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Research Questions

  1. What are the effects of interventions in PTSD on sleep outcomes, PTSD symptoms, and adverse events?
  2. Do the effects differ by type of intervention (e.g., those specifically aimed at improving sleep)?
  3. Do the effects differ by trauma type?
  4. Do the effects differ by treatment setting and modality?

Posttraumatic stress disorder (PTSD) is a condition that can emerge after exposure to a traumatic event. It involves several symptoms, including distressing memories or dreams and/or dissociative reactions; psychological distress at exposure to trauma cues; physiologic reactions to cues; avoidance of stimuli associated with the event; negative alterations in cognitions and mood associated with the trauma; and alterations in arousal and reactivity, including sleep disturbance. The purpose of this systematic review is to synthesize the evidence from randomized controlled trials on the effects that interventions for adults with PTSD have on sleep outcomes.

The authors searched research databases and bibliographies of existing systematic reviews to identify pertinent trials published in English; literature was identified by the searches using predetermined eligibility criteria. The primary outcome domain included sleep quality, insomnia, and nightmares. Secondary outcomes were PTSD symptoms and adverse events. Risk of bias and the quality of evidence were assessed for each outcome. The identified interventions addressed pharmacological, psychological, behavioral, complementary, and integrative medicine treatments aimed at improving sleep or lessening other PTSD symptoms.

Interventions in general showed an effect on sleep. Interventions explicitly targeting sleep—particularly psychotherapy targeting sleep—showed larger effects on sleep than did interventions not targeting sleep. Heterogeneity was considerable, but sleep effect estimates were not systematically affected by trauma type, setting, or modality. Comparative effectiveness studies are needed to support the findings.

Key Findings

  • There were positive effects on sleep across all interventions, including those that did not specifically address sleep.
  • Across interventions, there was a medium effect on PTSD symptoms.
  • Reported treatment effects were statistically significantly larger in studies that specifically targeted sleep—particularly sleep-focused psychotherapy—than in interventions aimed at treating PTSD without an explicit sleep focus.
  • Differentiating between military and nonmilitary trauma origins did not reveal systematic differences in treatment effects.
  • Across, studies, differentiating specialty care from primary care interventions did not indicate statistically significant differences in outcomes.
  • Treatment results did not differ by setting, such as inpatient versus outpatient treatment or treatment in specialty versus primary care.

Recommendations

  • Because sleep disturbances are often considered less stigmatizing than mental health symptoms and many treatments for PTSD are poorly tolerated, prioritizing sleep treatment might foster treatment compliance and improve the therapeutic alliance—that is, treating sleep problems could serve as a gateway to successful treatment for other comorbidities, including PTSD.
  • Healthy sleep is vital for mental and physical health, operational readiness, and performance, and untreated sleep problems can predict the onset and exacerbation of mental health symptoms, including PTSD; clinicians and policymakers should consider treating sleep disturbances as a critical factor in the armament of strategies to reduce the public health burden of PTSD.
  • Though PTSD treatments can be effective for sleep outcomes, patient needs and preferences should be taken into account; certain patients might feel most comfortable with treatments directly addressing their sleep symptoms, particularly if these symptoms are the most distressing or causing the greatest issues in ability to function.
  • More comparative effectiveness studies are needed to confirm systematic differences between intervention approaches.

This research was sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).

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