Addressing Sleep Impairment in Treatment Guidelines for PTSD

To the Editor: We reviewed Dr. Germain’s article (1) in the April issue with much interest. We would like to kindly correct Dr. Germain’s statement that no treatment guidelines have proposed that the initial treatment for posttraumatic stress disorder (PTSD) should focus on sleep impairment. The PTSD algorithm of the Psychopharmacology Algorithm Project at the Harvard South Shore Program (2), published in 2011, provides treatment guidelines that support exactly the idea that sleep evaluation and treatment should be the first step in assessing and treating PTSD. Notably, the first reference in the Psychopharmacology Algorithm Project article is to previous research by Dr. Germain and colleagues (3).

From a psychopharmacological perspective, the availability of prazosin (4), which has demonstrated a much larger effect size than the selective serotonin reuptake inhibitors (SSRIs), a greater tolerability profile, and a shorter time to response, makes this approach possible. Many experts continue to promote SSRIs as a first-line treatment for this disorder, but the evidence—despite U.S. Food and Drug Administration approval of two SSRIs—remains not at all impressive (5, 6). SSRIs have a small effect size in ameliorating the range of PTSD symptoms, and they frequently exacerbate insomnia and nightmares. Furthermore, they often produce disabling sexual side effects.

For many patients, sleep fragmentation may exacerbate daytime PTSD symptoms (hypervigilance, avoidance, and reexperiencing), and these symptoms may improve when sleep improves (7). The importance of sleep in regulating trauma-related memories and emotions has significant clinical implications, suggesting that prioritized interventions to correct sleep disturbances may facilitate the psychotherapeutic processing of traumatic events.