0325 A Comprehensive Evaluation of Sleep Disorders in Male and Female U.S. Military Personnel

Introduction

Sleep disorders are increasingly recognized in military personnel. However, no study has comprehensively evaluated male and female service members with clinically significant sleep disturbances. While, insomnia and obstructive sleep apnea (OSA) are the two most recognized sleep disorders, some studies have suggested that comorbid insomnia and OSA, also known as COMISA, potentially is the most frequent sleep disorder. Further little is known regarding the co-occurrence of nightmares, shift work disorder, depression, anxiety, and posttraumatic stress disorder (PTSD) in this population.

Methods

Participants were 309 active duty service members (females n = 113, male n = 196) in all branches of the military who underwent a clinically indicated sleep evaluation in a military sleep disorders center. All underwent an attended in-lab polysomnogram, were diagnosed with insomnia, OSA, or COMISA and completed self-report measures. Participants completed the Nightmare Disorder Index and Shift Work Disorder Index, and non-sleep questionnaires using the PCL-5 for post-traumatic stress disorder (PTSD), the PHQ-9 for depression, the GAD-7 for anxiety, and History of Head Injuries for traumatic brain injury (TBI).

Results

COMISA was diagnosed in 36.8% of the sample, insomnia in 32.7%, and OSA in 30.4%. Males were significantly more likely to have COMISA or OSA and females were more likely to have insomnia. Polysomnographic variables were consistent with the respective sleep diagnoses. Forty service members (12.9%) met criteria for nightmare disorder; those with OSA were significantly less likely to have nightmares. Shift work disorder was present in 49 (15.9%) and did not differ between sleep diagnoses. PTSD was present in 57 (18%) and those with COMISA were significantly more likely to have PTSD. A history of head injuries was reported by 38.2% and there was no difference in rates between the sleep disorder groups.

Conclusion

The most frequent sleep disorder profile in service members with sleep disturbances was COMISA, which was associated with significantly higher rates of PTSD and anxiety. Conversely, OSA alone was not associated with higher rates of any comorbid disorders. Nightmare disorder and shift work are relatively prevalent in military personnel with sleep disorders.

Support (If Any)

This work was supported by the Defense Health Agency, Defense Medical Research and Development Program, Clinical Research Intramural Initiative for Military Women’s Health (DM170708; Mysliwiec), and the Air Force Research Laboratory, Wright Patterson Air Force Base, Ohio (FA8650-18-2-6953; Peterson). The views expressed herein are solely those of the authors and do not represent an endorsement by or the official policy or position of the U.S. Air Force, the U.S. Army, the Defense Health Agency, the Department of Defense, the Department of Veterans Affairs, or the U.S. Government.

Suicidal Ideation Across Three Timepoints in Patients Discharged from Psychiatric Hospitalization

This article describes the rate of suicidal ideation (SI) across three timepoints among treatment-seeking patients recently discharged from psychiatric hospitalization-a group that is at ultrahigh-risk for suicide. Retrospective chart review was used to quantify the rate of SI in 252 consecutive patients discharged to a post-hospital mental health clinic. Data include patients' lifetime history of SI, SI at the time of hospital intake, and SI at post-hospital outpatient clinic intake, as well as demographics and diagnosis. Overall, 67% of the sample reported a lifetime history of SI, 49% reported SI during hospital intake, and 6% reported SI at post-hospital clinic intake. Age was the only variable associated with history of SI (p = .04), with younger patients more likely (OR = 1.85) to report a history of SI. These results may help inform the development of interventions for the population of ultrahigh-risk patients being discharged from hospital after psychiatric care.

The Military Service Sleep Assessment: an instrument to assess factors precipitating sleep disturbances in U.S. military personnel

STUDY OBJECTIVES

Military personnel frequently experience sleep difficulties, but little is known regarding which military or life events most impact their sleep. The Military Service Sleep Assessment (MSSA) was developed to assess the impact of initial military training, first duty assignment, permanent change of station, deployments, redeployments, and stressful life events on sleep. This study presents an initial psychometric evaluation of the MSSA and descriptive data in a cohort of service members.

METHODS

The MSSA was administered to 194 service members in a military sleep disorders clinic as part of a larger study.

RESULTS

Average sleep quality on the MSSA was 2.14 (on a Likert scale, with 1 indicating low and 5 indicating high sleep quality), and 72.7% (n = 140) of participants rated their sleep quality as low to low average. The events most reported to negatively impact sleep were stressful life events (41.8%), followed by deployments (40.6%). Military leadership position (24.7%) and birth/adoption of a child (9.7%) were the most frequently reported stressful life events to negatively impact sleep. There were no significant differences in current sleep quality among service members with a history of deployment compared with service members who had not deployed.

