A Qualitative Investigation of Long-Term Zopiclone Use and Sleep Quality Among Vietnam War Veterans With PTSD

Abstract and Introduction

Abstract

Background: Self-reported sleep difficulties are common among patients with posttraumatic stress disorder (PTSD), but the routine use of hypnosedatives over extended periods is not generally recommended.
Objective: To examine the effects of the extended use of zopiclone among a cohort of patients with combat-related PTSD.
Methods: We conducted a 6-month follow-up cohort study of zopiclone usage characteristics for 26 combat veterans with PTSD. Psychometric and sleep assessments were also conducted at baseline and 6 months.
Results: The mean baseline score obtained on the tranquilizer dependence questionnaire was 20.4 ± 13.4, below the cutoff score proposed as indicative of a high likelihood of dependence (23 points). Eight (30.7%) subjects exceeded the proposed cutoff score for dependence at baseline. Most (n = 24) subjects reported poor sleep quality at baseline. Actigraphy revealed that the mean sleep efficiency score was 71.2 ± 13.7% at baseline. A cohort of 13 men was available for inclusion in the follow-up phase of the study. The tranquilizer dependence questionnaire score at follow-up was broadly similar to the baseline score after a further 6 months of zopiclone use (18.9 at baseline compared with 19.9 ± 2.6 at follow-up). Individual analysis revealed that the tranquilizer dependence scale score increased for 5 subjects and decreased for 8 subjects at follow-up. Four (30.7%) subjects in the follow-up cohort exceeded the proposed cutoff score for dependence at baseline and 6 (46.1%) subjects exceeded it at follow-up. Actigraphy data were consistent across measurements for individual subjects at baseline and follow-up, with similar mean sleep efficiency scores at baseline and after 6 months of treatment with zopiclone (69.6 ± 12.7% at baseline; 71.33 ± 19.0% at follow-up). The proportion of relatively poor sleepers (5/13 at baseline and 4/13 at follow-up) remained essentially unchanged.
Conclusions: Overall, the results of this study suggest that, although the subjects in the follow-up phase of the research continued to use zopiclone on a regular basis for an extended period, the efficacy of this intervention for addressing PTSD-related sleep disturbance was low. Extended treatment with zopiclone may not necessarily be associated with increased risk for dependence. Further robust research to examine the consequences of long-term zopiclone therapy for PTSD-related sleep disturbance is warranted.

Introduction

The deployment of Australian military personnel to Vietnam during the 1960s and 1970s remains the most substantial national military commitment from Australia since World War II.^[1] Many of these men and women are now affected by severe posttraumatic stress disorder (PTSD). For example, Streimer et al.^[2] found that 10% of a cohort of veteran inpatients had a diagnosis of PTSD, but the prevalence was 27% among veterans who had combat exposure. The prominent association between PTSD and substance use disorders^[3,4] presents difficulties in the management of PTSD symptoms. Many Vietnam War veterans with PTSD complain of sleep disturbance, and the diagnostic criteria for PTSD specifically include features such as difficulty in falling or staying asleep and recurrent distressing dreams.^[5] Many Vietnam War veterans request prescriptions for ongoing use of hypnosedatives, although this is at odds with the recommended PTSD management strategies in accepted treatment guidelines.^[6,7,8] Australian research found that chronic, long-term use of minor tranquilizers was common among Vietnam War veterans, who reported daily use and use duration for longer than 6 months in over 70% of cases.^[9] In the same study, the single most commonly encountered minor tranquilizer was the nonbenzodiazepine hypnosedative zopiclone, a short-acting hypnotic agent with an elimination half-life of approximately 5 hours.^[10]

To date, there has not been any detailed research that addresses the possible benefits and problems associated with the long-term use of zopiclone among Vietnam War veterans with PTSD. Based on the understanding of the sleep disturbances that affect Vietnam War veterans with PTSD and the inherent limitations of long-term hypnosedative treatment in the management of insomnia, this qualitative study was designed to explore the characteristics of zopiclone usage for the long-term management of sleep disturbance associated with combat-related PTSD in a naturalistic setting.

Table 1. Characteristics of Zopiclone Use
Characteristic	Subjects, n (%)
Frequency of use
every night	18 (69.2)
4-5 nights/wk	6 (23.1)
1-3 nights/wk	2 (7.6)
Nightly dosage (mg)
7.5	6 (23.1)
11.25	1 (3.8)
15	19 (73.1)

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