person follow up session at week 3 + phone calls on weeks 2 and 4 Rationale based on the 2-process model of sleep regulation

47 2-process model of sleep regulation 1. Sleep Drive Sleep Drive Nap 2. Biological Clock Sleep Drive

48 BBTI: Rules to Sleep Better 1. Reduce your time in bed to match your sleep time + 30 minutes 2. Don t go to bed unless you are sleepy 3. Don t stay in bed unless you are asleep 4. Wake up at the same time every day, no matter how much sleep you got the night before

49 1. Reducing Time in Bed: Current Total Sleep Time + 30 minutes 6.5/10*100 = 65% sleep efficiency Aim is 85% Restrict time in bed to match sleep time 10 pm Average bed time: 8 am Average rise time: 10 hours Total time in bed: 1.5 hour Time to fall asleep: 2 hours Wakefulness during the night: 3.5 hours Total wake time: Average amount of TOTAL SLEEP 6.5 hours (Total time Total wake time):

50 Activities to do when out of bed In the evening: (not too stimulating, boring, calming, reduced light) In the middle of the night: ( safe, low stimulation, boring, calming, reduced light) In the morning: (active, optimize light exposure, stimulating, motivating, pleasant) Be creative! (yet realistic) What would you do?

51 Follow-up Plan: Adjusting time allowed in bed If you ARE sleeping soundly INCREASE time in bed by 15 min. If you are NOT sleeping well DECREASE time in bed by 15 min.

52 Mean Scores Brief Behavioral Treatment of Insomnia Acute Effects of BBTI in OEF/OIF Returnees Germain et al., 2010, unpublished data ISI Pre-BBTI Post-BBTI d = 2.94 d = 1.85 PSQI 75% achieved post-treatment scores below clinical thresholds on both sleep measures, indicative of remission.

53 Mean Scores Brief Behavioral Treatment of Insomnia Acute Effects of BBTI in OEF/OIF Returnees Pre-BBTI Post-BBTI d = 1.5 d =.73 d = 1.19 PTSD Anxiety Depression Germain et al., 2010, unpublished data

54 Acute BBTI Effects: Hot-off the press preliminary findings from RCT Insomnia Severity Overall Sleep Quality Pre Post (4 weeks) Pre Post BBTI INFO BBTI INFO ISI < 7 post-treatment: 13 % INFO 69% BBTI PSQI < 5 post-treatment: 33 % INFO 67 % BBTI

55 Summary 1. Nightmares and insomnia are common sleep disturbances in military veterans. 2. Sleep disturbances contribute to poor clinical outcomes. 3. Sleep disturbances are the norm rather than the exception in (returning) military veterans Culturally acceptable Less stigmatizing entry into post-deployment behavioral care Important to consider as primary evaluation/ treatment targets

56 Summary 4. Sleep disturbances can be effectively treated with cognitive-behavioral treatments. IRT for nightmares Cognitive-behavioral treatment Minimizes exposure to distressing memories May be more beneficial to start with non-replay nightmares in military veterans with chronic PTSD CBT-I or BBTI for insomnia Format depends on resources and time Based on physiological mechanisms of sleep regulation Effective in 80% of patients Consider medications as adjunct when needed

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