Research roundup: Sleep disturbance in veterans and active duty military
Practice Research & Policy staff
With approximately 2.2 million active duty military personnel and more than 22 million veterans in the U.S., psychologists are likely to treat this population. This issue of research roundup explores sleep disturbance and disorders in active duty and redeployed military personnel and veterans.
Mysliwiec, V., McGraw, L., Pierce, R., Smith, P., Trapp, B., & Roth, B. J. (2013). Sleep disorders and associated medical comorbidities in active duty military personnel. Sleep, 36 (2), 167 -174. doi: http://dx.doi.org/10.5665/sleep.2364
Seven hundred twenty five active duty military personnel (93.2 percent male and 85.2 percent combat veterans) underwent diagnostic polysomnography sleep studies following referral from their primary care or behavioral health provider for sleep complaints. Over half of the individuals were diagnosed with obstructive sleep apnea, which is also common among civilians with sleep difficulties.
Military personnel were found to be more likely to suffer from insomnia or behaviorally induced insufficient sleep syndrome (BIISS) than civilians. Military members reported averaging 5.74 hours of sleep at home with more than 40 percent reporting less than five hours of sleep — referred to as short sleep duration (SSD). In fact, military members reported far less sleep than civilians, which is not necessarily surprising given their work demands and military culture.
An unusually high number of individuals (17 percent) had paradoxical insomnia (the subjective perception of little or no sleep, despite a normal sleep duration) as compared to the civilian population. Additionally, individuals with sleep disorders were more likely to be diagnosed with depression and anxiety than their non-sleep disordered counterparts. Lastly, those individuals with pain syndromes were more likely to have insomnia.
While this study did not report on the general incidence of sleep disorders in the military population, it did indicate the kinds of sleep problems typically endured by members of the military. Of particular concern is the reported low numbers of hours of sleep as well as the relatively high incidence of paradoxical insomnia.
Both problems seem to be consistent with military culture and functioning. Military personnel frequently have high-stress jobs requiring vigilance, especially when deployed, which can disrupt healthy sleep patterns. Psychologists may want to educate military members and veterans regarding the benefits of adequate sleep, typical amounts of sleep needed and strategies to promote good sleep hygiene.
Luxton, D. D., Greenburg, D., Ryan, J., Niven, A., Wheeler, G., & Myalwiec, V. (2011). Prevalence and Impact of Short Sleep Duration in Redeployed OIF Soldiers. Sleep, 34(9), 1189-1195. doi: 10.5665/SLEEP.1236
This study assessed 3,152 U.S. Army soldiers 90-180 days after completion of redeployment in Iraq during Operation Iraqi Freedom (OIF) that ranged from six to 15 months to determine the prevalence of Short Sleep Duration (SSD). Most soldiers (72 percent) reported SSD, defined as reliably getting less than seven hours of sleep per night. The majority (93 percent) were enlisted soldiers and the remaining 7 percent were officers. Participant age ranged from 18-54, though males in their 20s comprised the largest group (72 percent).
The analyses found that SSD was more common for soldiers who had combat exposure. SSD was also associated with symptoms of depression, Post Traumatic Stress Disorder (PTSD), panic disorder and high-risk behaviors such as tobacco and alcohol abuse, as well as suicide attempts. Seventy five percent of soldiers diagnosed with PTSD reported sleeping six hours or less. SSD is common among redeployed soldiers, and those who experienced combat are at increased risk for persistent SSD along with comorbidities associated with SSD.
While there are many problems associated with short sleep duration and other sleep disorders, the relationship with PTSD is quite strong. Psychologists are encouraged to assess for sleep problems with military personnel with PTSD and develop a comprehensive plan to address both problems when present. Additionally, those who have one problem but not the other might benefit from psychoeducation or some prophylactic intervention in order to reduce the likelihood of developing the associated problem.
Macera, C. A., Aralis, H. J., Raugh, M. J., & MacGregor, A. J. (2013). Do sleep problems mediate the relationship between traumatic brain injury and development of mental health symptoms after deployment?. Sleep, 36(1), 83 - 90. doi: http://dx.doi.org/10.5665/sleep.2306
In this study, 29,640 male active duty members of the U.S. Navy and Marine Corps who had a blast-related traumatic brain injury (TBI) and sleep problems were tested to find out whether their sleep problems were related to a subsequent diagnosis of Post Traumatic Stress Disorder (PTSD) or depression. There is correlation between TBI and later development of mental health problems, but less is known about the mediating variables.
The prospective study evaluated symptoms at two time points: end of deployment and three to six months post-deployment. The results found that if sleep problems are controlled adequately, the odds of receiving a positive PTSD screening during a follow-up significantly decreased for a person already screened positive for TBI. Additionally, controlling sleep problems decreased the chances of military personnel with a positive TBI screening result later developing depression. Controlling sleep problems mediated 26 percent of a TBI's effect on development of PTSD, and 41 percent of a TBI's effect on development of depression.
Psychologists treating active duty military and veterans may want to screen for sleep difficulties in addition to mental health symptoms and history of traumatic brain injury. This data suggests that those individuals who are able to control their sleep problems are less likely to develop other problems. Psychologists have a variety of strategies to help individuals with sleep and may therefore be able to ameliorate some of the challenges faced by this population.
Pigeon, W. R., Britton, P. C., Ilgen, M. A., Chapman, B., & Conner, K. R. (2012). Sleep disturbance preceding sucide among veterans. American Journal of Public Health, 102(S1), S93 -S97.
Data was analyzed on 423 veterans who received care at the Veterans Health Administration (VHA) between 2000 and 2006 and later committed suicide. Of the 423 veterans studied, 45.4 percent of those who had committed suicide had clinician documented sleep disturbance, whereas 54.6 percent had no recorded sleep problems. Sleep disturbance included a variety of problems, including insomnia and nightmares.
The presence of psychiatric or substance use symptoms was significantly associated with sleep disturbance. Even after controlling for age and psychiatric and substance use problems, clinician documented sleep disturbance predicted a shorter time to suicide following patients' last VHA visit.
Sleep disturbance encompasses a range of problems from actual disorders to poor sleep and nightmares. Sleep problems also are connected to a variety of mental health concerns such as anxiety and depression. Psychologists are encouraged to identify, monitor and treat all variety of sleep disturbances, particularly in military and veteran populations. Psychologists may find it particularly useful to inquire about sleep as people may be more likely to disclose sleep problems given the lesser stigma associated with such concerns.