Psychotherapeutic and pharmacological agents for post-traumatic stress disorder with sleep disorder: network meta-analysis

Abstract

Objective: The current guidelines and canonical norms of diagnosis or treatment for Post-traumatic stress disorder (PTSD) with sleep disorder are still conflicting and have not yet reached a consensus. This study aimed to unravel the most effective countermeasures between two categories (psychotherapy and pharmacotherapy) put forward by the National Institute for Health and Clinical Excellence (NICE) and World Federation of Societies of Biological Psychiatry (WFSBP) respectively to treat PTSD individuals co-exist with sleep disorders.

Methods: Four databases, including PubMed, EMBASE, Cochrane Library, and APA PsyNet, were searched from inception to February 02, 2023.

Results: Twenty articles with 24 Randomized controlled trials (RCTs) and a total number of 1,647 participants were included. As demonstrated in the network meta-analysis comparison results, CBT-I (standardized mean differences (SMD) = -1.51,95% confidence interval (CI):-2.55 to -0.47), CBT-I plus IRT (SMD = -1.71, 95%CI:-3.39, -0.03), prazosin (SMD = -0.87,95%CI:-1.59 to -0.16) and hydroxyzine (SMD = -1.06, 95%CI: -1.94 to -0.19) significantly reduced PTSD symptoms compared with placebo. In contrast to placebo, CBT-I (SMD = -5.61,95%CI:-8.82 to -2.40) significantly improved sleep quality. For nightmare severity, IRT (SMD =-0.65, 95%CI:-1.00 to -0.31), prazosin (SMD = -1.20,95%CI:-1.72 to -0.67) and hydroxyzine (SMD = -0.98,95%CI:-1.58 to -0.37) significantly reduced nightmare severity in comparison with placebo.

Conclusions: This study suggested that under most circumstances, psychotherapy namely CBT-I had a favorable profile, but pharmacotherapy with prazosin was effective in managing nightmare severity. The sole avail of CBT-I was recommended to improving sleep quality while CBT-I and CBT-I plus IRT showed excellent management of PTSD symptom severity. Exposure to CBT-I isrecommended for depression. The relevant clinical guidelines for the management of individuals with PTSD and sleep disorders may regard this as a reference.

Prospero: CRD42023415240.

Keywords: Post-traumatic stress disorder; cognitive behavioral therapy for insomnia; pharmacotherapy; prazosin; psychotherapy; sleep disorders.

Figure 1.

The evidence network of all outcomes. Note: Panel (A) PTSD symptom severity; Panel (B) depression; Panel (C) sleep quality; Panel (D) nightmare severity; Panel (E) total sleep time and Panel (F) acceptability. Figure geometry explained as the size of the node corresponds to the number of trials that investigated the treatments. Directly comparable treatments were linked with a line, and the thickness of the line corresponded to the sum of the number of studies in each pairwise treatment comparison. IRT: Imagery Rehearsal Therapy, CBT-I: Cognitive-Behavioral Therapy for Insomnia.

Figure 2.

Rank − sheat plot based on SUCRA. Note: Each sector is colored according to the SUCRA value for the corresponding treatment and outcome. The scale consists of the transformation of three colors red (0%), yellow (50%), and green (100%). Each color is associated with a different pattern. Uncolored sectors show that the underlying treatment was not included in the network meta-analysis for a particular outcome. SUCRA: Surface under cumulative ranking. SUCRA is a numeric representation of the overall ranking and presents a single number associated with each treatment. SUCRA values ranged from 0 to 100%. The higher the SUCRA value, and the closer to 100%, the higher the likelihood that a therapy is in the top rank or one of the top ranks; the closer to 0 the SUCRA vaslue, the more likely that a therapy is in the bottom rank or one of the bottom ranks.