Comparative efficacy of imagery rehearsal therapy and prazosin in the treatment of trauma-related nightmares in adults: A meta-analysis of randomized controlled trials

Abstract

Pharmacological treatment with prazosin and psychological treatment with imagery rehearsal therapy (IRT) are the two main treatments of posttraumatic nightmares. The American Academy of Sleep Medicine task force recently listed IRT as the recommended treatment for trauma-related nightmares and changed the recommendation of prazosin to 'may be used'. This new recommendation was based on a single prazosin trial and not on a meta-analytic review of all available trials. The current meta-analysis aims to fill this gap in the literature. Eight studies on IRT and seven studies on prazosin (N ¼ 1.078) were analyzed based on the random effects model. Relative to control groups, prazosin had a moderate to large effect on nightmare frequency (g ¼ 0.61), posttraumatic stress symptoms (g ¼ 0.81), and sleep quality (g ¼ 0.85). IRT showed small to moderate effects on nightmare frequency (g ¼ 0.51), posttraumatic symptoms (g ¼ 0.31), and sleep quality (g ¼ 0.51). No significant differences in effect were observed between prazosin and IRT on any of these outcomes (all p's > 0.10). It is concluded that downgrading the recommendation of prazosin may be a premature decision and that the aggregated results in this metaanalysis clearly show efficacy of both treatments.

Telephone‐guided imagery rehearsal therapy for nightmares: Efficacy and mediator of change

“…Even though the effects on nights with nightmares did not reach the statistical threshold (possibly due to power), all effect sizes were in the moderate to large range. These effects are in general larger than those observed in earlier meta-analytic findings on the efficacy of mostly face-to-face IRT treatment (Augedal et al, 2013;Hansen et al, 2013;Seda et al, 2015;Yücel et al, 2020).…”

“…Nightmare sufferers rarely seek help (Gieselmann et al., 2019), even though there are various treatments available for nightmares. The two main treatment options are the alpha‐1 antagonist prazosin and the psychological treatment imagery rehearsal therapy (IRT; Seda, Sanchez‐Ortuno, Welsh, Halbower, & Edinger, 2015; Yücel, van Emmerik, Souama, & Lancee, 2020). The efficacy of prazosin treatment for nightmares has mainly been tested for post‐traumatic nightmares, and has recently been under debate because a large‐scale trial could not detect any relevant treatment effects (Morgenthaler et al., 2018; Raskind et al., 2018).…”

“…The efficacy of prazosin treatment for nightmares has mainly been tested for post‐traumatic nightmares, and has recently been under debate because a large‐scale trial could not detect any relevant treatment effects (Morgenthaler et al., 2018; Raskind et al., 2018). However, a recent meta‐analysis still indicated efficacy for both treatment formats with similar effect sizes (Yücel et al., 2020).…”

Interest in telephone nightmare counselling in patients with sleep-related breathing disorders

“…The prevalence of nightmare disorder in the general population is estimated to be about 2 to 6% [11] and about 30% in a patient group with various mental disorders, e.g., mood and anxiety disorders [27]. Even though effective treatment strategies such as like imagery rehearsal therapy (IRT) are available [2,5,30], nightmares are typically undertreated [12,17]. This is of clinical importance as frequent nightmare sufferers often report severe burden [6], and nightmares have been identified as an independent predictor of suicidal ideation and suicide [13].…”

Methodological Recommendations to Control for Factors Influencing Dream and Nightmare Recall in Clinical and Experimental Studies of Dreaming

“…Prazosin is an alpha blocker recommended for the treatment of chronic nightmares in PTSD patients ( 107 – 109 ), and in this case, inhibition of the sympathetic nervous system may desensitize memories of fear which could explain the reduction of nightmare frequency induced by this treatment. To our knowledge, the impact of Prazosin on DRF is unknown.…”