FIVE. Evidence-Based Interventions to Treat Sleep Disturbances Among Servicemembers
As discussed in the prior chapters, sleep disturbances—including insomnia, insufficient sleep duration, and nightmares—are highly prevalent among servicemembers both during and after deployments, are associated with a host of adverse mental and physical health outcomes, and can compromise operational readiness by diminishing attention, emotion regulation, and concentration. In fact, sleep disturbances are the most commonly reported symptoms among servicemembers returning from deployments. Sleep disturbances are also highly comorbid with several of the signature "wounds" servicemembers have experienced in OEF/OIF combat operations, including PTSD, depression, TBI, and chronic pain conditions. Even with effective treatments for these co-occurring conditions, sleep disturbances remain among the most intractable symptoms.
Given this, there is increasing recognition of the need for empirically supported treatments that target sleep disturbances in servicemember populations, regardless of whether such disturbances are the primary disorder or comorbid with other conditions. Fortunately, several cognitive-behavioral interventions and some pharmacologic approaches have demonstrated efficacy in treating sleep problems in civilian and servicemember populations. However, the most robust clinical trials on sleep interventions have been conducted in civilian populations. Given that servicemember populations may have unique characteristics (e.g., younger age, predominantly male, high consumption of caffeinated products to sustain operational demands) and that the precipitating factors that may initiate the onset of sleep disturbances (e.g., sustained conditions of hyperarousal in deployed settings) may differ between servicemember and civilian populations, it is not clear whether the efficacy data on civilian populations can be extended to servicemember populations or settings. By way of example, selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in treating PTSD in civilians (predominantly women exposed to sexual trauma); however, SSRIs have not consistently demonstrated efficacy in treating combat-related PTSD in veteran populations (Alexander, 2012).
Thus, this chapter reviews the extant literature on evidence-based interventions to treat combat-related sleep problems among servicemember populations. In particular, it examines evidence-based behavioral interventions to treat insomnia and nightmares and technological developments in treatment delivery. With few exceptions, there is scant evidence to support the use of pharmacologic strategies specifically within servicemember populations or military contexts, though there is considerable literature on the civilian population. Medications to treat insomnia in servicemembers are generally the same as those used in civilian populations and include antidepressants, sedatives/hypnotics, and adrenergic antagonists/anticonvulsants. Comprehensively reviewing this literature was beyond the scope of this study, but this literature has recently been reviewed elsewhere (Brown, Berry, and Schmidt, 2013; DCoE, 2012). Given this, and to provide context for evaluating behavioral interventions, we briefly summarize current pharmacologic strategies for treating sleep disturbances. We also note that a review of wake-promoting agents (i.e., stimulants) in servicemem-ber populations was beyond the scope of this review and refer the reader to existing review articles (Caldwell and Caldwell, 2005; DCoE, 2012).