Monday, November 1, 2010

Sleep Apnea in PTSD Needs its Own Treatment

"You'll be darned if you just keep treating it with medications, cognitive behavioral therapy, and all the other modalities you use for PTSD, when you haven't addressed possible sleep apnea, which could get restorative sleep and kind of break the cycle for the PTSD symptoms," he told MedPage Today.

Full Article at:
CHEST: Apnea Elevated in Vets With PTSD


By Crystal Phend , Senior Staff Writer, MedPage Today
Published: October 31, 2010
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

VANCOUVER -- "Combat veterans with post-traumatic stress disorder (PTSD) almost universally suffer sleep problems -- with more cases of sleep apnea than might otherwise be expected -- U.S. Army researchers found.

In a group of 135 young, otherwise healthy combat veterans with PTSD, 98.5% reported sleep complaints, Nick Orr, MD, and colleagues at the Walter Reed Army Medical Center in Washington, D.C., reported here at the annual international scientific meeting of the American College of Chest Physicians (CHEST).

Despite their relatively young age (around 35) and slightly overweight physique, 54% of the PTSD patients who underwent polysomnography at Walter Reed were diagnosed with obstructive sleep apnea (OSA) -- whereas, in the general population, the rate of OSA is only 20%.

It can be all too easy to dismiss daytime sleepiness and other symptoms as part of depression and PTSD, Orr explained. But these results argue for screening all military PTSD patients for sleep apnea, Orr said in an interview.

"You'll be darned if you just keep treating it with medications, cognitive behavioral therapy, and all the other modalities you use for PTSD, when you haven't addressed possible sleep apnea, which could get restorative sleep and kind of break the cycle for the PTSD symptoms," he told MedPage Today.

Session co-moderator Andreea L. Antonescu-Turcu, MD, of the Medical College of Wisconsin and chief of pulmonology at the Zablocki VA Medical Center, both located in Milwaukee, agreed that the study results should justify the importance of screening for sleep problems in military patients with PTSD -- even when they don't fit the classical profile for OSA.

"As the data are coming out it probably should be part of their routine evaluations to screen for sleep disordered breathing," she told MedPage Today. "Maybe this is part of their disorder that we have to address early on in patients with PTSD."

The reason for the well-recognized sleep problems in PTSD isn't clear, but recent reports have argued that these symptoms should be considered a central feature of the disorder and not just a consequence of it, Orr noted.

His group retrospectively analyzed electronic medical records for all 135 service members (91.9% men, average age 35.3) with combat-related PTSD seen at the Walter Reed sleep clinic from March 2006 through April 2010.

Orr noted that these returning soldiers were assigned to the Warrior Transition Brigades, which were asked to refer PTSD cases with with traumatic brain injury to the sleep clinic.

Not surprisingly, the majority of veterans in the current study had been injured (80 of the 135) and about 70% were traumatic brain injuries, primarily mild concussions from blast incidents.

The average body mass index (BMI) was 28.91 -- putting most of the patients in the overweight but not obese category.

Comorbid psychiatric illness was nearly universal with PTSD in the study patients; 88.9% suffered from depression and 44.4% were diagnosed with anxiety.

Sleep complaints among the study patients included excessive daytime somnolence in 88.2% -- confirmed by an average Epworth Sleepiness Scale score in the "sleepy" range (10.7) -- as well as sleep fragmentation in 67.4% and difficulty falling asleep in 55.6%.

Polysomnography done in 80.7% of the study patients diagnosed insomnia in 55% and OSA in 54%.

Those patients with OSA were generally older, had a higher BMI, and were less likely to have suffered trauma or a traumatic brain injury compared with those who did not have sleep apnea (all P≤0.001).

Orr's group cautioned that they were unable to determine how many of the service members in the study had OSA before being deployed -- but the researchers assumed that it was largely preexistent.

High medication use, including painkillers and sedatives, might have contributed to the sleep characteristics of these populations, the investigators noted.

But Orr pointed out that comorbid depression and use of medication were similar in PTSD patients with and without OSA. Also, "the injured population had less obstructive sleep apnea, so if the narcotics were causing central apneas then why was it the opposite?" he asked."

Miami-VA Director Re-Assigned over Tainted Equipment, Returns to Maimi-VA

Full Article at: Miami VA official reassigned in scandal returns to post

With no public notice, the Miami Veterans Administration Healthcare director who was reassigned during a scandal over tainted equipment returns to her post.

BY FRED TASKER
ftasker@MiamiHerald.com

Mary Berrocal, director of the Miami Veterans Administration Healthcare System who was temporarily reassigned in July during a scandal in which thousands of South Florida veterans were given colonoscopies with improperly cleaned equipment, was back on the job Friday.

It happened quietly. The announcement was made internally, without public notice. VA officials at the local, regional and national levels failed to return phone calls and e-mails seeking comment.

``Effective today, Oct. 29, Ms. Mary Berrocal will resume her duties as director of the Miami VA Healthcare system,'' said a Friday memo from Nevin M. Weaver, director of the VA's VISN 8 healthcare network, which oversees VA healthcare in Florida, South Georgia, Puerto Rico and the Caribbean.

In March 2009, the Miami VA hospital sent letters to more than 2,400 veterans saying that colonoscopies performed at the facility since 2004 might have been with equipment that had been rinsed between uses instead of sterilized with chemicals per manufacturer's instructions.

Colonoscopies were temporarily suspended at the facility. Subsequent testing showed three veterans were HIV positive, seven had hepatitis C and one had hepatitis B.

Doctors, however, stressed there was no way to know whether the vets had contracted them from the colonoscopies.

At the time, Miami VA chief of staff Dr. John Vara suggested human error as a cause, saying some local employees had developed their own -- improper -- ways of cleaning the equipment."