Current Psychiatry Reports

, 15:401 | Cite as

Deployment-Related Insomnia in Military Personnel and Veterans

Sleep Disorders (RM Benca, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Sleep Disorders

Abstract

Insomnia is a prevalent disorder that greatly impacts military personnel, especially those deployed in support of combat efforts. Deployment-related stressors like combat exposure, mild traumatic brain injury (mTBI) irregular sleep-wake schedules, and adjustment to the return home all contribute to insomnia. However, insomnia can also exacerbate the deployment experience and is a risk factor for traumatic stress reactions such as PTSD, depression, and suicide. Military personnel with mTBI are significantly impacted by insomnia; the majority experience sleep disruption and this can impede recovery and rehabilitation. As more service members return home from deployment, treatment is vital to reduce the impact of insomnia. Preliminary outcome data, showing positive results for reduction of sleep disruption, has been found with treatments such as combined cognitive behavioral treatment of insomnia (CBTI) and imagery rehearsal therapy (IRT), preference-based interventions, as well as efforts to broadly disseminate CBTI. The recent literature on the impact and treatment of deployment-related insomnia is reviewed.

Keywords

Insomnia Comorbid insomnia Military personnel Veterans PTSD Depression Anxiety Traumatic brain injury Suicide Psychotherapy Pharmacotherapy Sleep disorders Psychiatry 

