Sleep-Related Medical Policies/Programs
U.S. Department of Defense Medical Policies/Programs
Overarching DoD policies related to sleep exist primarily to set medical standards and qualifications for initial military service or referral to a medical evaluation board (DoDI 6130.03, 2011). We also identified subordinate policies that set medical standards for each Service (see Appendix F). Each of these policies lists which sleep-related disorders affect Service eligibility or medical care options for sleep disorders for servicemembers. Additionally, DoDI 6490.11 (2012) prescribes guidelines for commands in managing concussion injuries. This instruction states that servicemembers with a recurrent concussion within a 12-month period will be afforded recovery care, which includes uninterrupted sleep and pain management. However, the policy does not refer to, or provide specific guidelines about, what the sleep or pain management plan should include, nor does it provide referral guidelines for care. Related policies on concussion management were also identified at the Service level.
In addition to medical standards, medical policies include screening for sleep disorders. Self-report assessments are the most commonly used tools to identify sleep problems among servicemembers. In 2005, in response to high numbers of physical and psychological casualties from the wars in Iraq and Afghanistan, DoD ordered the establishment of the Post-Deployment Health Assessment (PDHA) and the Post-Deployment Health Reassessment (PDHRA) programs through DoDI 6490.03 (2011; see McCarthy, Thompson, and Knox, 2012). They are used to screen for physical and mental health problems, including PTSD and troubled sleep. If servicemembers screen positive for any disorder, they are evaluated by a physician and enter treatment if necessary. The PDHA is administered immediately after leaving a deployed area of operations, and the PDHRA is completed three to six months after returning home.
While these broad screening tools may be useful for identifying sleep problems, the timing of the PDHA administration (i.e., between the end of a servicemember's deployment and his or her return home) may lead to underreporting of symptoms, as servicemembers may believe that reporting symptoms on the PDHA will result in further medical examinations that will delay their return. The advantage of the PDHRA is that its timing (six months after the servicemember has returned home) may avoid the risk of underreporting. Nevertheless, given that the six months following return from deployment is a dynamic period of adjustment for both the servicemember and his or her family, sleep problems may be less apparent or less salient in this more immediate reintegration period (Pincus et al., 2001).
Perceived stigma may also deter servicemembers from reporting symptoms of sleep disorders because the PDHA and PDHRA are official documents maintained in each servicemember's military record. A study by Hourani et al. (2012) found that problems sleeping and feeling tired were reported over twice as often on an anonymous survey (48-percent prevalence) than on the PDHRA (21-percent prevalence).
The surveys are compiled of items from existing health screeners, such as the PHQ and PCL. The limited number of sleep-related items on the PDHA and PDHRA raises questions about whether these screeners accurately identify individuals with insomnia or nightmares. Although one study has shown the diagnostic validity of the PDHRA in identifying PTSD, there have not been similar efforts to validate the PDHA or PDHRA when examining insomnia or nightmares (Skopp et al., 2012).
-  Researchers identified one Air Force policy that prescribes standards for servicemembers injured in the line of duty and that is being classified as a medical policy related to sleep. Air Force Guidance Memorandum (AFGM) 44-01.2, Deployment Related Concussion Management, dated February 15, 2012, prescribes medical recovery standards for those diagnosed with a concussion injury. This policy memorandum states that airmen who have had a first concussion will be allowed a recovery period of eight hours of uninterrupted sleep. This policy also uses a couple of questions on sleep as part of a battery of tests (neurobehavioral symptom inventory and acute stress response).