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Prevalence and Types of Specific Sleep Problems in the Post-Deployment Period

Research on the prevalence of sleep problems among servicemembers in the post-deployment period falls into two groups: (1) studies of sleep disorders, which are diagnosable clinical phenomena, and (2) studies of the symptoms of sleep problems, which are isolated sleep disturbances (e.g., difficulty initiating and maintaining sleep, nightmares). As for the former (sleep disorders), we focus on the specific sleep disorders that have a research base specific to military populations (i.e., insomnia and obstructive sleep apnea [OSA]) rather than the full scope of sleep disorders. Regarding the latter type of research, symptoms of sleep problems may or may not reflect an underlying sleep disorder and also may or may not reflect an underlying co-occurring mental health diagnosis, such as PTSD or depression, or a physical health condition (e.g., hypoglycemia). Table B.2 in Appendix B offers additional details on the prevalence studies we reviewed.

Diagnosed Sleep Disorders

The International Classification of Sleep Disorders Diagnostic and Coding Manual (American Academy of Sleep Medicine, 2005) is the diagnostic manual for sleep disorders. It currently contains more than 80 clinical sleep disorders in eight categories, including insomnias, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep disorders, parasomnias, and sleep-related movement disorders. There has been limited research on diagnosable sleep disorders in military populations, with the available evidence focusing on two of the most common sleep disorders in the general population: insomnia and OSA.

Insomnia

Insomnia is characterized by a persistent sleep complaint (lasting one month or longer), with associated daytime impairment. What distinguishes insomnia from sleep deprivation or insufficient sleep duration is that, in the former, there are adequate opportunities to sleep but the ability to sleep is compromised. In contrast, sleep deprivation is characterized by a restricted opportunity to sleep (e.g., because of lifestyle or shift work), despite adequate ability. This distinction is very important when considering the prevalence of insomnia in military populations, because such factors as operational demands, training environments, shift-work schedules, and cultural attitudes may restrict the opportunity for sleep among servicemembers, though the ability to sleep may remain intact.

Epidemiological studies on the prevalence of insomnia often vary widely, both in civilian and military populations. Some studies report on isolated symptoms of insomnia (which are considerably more prevalent than diagnosable disorders), whereas far fewer studies report on the insomnia disorder as defined by its stringent diagnostic criteria (Ohayon, 1997). Even with these more stringent diagnostic criteria, insomnia is still the most prevalent sleep disorder in the general U.S population, affecting between 9 and 12 percent of Americans (National Institutes of Health, 2005; Ohayon, 1997). However, estimates are considerably higher (up to 20-40 percent) in primary care medical settings (Shochat, Umphress, et al., 1999; Simon and VonKorff, 1997; Arroll et al., 2012). Among active-duty personnel, insomnia is one of the most frequent reasons for mental health referrals and the most common complaint reported by servicemembers post-deployment (Collen et al., 2012; McLay, Klam and Volkert, 2010; Mysliwiec, Gill, et al., 2013; Mysliwiec, McGraw, et al., 2013; Seelig et al., 2010).

DoD medical surveillance data between 2000 and 2009 document a marked increase in new diagnoses of insomnia across all Services (Armed Forces Health Surveillance Center, 2010b). In fact, the diagnostic rates of insomnia increased 19-fold over the nine-year surveillance period. Mysliwiec, Gill, et al. (2013) reported that 24 percent of OEF/OIF servicemembers referred for sleep studies received a diagnosis of insomnia.

Consistent with civilian samples, evidence from military populations also shows an even higher prevalence of insomnia in comorbid medical or psychiatric populations. In particular, mild traumatic brain injury (mTBI), chronic pain, anxiety, depression, and PTSD have been common diagnoses among servicemembers returning from OEF/OIF/OND operations. Not surprisingly, evidence suggests that insomnia diagnoses are even more prevalent among servicemembers with PTSD and pain syndromes (Mysliwiec, McGraw, et al., 2013). While data from these clinical samples is compelling, few comparisons can be made between insomnia prevalence in military and civilian samples, and more research is needed to understand insomnia diagnosis rates outside of clinical samples. Additionally, information about the use of validated diagnostic criteria by a clinician or mental health specialist is not always well documented in studies of insomnia.

 
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