REVIEW OF: Lappas AS et al, Sleep Med 2024;119:467–479

STUDY TYPE: Network meta-analysis

National studies report the prevalence of sleep disturbances in individuals with PTSD at greater than 90%. These debilitating symptoms independently affect treatment and quality of life. But what are the current best evidence-based treatment options for sleep disturbances in PTSD? 

In this paper, researchers performed a network meta-analysis, synthesizing evidence from 99 RCTs with a total of 10,481 participants. They compared the efficacy and safety of various pharmacological treatments for sleep-related symptoms in PTSD. Primary outcomes were total sleep time (TST), nightmares, and sleep quality. Secondary outcomes included sleep onset latency and treatment-emergent adverse effects like somnolence, vivid dreams, and insomnia. 

Prazosin significantly improved subjective TST compared to placebo, by 79.8 minutes on average (SMD = -0.88, 95% CI = [-1.22, -0.54]). It also reduced nightmares (SMD = -0.44, 95% CI = [-0.84, -0.04]) and poor sleep quality (SMD = -0.55, 95% CI = [-1.01, -0.10]). Hydroxyzine also had some modest benefits for TST compared to placebo, increasing it by 37.2 minutes on average (SMD -0.41, 95% CI = [-0.81, -0.03]). Trazodone, MDMA-assisted psychotherapy, olanzapine, paroxetine, topiramate, and nabilone were promising but did not show significant differences from placebo. Likewise, evidence regarding SSRIs, z-drugs, benzodiazepines, and mirtazapine for sleep in PTSD was scarce and indicated no significant benefit over placebo. Antipsychotics (primarily risperidone and quetiapine) were linked to significant ­treatment-emergent somnolence without clear therapeutic advantages.

CARLAT TAKE
In this meta-analysis, prazosin was the best pharmacological treatment for PTSD-related sleep issues, particularly nightmares. Unfortunately, other common treatment options such as SSRIs and benzodiazepines lacked strong evidence for efficacy, and benzodiazepines are known to carry the risk of worsening PTSD symptoms. For patients with little or no response to prazosin, consider hydroxyzine or trazodone. Use caution with antipsychotics, unless otherwise clearly indicated, due to risks of adverse effects. Continue to encourage adjunctive psychotherapy to maximize outcomes.