Comparative meta-analysis of prazosin and imagery rehearsal therapy for nightmare frequency, sleep quality, and posttraumatic stress

Abstract

Study objective: In this meta-analysis, we compare the short-term efficacy of prazosin vs. IRT on nightmares, sleep quality, and posttraumatic stress symptoms (PTSS).

Methods: Reference databases were searched for randomized controlled trials using IRT or prazosin for nightmares, sleep disturbance, and/or PTSS. Effect sizes were calculated by subtracting the mean posttest score in the control group from the mean posttest score in the treatment group, and dividing the result by the pooled standard deviation of both groups. Mixed effects models were performed to evaluate effects of treatment characteristics, as well as sample characteristics (veteran vs. civilian) on treatment efficacy.

Results: Four studies used prazosin, 10 used IRT alone or in combination with another psychological treatment, and 1 included a group receiving prazosin and another group receiving IRT. Overall effect sizes of both treatments were of moderate magnitude for nightmare frequency, sleep quality, and PTSS (p < 0.01). Effect size was not significantly different with type of treatment (psychological vs. pharmacological) on nightmare frequency (p = 0.79), sleep quality (p = 0.65), or PTSS, (p = 0.52). IRT combined with CBT for insomnia showed more improvement in sleep quality compared to prazosin (p = 0.03), IRT alone (p = 0.03), or IRT combined with another psychological intervention, (p < 0.01).

Conclusion: Although IRT interventions and prazosin yield comparable acute effects for the treatment of nightmares, adding CBT for insomnia to IRT seems to enhance treatment outcomes pertaining to sleep quality and PTSS. More randomized clinical trials with long-term follow-up are warranted.

Commentary: A commentary on this article appears in this issue on page 9.

Keywords: cognitive behavior therapy; imagery rehearsal therapy; insomnia; nightmares; posttraumatic stress disorder; prazosin.

Figure 1. Flow diagram.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram. RCT, randomized controlled trial; IRT, imagery rehearsal therapy.

Figure 2. Forest plot presenting the posttreatment total effect sizes and 95% confidence intervals (CI) for Prazosin and IRT on nightmares individually and for all studies combined, calculated with random effects model.

(1) = IRT; (2) = IRT+SH+LDT; (3) = IRT+SH; (I) = IRT; (P) = Prazosin; Std diff, standard difference. For numbers, commas are used as decimal separators.

Figure 3. Forest plot presenting the posttreatment total effect sizes and 95% confidence intervals (CI) for Prazosin and IRT on sleep quality individually and for all studies combined, calculated with random effects model.

(1) = IRT; (2) = IRT+SH+LDT; (3) = IRT+SH; (I) = IRT; (P) = Prazosin; Std diff, standard difference. For numbers, commas are used as decimal separators.

Figure 4. Forest plot presenting the posttreatment total effect sizes and 95% confidence intervals (CI) for Prazosin and IRT on posttraumatic stress symptoms (PTSS) individually and for all studies combined, calculated with random effects model.

(1) = IRT; (2) = IRT+SH+LDT; (3) = IRT+SH; (I) = IRT; (P) = Prazosin; Std diff, standard difference. For numbers, commas are used as decimal separators.