CONCLUSIONS

The MSSA is the first military-specific sleep questionnaire. This instrument provides insights into the events during a service member's career, beyond deployments, which precipitate and perpetuate sleep disturbances and likely chronic sleep disorders. Further evaluation of the MSSA in nontreatment-seeking military populations and veterans is required.

730 Prevalence and impact of sleep problems in active duty military personnel receiving Cognitive Processing Therapy for PTSD

Introduction

Sleep disturbances are common in active duty military personnel and play a key role in the development and maintenance of posttraumatic stress disorder (PTSD). Research indicates that although insomnia and nightmares improve with successful PTSD treatment, they may remain clinically significant. Few previous PTSD studies have assessed sleep disorder constructs using validated instruments. The objectives of this study were to examine the proportion of active duty military personnel seeking treatment for PTSD who reported clinically significant insomnia, nightmares, sleep duration, and excessive daytime sleepiness and to examine the impact PTSD treatment had on these sleep constructs using validated self-report questionnaires.

Methods

Sleep was evaluated in 223 active duty service members participating in a randomized clinical trial comparing group and individual Cognitive Processing Therapy (CPT) for PTSD. Sleep constructs were assessed using the Insomnia Severity Index (ISI), Trauma-Related Nightmare Survey (TRNS), Self-Assessment of Sleep (SAS), and Epworth Sleepiness Scale (ESS) at baseline and 2 weeks posttreatment.

Results

At baseline, 82% of participants reported clinically significant insomnia and 75% reported at least 1 moderately severe nightmare per week. Participants reported averaging 4.76 hours of sleep per night, and 65% reported excessive daytime sleepiness. Over the course of PTSD treatment, there were statistically significant improvements in insomnia, nightmares, and excessive daytime sleepiness, but scores remained in clinically significant ranges. Minimal increases were seen in sleep duration. Of the participants who no longer met criteria for PTSD at posttreatment, 50% continued to report clinically significant insomnia, 52% continued to report clinically significant nightmares, and 44% continued to report excessive daytime sleepiness.

Conclusion

Consistent with previous research, sleep problems persisted for a significant number of service members who completed treatment for PTSD. Insomnia, nightmare, and sleep extension interventions are likely an important part of comprehensive PTSD treatment plans.

Support (if any)

Funding for this work was made possible by the U.S. Department of Defense through the U.S. Army Medical Research and Materiel Command, Congressionally Directed Medical Research Programs, Psychological Health and Traumatic Brain Injury Research Program awards W81XWH-08-02-109 (Alan Peterson), W81XWH-08-02-0116 (Patricia Resick), W81XWH-10-1-0828 (Daniel Taylor), and W81XWH-08-02-0114 (Brett Litz).

Sleep difficulties as a predictor of attrition in United States Air Force recruits

STUDY OBJECTIVES

The objective of the study was to estimate the rates of "difficulty sleeping at night" in newly enlisted United States Air Force (USAF) recruits and determine if these sleep difficulties predicted 1-year attrition (discharge for any reason) independently and after controlling for all other Lackland Behavioral Questionnaire (LBQ) predictors.

METHODS

The LBQ was administered to 202,339 active duty, enlisted USAF trainees completing basic military training at Joint Base San Antonio-Lackland, Texas, from January 2006 to December 2012. Attrition data were obtained through the Defense Manpower Data Center.

RESULTS

Fifty percent of the sample reported at least occasional sleep difficulties in the past year, with 9% reporting frequent (6% = often and 3% = most of the time) sleep difficulties. Twelve percent of trainees had been discharged within one year, and sleep difficulties were the second strongest significant predictor of this attrition after accounting for all other predictor variables in the LBQ, Wald χ² = 254.19, p < .0001. Trainees with frequent sleep difficulties were 2.7 times more likely to be discharged than those without sleep difficulties based on the odds ratio statistic.

CONCLUSIONS

Rates of self-reported frequent "difficulty sleeping…," before basic training started, were similar to civilian populations and were the second strongest predictor of one-year attrition. "Difficulty sleeping…" encompasses many sleep problems (e.g., insomnia, sleep deprivation, circadian misalignment). Future studies should determine what specific sleep difficulties pose the greatest risk for attrition and then determine if they can be remediated, thus decreasing attrition risk, or if they should be a focus of screening.

