Dr. Williams is the chief of sleep medicine at the Womack Army Medical Center in Fort Bragg, North Carolina, and an assistant professor in the Department of Medicine at the Uniformed Services University in Bethesda, Maryland. Dr. Collen is a staff pulmonologist, intensivist, and sleep disorders physician at the San Antonio Military Medical Center in Fort Sam Houston, Texas, and an assistant professor in the Department of Medicine at the Uniformed Services University. Dr. Mysliwiec is chief of pulmonary, critical care, and sleep disorders in the Medical Specialties Clinic at the 121 Combat Support Hospital in Korea. Dr. Wickwire is an assistant professor for the departments of psychiatry and medicine at the University of Maryland School of Medicine in Baltimore. Ms. Ryan is a health strategist and lead communicator and Dr. Lim is a psychologist, both in the Office of the United States Army Surgeon General in Falls Church, Virginia.
Continuous positive airway pressure adherence is determined early (days to weeks), and initial use predicts long-term adherence.67-70 Patients are most likely to abandon therapy or fail to initiate therapy during this period. Given the potential adverse outcomes of comorbid mental illness and sleep disorders, including suicide, interventions should begin early.71 Continuous positive airway pressure devices with heated humidification, group education, peer success stories, and telephonic follow-up are all methods that improve adherence.72 There is conflicting evidence regarding the efficacy of nonbenzodiazepine sedative- hypnotics for improving diagnostic accuracy and CPAP adherence.73-76
Given this population’s high rate of comorbid insomnia, polypharmacy, and potentially pharmacotherapy refractory insomnia, the approach should be used cautiously in patients with PTSD OSA.77 Emerging efforts incorporate a biopsychosocial approach with an individualized focus on a patient’s unique barriers to adherence. Incorporating approaches such as motivational enhancement (for those ambivalent about change), educational approaches, and CBT may all be useful adjuncts.78-80
Ongoing VA trials have been designed to evaluate the impact of CPAP therapy on symptoms of PTSD and to compare CPAP and mandibular advancement devices with regards to efficacy in reducing the apneas and/or hypopneas per hour of sleep and improving symptoms.81,82
Discussion
Service members, like most adults, need about 8 hours of quality sleep per night to function at optimal levels and maximize operational readiness. The medical community is increasingly recognizing that sleep disturbances are inextricably linked to psychiatric disorders, particularly PTSD, depression, and anxiety.83,84 Balancing occupational performance and the demand of military missions with service member health remains a difficult leadership challenge.
Recent evidence suggests that disordered sleep may precede other PTSD symptom clusters.43,85 Sleep architecture in PTSD is disrupted, and abnormalities in both REM and non-REM sleep have been described.86,87 Insomnia not only is a component of depressive and anxiety disorders, but also impacts the course of disease severity.88 Sleep deprivation has been shown to be a risk factor for major depression in adolescents.89 In those with comorbid sleep problems, PTSD, and TBI, each disorder worsens QOL in an additive fashion.90
Severe mental illness impacts the military through a service member’s lost workdays, decreased productivity, impaired social relationships, and even suicide. Given that sleep quality is related to outcomes for patients with mental illnesses, access to medical professionals with specific training in sleep disorders becomes an integral part of a multidisciplinary approach to military health care. Encouragingly, treatment of insomnia and nightmares has been shown to improve PTSD symptom severity as well as headaches in veterans with mild TBI, even if neurologic deficits remain static.91 Similarly, treatment of insomnia is known to improve depressive symptoms in those with comorbid conditions.
Conclusion
The importance of sleep as a combat multiplier is increasingly recognized. The U.S. Army Surgeon General has acknowledged the interplay between inadequate sleep and impairments in other functional areas and placed specific emphasis on sleep as part of the Army Performance Triad. A core tenant of the Army Surgeon General’s message is that army medicine is on a mission to transform from a health care system to a system for health. The Army Wellness Centers, Army Medical Homes, Soldier-Centered Medical Homes, and embedded behavioral health are supporting the health of the force in these capacities. These functional areas treat behavioral health and sleep-related concerns across the continuum of disease from prevention, timely initial intervention once a condition has been identified, long-term treatment programs, and rehabilitative services.
Getting the proper quantity and quality of sleep, in addition to healthy activity and nutrition, increases readiness so that when called on to perform, soldiers are ready. A recent article by Wesensten and Balkin from the Walter Reed Army Institute of Research summarizes some guidelines for sleep from the Army Performance Triad Working Group to include sleep hygiene tips and judicious use of naps and caffeine.92 Efforts to improve soldier resiliency by improving sleep-related disorders have yet to be studied in a meaningful way, so additional research is needed to determine best practices and evidence-based guidelines.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
