What Actions Can Be Taken to Promote Sleep Health Among Servicemembers?

Based on the findings above, we provide recommendations for filling gaps and overcoming barriers to achieving healthy sleep in servicemembers. To some extent and in certain contexts (e.g., in the combat environment), it is accepted that the unique role and demands of the military will necessarily restrict the opportunity for sufficient sleep duration and quality. Thus, we put forth a set of actionable recommendations that take into account these exigencies while at the same time identifying opportunities for programs and policies to promote sleep health in multiple contexts, including both operational and medical or clinical settings and across a continuum of care from prevention to identification and intervention.

In terms of preventing sleep problems, our study found no evidence-based practices to prevent sleep disorders in military or civilian populations, with the possible exception of weight loss and management strategies that also reduce the risk of OSA. This dearth of prevention efforts is consistent with the history of sleep medicine and medicine in general, which has tended to focus on physical illnesses or disorders rather than promoting health. Thus, we provide several recommendations to support prevention efforts, with the ultimate goal of promoting sleep health.

As for increasing the identification and diagnosis of sleep problems, our study identified several factors that may facilitate the detection of sleep disturbances, including the family as a key mechanism for detection, primary care as a key setting for detection, and the use of objective assessments to quantify insufficient sleep and associated daytime impairment.

In terms of clinically managing sleep disorders and promoting sleep health, our study also suggests a need to improve the education of health providers on the assessment, diagnosis, and treatment of sleep problems and disorders; to improve education of servicemembers on healthy sleep-related behaviors, including the appropriate use of stimulants and sleep medications; and to systematically evaluate promising programs and intervention approaches, including the use of technology to monitor and treat sleep disturbances. Policies that support provider training and that offer incentives for specialized sleep medicine training are needed to fill gaps in provider capabilities and the shortage of providers able to confidently deliver care to prevent, identify, and treat sleep disorders among military populations. Moreover, to enhance the dissemination of sleep treatments, trained providers are needed in a variety of contexts, including primary care, rather than in specialty sleep clinics only, where fewer patients are likely to present initially. Although several of these efforts to disseminate evidence-based sleep treatments by providing training for providers are under way within both the VA and DoD, there still is a need for systematic evaluation of the efficacy of these programs in terms of increasing provider knowledge and improving patient outcomes.

Finally, in terms of improving sleep in training and operational contexts, our study found that policies related to sleep are generally Service-specific and sometimes inconsistent in the degree of emphasis placed on sleep in each of the occupational areas within each Service. To a certain extent, these observed variations are expected and necessary, given each Service's mission focus (e.g., Air Force air operations) and the associated sleep policy for that military community. Nevertheless, such variation can create challenges for leaders trying to integrate work schedules or manage shift work in a diverse occupational specialty or joint environment. There are clearly unique challenges to achieving quality sleep in the post-deployment setting, and it is in this context that chronic and debilitating sleep disorders are likely to manifest. Thus, efforts are needed—most likely at the DoD level—to communicate overarching guidance to the Services regarding sleep in terms that are consistent with, and coherent within, an operational framework. Our recommendations in this area are geared toward this end.

Table S.1 summarizes the recommendations in the four areas, which are discussed in more detail in Chapter Seven.

Table S.1. Recommendations to Promote Sleep Health

Prevent Sleep Problems

1.

Increase servicemember and line leader education about healthy sleep behaviors to increase self-awareness and knowledge about the factors that inhibit or promote adequate, restful sleep.

2.

Fund or conduct research to perform longitudinal studies on sleep and effects on operational readiness and resilience.

Increase Identification and Diagnosis of Sleep Problems

3.

Educate families on signs and symptoms of sleep disturbances as a way to bolster sleep detection efforts.

4.

Improve screening for sleep disturbances in primary care settings, including the routine use of validated screening tools to identify those at high risk for the broad range of sleep disorders.

Clinically Manage Sleep Disorders and Promote Sleep Health

5.

Develop provider education programs on preventing, identifying, and treating sleep disorders, with a focus on giving providers the latest findings in the field of sleep science to effectively advise patients on sleep issues and a focus on prevention as well as treatment.

6.

Develop a clinical practice guideline for sleep disorders that specifically addresses sleep and discusses prevention, identification, and treatment of sleep disorders.

7.

Increase the use of mobile technology for assessing and clinically managing sleep disorders, in particular to monitor sleep and alertness and to identify and manage sleep disorders before they become chronic or debilitating.

8.

Continue to research evidenced-based practices for advancing healthy sleep in military populations (e.g., mindfulness, teletherapy) and establish guidelines for treating servicemembers and veterans.

9.

Enhance dissemination of evidence-based sleep treatments (e.g., CBT-I, IRT) by training providers in primary care settings as well as behavioral health clinics.

10.

Improve continuity of care of sleep disorder treatments, such as through the use of electronic medical records that link records across the deployment cycle.

Improve Sleep in Training and Operational Contexts

11.

Make appropriate revisions to existing training and operational policies to minimize inconsistencies and align with current clinical guidelines about optimal sleep duration that recommend that the amount of sleep required among civilians is eight hours.

12.

Educate line leaders on creating sleep plans that align with current research on circadian rhythms, consider the physical sleeping environment, and factor in shift schedules of roommates or tent-mates when assigning duty.

13.

Create standardized operational and training policies across DoD to increase sleep duration and quality and reduce fatigue-related impairment.

14.

Link sleep-related surveillance data on mishaps to evaluate the role of sleep and fatigue.

15.

Prioritize sleep in reintegration policies to offer servicemembers a period of recuperation during which they might be able to begin to return to normal sleep habits and potentially prevent the onset of chronic sleep problems that develop well after the initial reintegration period.

16.

Disseminate positive messaging about sleep as an operational imperative (a vital sign, such as blood pressure) to increase awareness and reduce cultural barriers.

Final Words

Given the recent drawdown from combat operations in Iraq and Afghanistan, increasing attention has focused on the factors that promote or hinder servicemembers ability to reintegrate and rebuild their lives post-deployment. This report offers 16 policy recommendations to promote sleep health in the domains of prevention, identification, treatment, and training/operations. These recommendations should be addressed collectively by individual servicemembers, unit leaders, the military health system, training and operational commands, military health researchers, and DoD at large. Implementing these recommendations must go hand in hand with better messaging about the biological and operational necessity of sleep to overcome cultural, environmental, medical, and operational barriers to achieving healthy sleep among servicemembers. Carrying out such an integrated approach is critical for improving sleep, which is an important contributor to resilience and operational readiness in the U.S. military.

 
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