Discussion

The review of the literature and perspectives of our interviewees and working group attendees identified several promising strategies that are being used to promote sleep health, particularly with regard to intervention strategies. However, there are also several notable gaps, including a lack of evidence-based prevention programs and validated self-identification tools.

Our literature review was limited by the relative scarcity of studies on treatments for sleep disorders in military and veteran populations compared with those focusing on civilian samples. Of the studies that were included in our review, many had small sample sizes or did not use control groups, limiting the generalizability of the results. Additionally, some treatment modalities, such as meditation and video tele-therapy, remain relatively unexplored for treating post-deployed servicemembers with sleep disorders.

However, several treatments have demonstrated efficacy in military samples. In particular, CBT-I and IRT therapy have been shown to be efficacious treatments for insomnia and nightmares, respectively, two of the most common types of sleep disturbances that servicemembers experience in the post-deployment period. Unfortunately, to date, there have been no large-scale RCTs of these treatment modalities in military populations. There are also significant gaps between guidelines from scientific studies and current practices in DoD. In particular, pharmacologic therapies (e.g., sleep medications) continue to be the front-line treatment prescribed by many providers (Schmitz, Browning, and Webb-Murphy, 2009), though there is scant evidence on the efficacy of these treatments in treating servicemember sleep disturbances. Furthermore, there are known side effects to these medications, including daytime fatigue, which is particularly concerning in operational contexts and certain occupations that require sustained attention and cognitive vigilance.

The dissemination of efficacious cognitive-behavioral therapies to servicemembers is also lacking, largely as a result of a critical shortage of trained providers in behavioral sleep medicine techniques and relatively low provider awareness of the efficacy of these programs. These are critical issues that should be addressed. Hiring a greater number of qualified behavioral health specialists, creating more clinical training opportunities, and expanding treatment delivery options beyond specialty health care clinics, including primary care settings (Goodie et al., 2009), could help decrease this shortage and enhance dissemination (Troxel, Germain, and Buysse, 2012), as we discuss in Chapter Six.

Further research using robust RCTs and participants from military populations is also greatly needed to establish best-practice guidelines for treating servicemembers and veterans specifically. There is also a need for further research to evaluate the efficacy of innovative and promising treatment techniques that may fill treatment delivery gaps and be preferred by servicemembers, such as video teletherapy, therapies delivered through mobile technology, and CAM techniques (e.g., meditation).

Providing training for clinicians to effectively treat servicemembers and veterans with sleep disorders is an important and complex undertaking for policymakers. Facilitating the broader dissemination of evidence-based treatments for sleep problems and systematically evaluating promising, novel interventions will entail costs and resources, but the benefits accrued in improving sleep health and associated downstream consequences in servicemembers will likely outweigh those costs.

 
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