PTSD Treatment Algorithm Suggests First Targeting Sleep Problems

When it comes to alleviating symptoms of posttraumatic stress disorder (PTSD), physicians should prioritize treating patients’ sleep problems, said members of the Harvard South Shore Psychopharmacology Algorithms Project at this year’s Annual Meeting.

“PTSD is intimately associated with sleep disturbances,” said David Osser, M.D., an associate professor of psychiatry at Harvard Medical School. He noted that about 90% of people with PTSD have some co-occurring sleep problems, frequently involving disturbed sleep due to nightmares or night terrors.

Osser is the general editor of the Algorithms Project, an effort to speed the adoption of evidence-based pharmacotherapy into routine patient care. Osser and his team periodically conduct systematic reviews of the available evidence on the safety and efficacy of medications used for specific conditions. The most recent PTSD psychopharmacology algorithm developed by Osser and colleagues was finalized in 2021 and replaces an algorithm that was developed in 2011.

After screening patients thoroughly for such problems as sleep apnea or a TBI-related sleep problems, physicians should consider starting patients on the antihypertensive medication prazosin, said Laura Bajor, D.O., a psychiatrist with the James A. Haley Veterans' Hospital in Tampa and lead editor of the updated PTSD psychopharmacology algorithm.

While a trial of 300 veterans published in 2018 did not find prazosin to be more effective than placebo in reducing nightmares and increasing the quality of sleep (“Study Raises Questions About Effectiveness of Prazosin for PTSD-Related Sleep Disorders”), several smaller trials have found the drug to be effective for some patients, Bajor said. Studies suggest that people with elevated blood pressure are more likely to respond to prazosin, while those who drink alcohol or have suicidal thoughts are less likely, she said.

Doses of prazosin may need to be as high as 20 mg/night for males and 10/mg per night for females to be effective, she continued. The updated algorithm includes a 36-day titration guideline to reach these levels from the initial dose of 1 mg per night. Patients should be monitored closely during the first month to keep track of emergent side effects including dizziness, fatigue, or chest pain.

If prazosin does not work or is not available, physicians can consider the related hypertensive doxazosin for patients with PTSD who are experiencing nightmares. Though not as effective at crossing the blood-brain barrier as prazosin, Osser said some physicians favor doxazosin since it has a more gradual onset of action, which reduces the risk of severe hypotension following ingestion. Doxazosin also has a longer half-life (17 hours) compared with prazosin (5 hours), which means a dose taken at night might still have some effects the following day and possibly reduce daytime stress.

If a patient presents with insomnia but no nightmare disorder or continues to experience insomnia symptoms following the resolution of nightmare symptoms, physicians should consider trazodone or hydroxyzine to help patients fall asleep, Bojar said. She recommended against prescribing tricyclic antidepressants, benzodiazepines, or quetiapine for sleep problems due to their side-effect profiles.

Bajor said that improving sleep should be a priority because it can impact all other aspects of PTSD treatment. “We know that psychotherapies are highly effective,” she said, reiterating that the PTSD algorithm only assists with the selection of medications as part of multimodal treatment plan. “But if your patient is only sleeping two or three hours a night, they are not in the ideal state to benefit from these interventions.”

Reducing a patient’s sleep problems may ameliorate daytime PTSD symptoms including arousal or irritability without the need of further medications, Bajor said. If not, the algorithm recommends prescribing the antidepressants sertraline or paroxetine, which have been approved by the FDA approved for these symptoms).

In cases where a patient with PTSD is experiencing severe psychotic symptoms, both experts recommended these symptoms be treated first with antipsychotics, before addressing sleep issues. The updated algorithm suggests treating such patients with risperidone, as it has the most evidence of benefit in PTSD patients. Another good option is aripiprazole, which may result in fewer side effects for patients. ■