Courses of suicidal ideation among military veterans in residential treatment for posttraumatic stress disorder

BACKGROUND

Suicidal thoughts are common among veterans with posttraumatic stress disorder (PTSD). The aim of this study was to examine the prevalence and correlates of four courses of suicidal (SI) among veterans receiving residential PTSD treatment.

METHODS

A total of 1,807 veterans receiving residential PTSD treatment at Department of Veterans Affairs medical facilities who completed self-report measures at admission and discharge were included.

RESULTS

The prevalence of SI courses were No SI (33.6%), Remitted SI (23.0%), SI onset (6.0%), and Chronic SI (37.4%). There were group differences between the four SI courses in PTSD symptoms at baseline, magnitude of PTSD symptom change during treatment, race/ethnicity and baseline depression, substance use, physical functioning, and pain. Chronic SI was associated with highest baseline PTSD, depression, substance use, pain and worse physical functioning. Remitted SI course was associated with greatest pre-posttreatment PTSD improvement, followed by No SI, Chronic SI, and SI Onset. Multinomial logistic regressions revealed that PTSD symptom improvement and baseline PTSD symptoms most consistently related to symptomatic SI courses compared to less symptomatic or No SI courses. Receipt of trauma-focused psychotherapy (none, some, or adequate) and length of stay were not related to SI courses and did not differ between groups.

CONCLUSIONS

Findings indicate that treating PTSD symptoms could be impactful for reducing suicidal thoughts. Although many veterans had remitted or reduced severity of SI at discharge, a significant proportion of veterans reported SI at discharge (43.4%), potentially highlighting the need for suicide specific treatment interventions within the context of PTSD treatment.

Conceptualizing comorbid PTSD and depression among treatment-seeking, active duty military service members

BACKGROUND

Among active duty service members and veterans with PTSD, depression is the most commonly diagnosed comorbid psychiatric condition. More research is warranted to investigate the relationship between PTSD and depression to improve treatment approaches. Byllesby et al. (2017) used confirmatory factor analyses in a sample of trauma-exposed combat veterans with PTSD and found that only the general distress factor, and not any specific symptom cluster of PTSD, predicted depression. This study seeks to replicate Byllesby et al. (2017) in a sample of treatment-seeking active duty soldiers.

METHODS

Confirmatory factor analyses, bifactor modeling, and structural equation modeling (SEM) were used with data gathered at pretreatment and posttreatment as part of a large randomized clinical trial.

RESULTS

Confirmatory factor analyses and bifactor modeling demonstrated that PTSD symptom clusters, Negative Alterations in Cognition and Mood (NACM) and Alterations in Arousal and Reactivity (AAR), as well as the general distress factor significantly predicted depression at pretreatment and posttreatment.

LIMITATIONS

The current study was predominantly male, limiting the generalizability to female service members with PTSD. Also, self-report measures were used, which may introduce response-bias.

CONCLUSIONS

The current study did not replicate Byllesby et al. (2017). Results demonstrated that the relationship between PTSD and depression among active duty service members can be explained by both transdiagnostic factors and disorder-specific symptoms.

Intensive prolonged exposure therapy for combat-related posttraumatic stress disorder: Design and methodology of a randomized clinical trial

Combat-related posttraumatic stress disorder (PTSD) is the most common psychological health condition in military service members and veterans who have deployed to the combat theater since September 11, 2001. One of the highest research priorities for the Department of Defense and the Department of Veterans Affairs is to develop and evaluate the most efficient and efficacious treatments possible for combat-related PTSD. However, the treatment of combat-related PTSD in military service members and veterans has been significantly more challenging than the treatment of PTSD in civilians. Randomized clinical trials have demonstrated large posttreatment effect sizes for PTSD in civilian populations. However, recent randomized clinical trials of service members and veterans have achieved lesser reductions in PTSD symptoms. These results suggest that combat-related PTSD is unique. Innovative approaches are needed to augment established evidence-based treatments with targeted interventions that address the distinctive elements of combat-related traumas. This paper describes the design, methodology, and protocol of a randomized clinical trial to compare two intensive prolonged exposure therapy treatments for combat-related PTSD in active duty military service members and veterans and that can be administered in an acceptable, efficient manner in this population. Both interventions include intensive daily treatment over a 3-week period and a number of treatment enhancements hypothesized to result in greater reductions in combat-related PTSD symptoms. The study is designed to advance the delivery of care for combat-related PTSD by developing and evaluating the most potent treatments possible to reduce PTSD symptomatology and improve psychological, social, and occupational functioning.