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Correlates and Consequences of Sleep Problems in the Post-Deployment Period

In this section on the correlates and consequences of sleep disturbances, we review the available literature on mental health problems and physical health problems, noting that evidence suggests that many of these relationships are bidirectional (e.g., sleep problems are a symptom of mental health disorders but also can predict the onset of a mental health disorder). Recognizing the complexity of these relationships and the inability of cross-sectional studies to elucidate their directionality, we highlight findings from longitudinal studies and summarize suggestive cross-sectional data. This section also includes studies of operational readiness, which generally focus on longitudinal experiments or field studies that simulate sleep-deprived environments. Appendix B, Tables B.3 (cross-sectional studies) and B.4 (longitudinal studies), provide details of the reviewed studies.

Mental Health Problems

Sleep disturbances are a core feature of many psychological disorders, including PTSD (Germain, Buysse, et al., 2004), depression (Taylor et al., 2005), and TBI (Lew et al., 2010; Ouellet, Beaulieu-Bonneau, and Morin, 2006), which are the three most prevalent mental health diagnoses among active-duty military and veteran populations following deployments (Hoge, Castro, et al., 2004). Thus, it is not surprising that sleep problems are particularly prevalent among servicemembers with these and other medical or psychological conditions (Goff et al., 2007; Swinkels et al., 2013; Plumb, Peachey, and Zelman, 2014). For instance, sleep disturbances are the most prevalent symptoms of PTSD (Insana, Kolko, and Germain, 2012; Lew et al., 2010; McLay, Klam, and Volkert, 2010; Wallace et al., 2011), and those with PTSD are significantly more likely to report sleep problems and diagnosed insomnia or OSA than are those with other mental health problems or no mental health problems (Capaldi, Guerrero, and Killgore, 2011; Gellis et al., 2010; Hoge, Terhakopian, et al., 2007; Hughes et al., 2013; Picchioni et al., 2010; Seelig et al., 2010; Mysliwiec, Gill, et al., 2013). Sleep disturbances are also among the most prevalent symptoms reported by servicemembers and veterans with TBI (Hoge, McGurk, et al., 2008; Lew et al., 2010; Wallace et al., 2011). For example, in one study, nearly all patients receiving treatment for TBI at Walter Reed Medical Center reported sleep complaints (97.4 percent; Collen et al., 2012). In this patient sample, OSA was associated with blunt injuries, while insomnia was associated with blast injuries. A head injury with a loss of consciousness has also been associated with sleep difficulties among OEF/OIF veterans (Gellis et al., 2010), particularly among those with more-severe symptoms of PTSD (Cooper et al., 2011; Lew et al., 2010). Servicemembers who screen positive for TBI are more likely to report sleep problems than are those who screen negative (Macera et al., 2013).

Beyond these studies demonstrating that sleep problems are a key correlate or symptom of virtually every mental health diagnosis, substantial evidence from both civilian and military studies suggests that sleep problems can also be a cause of downstream mental health consequences. For example, multiple longitudinal studies in civilian samples have shown that sleep disturbances are a significant risk factor for developing depression, PTSD, anxiety disorders (e.g., panic disorder, obsessive-compulsive disorder), substance-use disorders, and suicidality (Breslau et al., 1996; Bryant et al., 2010; Buysse, Angst, et al., 2008; Koren et al., 2002; Ohayon and Roth, 2003; Riemann and Voderholzer, 2003; Weissman et al., 1997).

Our review identified 11 longitudinal studies involving military populations that investigated the temporal relationships between sleep and the development of mental health problems, including PTSD, depression, anxiety, and suicidality (Britton et al., 2012; Gehrman et al., 2013; Insana, Kolko, and Germain, 2012; McLay, Klam, and Volkert, 2010; Pigeon et al., 2012; Ribeiro et al., 2012; Seelig et al., 2010; van Liempt et al., 2013; Wright et al., 2011a, 2011b; Macera et al., 2013). We review the longitudinal research in the mental health areas of (1) depression, anxiety, PTSD, and substance-use disorders and (2) suicidality.

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