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Depression, Anxiety, PTSD, and Substance-Use Disorders

Although there are a limited number of rigorous longitudinal studies with military samples, the available longitudinal evidence is strong for sleep problems (e.g., nightmares, insomnia) predicting symptoms and diagnoses of depression, anxiety, and PTSD. For example, in a sample of 15,204 servicemembers from all military branches, pre-deployment insomnia preceded new-onset PTSD, anxiety, and depression diagnosed post-deployment (Gehrman et al., 2013). Pre-deployment short sleep duration (less than six hours) predicted PTSD and anxiety post-deployment. Servicemembers with both predeployment insomnia and short sleep duration were at greatest risk for PTSD and anxiety. In addition, those with combat trauma during their most recent deployment and those with pre-deployment insomnia were at greatest risk of new-onset depression. In another recent longitudinal study of Dutch servicemembers deployed to Afghanistan, researchers found that pre-deployment nightmares predicted symptoms of PTSD six months post-deployment (van Liempt et al., 2013). As for PTSD and depression, researchers found that, among 29,640 sailors and Marines, post-deployment sleep problems explained the relationship between potential TBI diagnoses immediately post-deployment and positive PTSD screens three to six months later (Macera et al., 2013). Researchers also found that insomnia at four months post-deployment was a significant predictor of depression and PTSD at 12 months post-deployment. In contrast, depression and PTSD four months post-deployment did not predict insomnia at 12 months post-deployment (Wright et al., 2011a); these findings suggests that sleep may be a stronger predictor of the development of a subsequent mental health condition, rather than the reverse. In a subsequent study by Wright and colleagues (2011b), combat exposure in Iraq, combined with poor post-deployment sleep, explained a significant portion of the variance in post-deployment PTSD, even after controlling for pre-deployment PTSD symptoms. Furthermore, in this same study, sleep problems, combined with greater levels of combat exposure, predicted alcohol problem severity after controlling for pre-deployment alcohol-use problems (Wright et al., 2011b).

Key informant interviews corroborated these research findings. Those we interviewed were generally attuned to the idea that sleep problems were not a specific or isolated symptom of a larger mental health disorder but, rather, were independent correlates within a larger system of personal mental health problems that warranted further attention.


There is also an established link between sleep problems and suicidality (i.e., suicidal ideation, suicide attempts, completed suicide, self-harm) in civilian studies, along with a growing body of evidence demonstrating similar associations in military populations. Specifically, in civilian studies, the risk of suicidality is associated with short sleep duration, insomnia symptoms (difficulty initiating and maintaining sleep), and nightmares, even after controlling for other known risk factors, including depression (Goodwin and Marusic, 2008; Pigeon et al., 2012; Sjostrom, Waern, and Hetta, 2007; Tanskanen et al., 2001). Similarly, in a large military sample, Ribeiro et al. (2012) found that insomnia predicted future suicidal ideation one month later, even after controlling for baseline suicidal ideation, depression, and hopelessness. Cross-sectional work has also indicated that post-deployed soldiers with very short sleep duration (less than six hours) were over three times more likely to have attempted suicide than those with more adequate sleep (Luxton, Greenburg, et al., 2011). These findings, coupled with the evidence from civilian research, suggest that sleep problems are an independent predictor of suicidality, not merely an epiphenomenon of an established mental health disorder, such as depression.

Retrospective examinations of the VHA medical records of 381 veterans who died by suicide show that veterans with reported poor sleep during their most recent visit to the VHA in the year prior to their death died approximately 100 days sooner than those who did not report sleep problems (Pigeon et al., 2012).

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