Drug treatment strategies for insomnia in patients with post-traumatic stress disorder

ABSTRACT

Introduction: Insomnia is among the most reported sleep disturbances in patients with post-traumatic stress disorder (PTSD). The pervasiveness of this disorder among trauma-inflicted civilians and military personnel has been associated with reduced quality of life, impaired psychosocial functioning including cognitive impairments, negative mood swings, cardiovascular complications, and increased utilization of medical services.

Areas covered: This review describes the current state of science with respect to the impact of the most dispensed pharmacological interventions for posttraumatic insomnia. At the present, there are no established treatment algorithms for PTSD-related insomnia. Pharmacotherapy offers an alternative treatment modality for patients with PTSD who fail or decline cognitive behavioral therapy (CBT). Selection of a hypnotic/sedative agent should be based on the patient’s history, precipitating and perpetuating factors of insomnia, side effect profile, and potential medication-related interactions. Antipsychotics and benzodiazepines appear ineffective or are associated with significant harm in treating PTSD-related insomnia.

Expert opinion: In the absence of randomized controlled trials, prescription patterns have been guided by anecdotal reports and expert opinion. Due to the complexity and multifactorial etiology of insomnia in PTSD, clinical investigations should examine available pharmacologic agents in comparative trials or in combination with CBT or complementary therapies to assess both short-term and long-term sleep outcomes in this population.

KEYWORDS:

• Insomnia
• post-traumatic stress disorder
• pharmacotherapy
• hypnotics
• antidepressants
• orexin antagonists
• cannabinoids

Article highlights

• Insomnia complicates the course and treatment of PTSD and may be also the precursor of subsequent PTSD development.

• Although cognitive behavioral therapy is considered first-line therapy for PTSD-related insomnia, pharmacological intervention is warranted when patients are treatment-refractory or when patients are not adherent with non-pharmacological measures.

• Benzodiazepines, although often prescribed for sleep disturbances, are not recommended to be used in the treatment of PTSD patients with insomnia because the potential risks of these agents outweigh the benefits.

• Much of the literature surrounding the use of antidepressants, atypical antipsychotics, or melatonin derivatives is conflicting or inconclusive because most of the existing studies are uncontrolled, lack appropriate follow-up, or does not use validated assessment tools for insomnia.

• Newer pharmaceutical agents with novel mechanisms of action such as orexin antagonists or endocannabinoid receptor agonist may offer acceptable alternatives for the treatment of PTSD-related insomnia, but their efficacy is yet to be established in RCTs.

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Acknowledgments

The views expressed in this manuscript do not communicate an official position of the Department of Veterans Affairs.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

The authors declare grant funding from the Department of Veteran Affairs of the Clinical Service Research and Development (CX001656).