Insomnia and Chronic Pain Mediate the Relationship Between Traumatic Brain Injury and Reduced Positive Airway Pressure Adherence Among Veterans

Adam R Kinney; Alexandra L Schneider; Carolyn Welsh; Kathleen F Sarmiento; Christi S Ulmer; Jeri E Forster; Zachary Abbott; Nazanin H Bahraini

doi:10.1097/HTR.0000000000001019

Insomnia and Chronic Pain Mediate the Relationship Between Traumatic Brain Injury and Reduced Positive Airway Pressure Adherence Among Veterans

J Head Trauma Rehabil. 2024 Oct 29. doi: 10.1097/HTR.0000000000001019. Online ahead of print.

Authors

Adam R Kinney¹, Alexandra L Schneider, Carolyn Welsh, Kathleen F Sarmiento, Christi S Ulmer, Jeri E Forster, Zachary Abbott, Nazanin H Bahraini

Affiliation

¹ Author Affiliations: Department of Veterans Affairs, Veteran Affairs Rocky Mountain Mental Illness Research, Education, and Clinical Center (MIRECC) for Suicide Prevention (Dr Kinney, Ms Schneider, and Drs Forster and Bahraini), Aurora, Colorado; Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, Colorado (Drs Kinney, Forster, and Abbott), Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Anschutz Medical Campus, Aurora, Colorado (Dr Welsh), Departments of Physical Medicine and Rehabilitation and Psychiatry (Dr Bahraini), University of Colorado, Anschutz Medical Campus, Aurora, Colorado; Rocky Mountain Regional VA Health Care System (Dr Welsh), Aurora, Colorado; San Francisco VA Health Care System (Dr Sarmiento), San Francisco, California; University of California San Francisco (Dr Sarmiento), San Francisco, California; Durham Veterans Affairs Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) (Dr Ulmer), Durham, North Carolina; and Department of Psychiatry and Behavioral Sciences (Dr Ulmer), Duke University School of Medicine, Durham, North Carolina.

PMID: 39531320
DOI: 10.1097/HTR.0000000000001019

Abstract

Objective: To examine whether co-morbid insomnia, post-traumatic stress disorder (PTSD), depression, and chronic pain mediate the relationship between traumatic brain injury (TBI) and positive airway pressure (PAP) treatment adherence.

Setting: One Veterans Health Administration (VHA) sleep medicine site.

Participants: Veterans (n = 8836) who were prescribed a modem-enabled PAP device.

Design: Secondary analysis of clinical data. We used path analysis to examine: (1) whether Veterans with a history of TBI were more likely to experience insomnia, PTSD, depression, and chronic pain; (2) in turn, whether Veterans with these co-morbid conditions exhibited lesser PAP adherence; and (3) whether Veterans with a history of TBI will exhibit lesser PAP adherence, even while accounting for such co-morbid conditions. Model estimates were adjusted for sociodemographic (eg, race/ethnicity) and clinical characteristics (eg, mask leakage).

Main measures: Health conditions were abstracted from the VHA medical record. PAP adherence was measured using average nightly use (hours).

Results: Among 8836 Veterans, 12% had a history of TBI. TBI history was not associated with PAP adherence when accounting for the presence of insomnia, PTSD, depression, and chronic pain. Indirect effect estimates indicated that a history of mild, moderate-severe, or unclassified TBI was associated with lesser PAP adherence, as mediated by the presence of co-morbid insomnia and chronic pain. Generally, TBI was associated with an increased likelihood of co-morbid insomnia, PTSD, depression, and chronic pain. In turn, insomnia and chronic pain, but not PTSD or depression, were associated with lesser PAP adherence.

Conclusions: Our study offers empirical support for insomnia and chronic pain as potential explanatory mechanisms underlying the relationship between TBI history and suboptimal PAP adherence. While additional research is needed to confirm causality, findings offer preliminary evidence that can inform the development of tailored PAP adherence interventions for Veterans with TBI and obstructive sleep apnea.