Psychotherapeutic, pharmacological and other active interventions from the NICE guideline for post-traumatic stress disorder with sleep disorder: systematic review and meta-analysis

Post-traumatic stress disorder (PTSD) is strongly associated with sleep disorders, and current clinical guidelines for PTSD differ in recommending treatment for patients with PTSD associated with sleep disorders. This meta-analysis evaluates the acceptability and efficacy of psychotherapy, pharmacotherapy, and other complementary/alternative therapies, to help clinicians make decisions about treatment regimens for individuals with PTSD and sleep disorders. We systematically searched PubMed, EMBASE, the Cochrane Library, and American Psychological Association PsyNet for randomized controlled trials (RCTs) related to placebo-controlled and active intervention trials for PTSD with sleep disorders up to February 2, 2023. Active intervention significantly improved PTSD (standardized mean difference (SMD) = 0.86, 95% confidence interval (CI): 1.21, 0.50), sleep disorders (SMD = 1.06, 95%CI: 1.50, 0.63), and depression (SMD = 0.58, 95%CI: -0.96, -0.19). Regarding compliance, the active intervention group did not show lower acceptability ((Risk ratios (RR) = 1.08, 95%CI: 0.92, 1.26). Compared to placebo or supportive groups, the active intervention did not exhibit statistically significant improvements in total sleep time (SMD = 0.87, 95%CI: -0.27, 1.47) and overall psychological symptoms (SMD = 0.13, 95%CI: -0.12, 0.37). Details results of the subgroup analyses were provided in the text. Bias may be present in total PTSD symptoms, change of total sleep symptoms and change of depression symptoms, and no significant bias was observed in acceptability. Active intervention effectively reduces the main symptoms of PTSD in patients with sleep disorders. Consideration of pharmacotherapy (hydroxyzine) is recommended over prazosin, as suggested by the WFSBP clinical guidelines, especially when patients are insensitive to psychotherapy or have urgent symptoms. Psychological interventions, particularly IRT or IRT plus CBT-I, are recommended. Stratified by population, psychotherapy is more advisable for veterans and those with involuntary sexual experiences, while pharmacotherapy is more suitable for military staff. For patients with only nightmare symptoms, both psychotherapy and pharmacotherapy could be considered. When patients have insomnia symptoms, psychotherapy is preferable. The effect of psychotherapy is particularly recommended for females, while the effect of pharmacotherapy is emphasized for males.