What Are the Evidence-Based Interventions to Treat Sleep Disorders Among Servicemembers?
A review of the peer-reviewed academic literature showed that both pharmacologic and non-pharmacologic (i.e., behavioral or cognitive-behavioral) interventions have demonstrated efficacy in treating insomnia in civilian studies. Specifically, meta-analytic studies have found that pharmacologic and non-pharmacologic interventions have comparable efficacy in treating insomnia, with effect sizes in the moderate to large range for reducing insomnia for both types of interventions (Morin, Culbert, and Schwartz, 1994; Irwin, Cole, and Nicassio, 2006; Mitchell et al., 2012). However, the effects of nonpharmacologic interventions tend to be more durable (National Institutes of Health, 2005; i.e., treatment gains persist after active treatment has terminated). Nevertheless, pharmacologic approaches remain the front-line treatment in military and civilian populations, despite the fact that there is a notable lack of evidence supporting the efficacy or safety of pharmacologic approaches in treating insomnia in military settings (Brown, Berry, and Schmidt, 2013; DCoE, 2012). Key informants and expert panelists noted that this lack of systematic evidence is concerning because the safety issues pertaining to medication side effects may be particularly germane to servicemember populations, given operational demands and occupational hazards (Brown, Berry, and Schmidt, 2013). In contrast, there is a sizable and growing evidence base supporting the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for insomnia, specifically within servicemember populations (see, e.g., Talbot et al., 2014; Margolies, 2011; Gellis and Gehrman, 2011; Koffel and Farrell-Carnahan, 2014; Perlman et al., 2008).
The dissemination of efficacious cognitive-behavioral therapies for sleep disturbances has been limited, partly because of a critical shortage of trained providers in behavioral sleep medicine techniques and a lack of provider awareness of the efficacy of these programs in both civilian and military settings (Siebern and Manber, 2011). Training or hiring a greater number of qualified behavioral health specialists and creating more clinical training opportunities could help decrease this shortage, and efforts are underway both through VA and the Center for Deployment Psychology. Further research using robust randomized controlled trials in military contexts is also greatly needed to establish best-practice guidelines for treating servicemembers and veterans, because the nature of sleep problems and the efficacy of specific treatment strategies may differ for servicemember or veteran populations versus civilian populations. There is also a critical need to develop and validate evidence-based identification and prevention programs, including the use of objective sleep- and fatigue-monitoring devices, to promote healthy sleep behaviors and to provide opportunities for intervention before acute sleep disturbances become chronic and debilitating.