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Pharmacotherapy Refractory Insomnia in Soldiers With Traumatic Brain InjuryInsomnia in Soldiers With Traumatic Brain Injury FREE TO VIEW

Vincent Mysliwiec, MD, FCCP; Bernard Roth, MD, FCCP
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From the Department of Pulmonary, Critical Care and Sleep Medicine, Madigan Healthcare System.

Correspondence to: Vincent Mysliwiec, MD, FCCP, Department of Pulmonary, Critical Care and Sleep Medicine, Madigan Healthcare System, 9040A Fitzsimmons Ave, Tacoma, WA 98431; e-mail: vincent.mysliwiec@amedd.army.mil


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(2):582-583. doi:10.1378/chest.12-2269
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To the Editor:

The article by Collen et al1 in a recent issue of CHEST (September 2012) highlighted multiple important aspects of the complex medical problems of wounded soldiers. Most of the cohort exhibited multiple comorbid illnesses of depression, anxiety, posttraumatic stress disorder and traumatic brain injury (TBI), and either insomnia or obstructive sleep apnea (OSA). Despite 94.0% of the soldiers receiving psychoactive medications, the most common sleep diagnosis was insomnia, calling into question the role of the aforementioned medications.

The retrospective nature of the study, especially with the frequency of pharmacotherapy, likely led to an underestimation of the prevalence of insomnia. Medications that are used almost exclusively for their sedative properties, trazodone, antipsychotics,2 and nonbenzodiazepine receptor agonists, were prescribed in 22.9%, 38.5%, and 57.8%, respectively; however, only 55.2% of patients were given a formal diagnosis of insomnia. In fact, a greater proportion was receiving sedative medications than had actually received a diagnosis.

A large percentage of their patients likely had pharmacotherapy refractory insomnia. This is suggested by the near universal symptom of sleep complaints and their corresponding polysomnographic variables, despite medication usage. In the 79.3% who underwent a sleep study, an increased sleep latency of 28.1 min and a decreased sleep efficiency of 86.3% were recorded, with wakefulness after sleep onset not reported. These polysomnographic variables are consistent with insomnia3 and suggest that the medications prescribed are likely not efficacious.

Krakow et al4 previously reported a study showing that patients with chronic insomnia despite pharmacotherapy had a high prevalence of sleep-disordered breathing. In soldiers with TBI and insomnia who did not receive a polysomnogram as part of their sleep evaluation, OSA could have been missed. Another potential benefit of the polysomnogram could have occurred in assessing the efficacy of medical therapy, given their persistent symptoms of sleep disturbances.

As the authors conclude, an earlier sleep medicine evaluation and assessment with polysomnography in this complex patient population could only aid in its management. The resulting improved sleep quantity and quality could potentially improve cognition.5 Considering that this study does not support the use of psychoactive medications in improving either the subjective or objective sleep quality of soldiers with TBI, prospective studies specifically assessing the nature and optimal treatment of insomnia in the setting of TBI are required. Pending these studies, nonpharmacologic treatments such as cognitive behavioral therapy should be strongly considered.

Acknowledgments

Other contributions: The opinions and assertions in this article are those of the authors and do not necessarily represent those of the Department of the Army, the Department of Defense, or the US Government.

Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest. 2012;142(3):622-630. [CrossRef] [PubMed]
 
Mysliwiec V, Thomas D, Greenburg D, Pierce R. Quetiapine therapy and monitoring in active duty patients. Sleep. 2011;34(suppl 0523):A179
 
Okun ML, Kravitz HM, Sowers MF, Moul DE, Buysse DJ, Hall M. Psychometric evaluation of the Insomnia Symptom Questionnaire: a self-report measure to identify chronic insomnia. J Clin Sleep Med. 2009;5(1):41-51. [PubMed]
 
Krakow B, Ulibarri VA, Romero E. Persistent insomnia in chronic hypnotic users presenting to a sleep medical center: a retrospective chart review of 137 consecutive patients. J Nerv Ment Dis. 2010;198(10):734-741. [CrossRef] [PubMed]
 
Ancoli-Israel S, Palmer BW, Cooke JR, et al. Cognitive effects of treating obstructive sleep apnea in Alzheimer’s disease: a randomized controlled study. J Am Geriatr Soc. 2008;56(11):2076-2081. [CrossRef] [PubMed]
 

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References

Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest. 2012;142(3):622-630. [CrossRef] [PubMed]
 
Mysliwiec V, Thomas D, Greenburg D, Pierce R. Quetiapine therapy and monitoring in active duty patients. Sleep. 2011;34(suppl 0523):A179
 
Okun ML, Kravitz HM, Sowers MF, Moul DE, Buysse DJ, Hall M. Psychometric evaluation of the Insomnia Symptom Questionnaire: a self-report measure to identify chronic insomnia. J Clin Sleep Med. 2009;5(1):41-51. [PubMed]
 
Krakow B, Ulibarri VA, Romero E. Persistent insomnia in chronic hypnotic users presenting to a sleep medical center: a retrospective chart review of 137 consecutive patients. J Nerv Ment Dis. 2010;198(10):734-741. [CrossRef] [PubMed]
 
Ancoli-Israel S, Palmer BW, Cooke JR, et al. Cognitive effects of treating obstructive sleep apnea in Alzheimer’s disease: a randomized controlled study. J Am Geriatr Soc. 2008;56(11):2076-2081. [CrossRef] [PubMed]
 
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