Sleep Apnea Elevated in Veterans with PTSD

By Crystal Phend, Senior Staff Writer, MedPage Today VANCOUVER — Combat veterans with post-traumatic stress disorder (PTSD) almost universally suffer sleep problems — with more cases of sleep apnea than might otherwise be expected — U.S. Army researchers found. In a group of 135 young, otherwise healthy combat veterans with PTSD, 98.5% reported sleep complaints, Nick Orr, MD, and colleagues at the Walter Reed Army Medical Center in Washington, D.C., reported here at the annual international scientific meeting of the American College of Chest Physicians (CHEST). Despite their relatively young age (around 35) and slightly overweight physique, 54% of the PTSD patients who underwent polysomnography at Walter Reed were diagnosed with obstructive sleep apnea (OSA) — whereas, in the general population, the rate of OSA is only 20%. It can be all too easy to dismiss daytime sleepiness and other symptoms as part of depression and PTSD, Orr explained. But these results argue for screening all military PTSD patients for sleep apnea, Orr said in an interview. “You’ll be darned if you just keep treating it with medications, cognitive behavioral therapy, and all the other modalities you use for PTSD, when you haven’t addressed possible sleep apnea, which could get restorative sleep and kind of break the cycle for the PTSD symptoms,” he told MedPage Today. Session co-moderator Andreea L. Antonescu-Turcu, MD, of the Medical College of Wisconsin and chief of pulmonology at the Zablocki VA Medical Center, both located in Milwaukee, agreed that the study results should justify the importance of screening for sleep problems in military patients with PTSD — even when they don’t fit the classical profile for OSA. “As the data are coming out it probably should be part of their routine evaluations to screen for sleep disordered breathing,” she told MedPage Today. “Maybe this is part of their disorder that we have to address early on in patients with PTSD.” The reason for the well-recognized sleep problems in PTSD isn’t clear, but recent reports have argued that these symptoms should be considered a central feature of the disorder and not just a consequence of it, Orr noted. His group retrospectively analyzed electronic medical records for all 135 service members (91.9% men, average age 35.3) with combat-related PTSD seen at the Walter Reed sleep clinic from March 2006 through April 2010. Orr noted that these returning soldiers were assigned to the Warrior Transition Brigades, which were asked to refer PTSD cases with with traumatic brain injury to the sleep clinic. Not surprisingly, the majority of veterans in the current study had been injured (80 of the 135) and about 70% were traumatic brain injuries, primarily mild concussions from blast incidents. The average body mass index (BMI) was 28.91 — putting most of the patients in the overweight but not obese category. Comorbid psychiatric illness was nearly universal with PTSD in the study patients; 88.9% suffered from depression and 44.4% were diagnosed with anxiety. Sleep complaints among the study patients included excessive daytime somnolence in 88.2% — confirmed by an average Epworth Sleepiness Scale score in the “sleepy” range (10.7) — as well as sleep fragmentation in 67.4% and difficulty falling asleep in 55.6%. Polysomnography done in 80.7% of the study patients diagnosed insomnia in 55% and OSA in 54%. Those patients with OSA were generally older, had a higher BMI, and were less likely to have suffered trauma or a traumatic brain injury compared with those who did not have sleep apnea (all P?0.001). Orr’s group cautioned that they were unable to determine how many of the service members in the study had OSA before being deployed — but the researchers assumed that it was largely preexistent. High medication use, including painkillers and sedatives, might have contributed to the sleep characteristics of these populations, the investigators noted. But Orr pointed out that comorbid depression and use of medication were similar in PTSD patients with and without OSA. Also, “the injured population had less obstructive sleep apnea, so if the narcotics were causing central apneas then why was it the opposite?” he asked. The study was limited to service members returning from combat situations. But in terms of generalizability, Orr noted that sleep disordered breathing was almost universal in a prior study of female sexual assault victims and in another study conducted among crime victims with sleep problems — most of whom also had PTSD. One problem with finding sleep apnea in this fairly young PTSD population was that compliance with treatment — continuous positive airway pressure (CPAP) — is a problem, cautioned co-author Jacob Collen, MD, also of Walter Reed. Whether CPAP — if adhered to — can actually reverse some of the symptoms of PTSD still remains to be seen, he said in an interview with MedPage Today.

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