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002;6:97–111.PubMedCrossRefGoogle Scholar
  2. 2.
    Roth T, Coulouvrat C, Hajak G, Lakoma MD, Sampson NA, Shahly V, et al. Prevalence and perceived health associated with insomnia based on DSM-IV-TR; International Statistical Classification of Diseases and Related Health Problems, Tenth Revision; and Research Diagnostic Criteria/International Classification of Sleep Disorders, Second Edition criteria: results from the America Insomnia Survey. Biol Psychiatry. 2011;69:592–600.PubMedCrossRefGoogle Scholar
  3. 3.
    Cozza SJ, Benedek DM, Bradley JC, Grieger TA, Nam TS, Waldrep DA. Topics specific to the psychiatric treatment of military personnel. In The Iraq War Clinician Guide, edn 2nd. Edited by Schnurr PP, Cozza SJ. National Center for PTSD and Department of Defense; 2004.Google Scholar
  4. 4.
    Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in U.S. Soldiers returning from Iraq. N Engl J Med. 2008;358:453–63.PubMedCrossRefGoogle Scholar
  5. 5.
    Spielman AJ, Glovinsky PB. Introduction - the varied nature of insomnia. In: Hauri PJ, editor. Case studies in insomnia. New York: Plenum Publishing Corporation; 1991. p. 1–15.CrossRefGoogle Scholar
  6. 6.
    Sareen J, Henriksen CA, Bolton SL, Afifi TO, Stein MB, Asmundson GJ. Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel. Psychol Med. 2013;43:73–84.PubMedCrossRefGoogle Scholar
  7. 7.
    Leardmann CA, Smith B, Ryan MA. Do adverse childhood experiences increase the risk of postdeployment posttraumatic stress disorder in US Marines? BMC Publ Health. 2010;10:437.CrossRefGoogle Scholar
  8. 8.
    Insana SP, Kolko DJ, Germain A. Early-life trauma is associated with rapid eye movement sleep fragmentation among military veterans. Biol Psychol. 2012;89:570–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Toblin RL, Clarke-Walper K, Kok BC, Sipos ML, Thomas JL. Energy drink consumption and its association with sleep problems among U.S. service members on a combat deployment - Afghanistan, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:895–8.Google Scholar
  10. 10.
    Reissig CJ, Strain EC, Griffiths RR. Caffeinated energy drinks–a growing problem. Drug Alcohol Depend. 2009;99:1–10.PubMedCrossRefGoogle Scholar
  11. 11.
    Roehrs T, Roth T. Caffeine: sleep and daytime sleepiness. Sleep Med Rev. 2008;12:153–62.PubMedCrossRefGoogle Scholar
  12. 12.
    •• Wallace DM, Shafazand S, Ramos AR, Carvalho DZ, Gardener H, Lorenzo D, et al. Insomnia characteristics and clinical correlates in Operation Enduring Freedom/Operation Iraqi Freedom veterans with post-traumatic stress disorder and mild traumatic brain injury: an exploratory study. Sleep Med. 2011;12:850–9. Highlights the prevalence and impact of insomnia among OEF/OIF Veterans with PTSD and mTBI.PubMedCrossRefGoogle Scholar
  13. 13.
    Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev. 2004;8:119–32.PubMedCrossRefGoogle Scholar
  14. 14.
    Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, depression, and anxiety. Sleep. 2005;28:1457–64.PubMedGoogle Scholar
  15. 15.
    Wright KM, Britt TW, Bliese PD, Adler AB, Picchioni D, Moore D. Insomnia as predictor versus outcome of PTSD and depression among Iraq combat veterans. J Clin Psychol. 2011;67:1240–58.PubMedCrossRefGoogle Scholar
  16. 16.
    Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135:10–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Roane BM, Taylor DJ. Adolescent insomnia as a risk factor for early adult depression and substance abuse. Sleep. 2008;31:1351–6.PubMedGoogle Scholar
  18. 18.
    Bryant RA, Creamer M, O'Donnell M, Silove D, McFarlane AC. Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder. Sleep. 2010;33:69–74.PubMedGoogle Scholar
  19. 19.
    Weathers F, Litz B, Herman DS, Huska JA, Keane T. The PTSD checklist: reliabilty, validity, & diagnostic utility. 1993.Google Scholar
  20. 20.
    McLay RN, Klam WP, Volkert SL. Insomnia is the most commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from military deployments. Mil Med. 2010;175:759–62.PubMedGoogle Scholar
  21. 21.
    van Liempt S, van Zuiden M, Westenberg H, Super A, Vermetten E. Impact of impaired sleep on the development of PTSD symptoms in combat veterans: a prospective longitudinal cohort study. Depress Anxiety. 2013;30:469–74.PubMedCrossRefGoogle Scholar
  22. 22.
    Koren D, Arnon I, Lavie P, Klein E. Sleep complaints as early predictors of posttraumatic stress disorder: a 1-year prospective study of injured survivors of motor vehicle accidents. Am J Psychiatry. 2002;159:855–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Mellman TA, David D, Kulick-Bell R, Hebding J, Nolan B. Sleep disturbance and its relationship to psychiatric morbidity after Hurricane Andrew. Am J Psychiatry. 1995;152:1659–63.PubMedGoogle Scholar
  24. 24.
    Hughes J, Jouldjian S, Washington DL, Alessi CA, Martin JL. Insomnia and symptoms of post-traumatic stress disorder among women veterans. Behav Sleep Med. 2013;11:258–74.Google Scholar
  25. 25.
    Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28:193–213.PubMedCrossRefGoogle Scholar
  26. 26.
    Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307.PubMedCrossRefGoogle Scholar
  27. 27.
    Edinger JD, Wohlgemuth WK. Psychometric comparisons of the standard and abbreviated DBAS-10 versions of the dysfunctional beliefs and attitudes about sleep questionnaire. Sleep Med. 2001;2:493–500.PubMedCrossRefGoogle Scholar
  28. 28.
    Agargun MY, Kara H, Solmaz M. Sleep disturbances and suicidal behavior in patients with major depression. J Clin Psychiatry. 1997;58:249–51.PubMedCrossRefGoogle Scholar
  29. 29.
    Bernert RA, Joiner Jr TE, Cukrowicz KC, Schmidt NB, Krakow B. Suicidality and sleep disturbances. Sleep. 2005;28:1135–41.PubMedGoogle Scholar
  30. 30.
    Fawcett J, Scheftner WA, Fogg L, Clark DC, Young MA, Hedeker D, et al. Time-related predictors of suicide in major affective disorder. Am J Psychiatry. 1990;147:1189–94.PubMedGoogle Scholar
  31. 31.
    Bryan CJ, Kanzler KE, Durham TL, West CL, Greene E. Challenges and considerations for managing suicide risk in combat zones. Mil Med. 2010;175:713–8.PubMedGoogle Scholar
  32. 32.
    Pigeon WR, Britton PC, Ilgen MA, Chapman B, Conner KR. Sleep disturbance preceding suicide among veterans. Am J Public Health. 2012;102 Suppl 1:S93–7.PubMedCrossRefGoogle Scholar
  33. 33.
    Kontos AP, Kotwal RS, Elbin RJ, Lutz RH, Forsten RD, Benson PR, Guskiewicz KM. Residual effects of combat-related mild traumatic brain injury. J Neurotrauma. 2013;30:680–6.Google Scholar
  34. 34.
    Wilk JE, Herrell RK, Wynn GH, Riviere LA, Hoge CW. Mild traumatic brain injury (concussion), posttraumatic stress disorder, and depression in U.S. soldiers involved in combat deployments: association with postdeployment symptoms. Psychosom Med. 2012;74:249–57.PubMedCrossRefGoogle Scholar
  35. 35.
    Rand Corporation, Adamson DM, Burnam MA, Burns RM, Caldarone LB, Cox RA, et al. Invisible wounds of war: psychological and cognitive injuries, their consequences, and services to assist recovery. Edited by Tanielian T, Jaycox LH. ISBN/EAN: 9780833044549. 2008. RAND Corporation monograph series.Google Scholar
  36. 36.
    Wilk JE, Thomas JL, McGurk DM, Riviere LA, Castro CA, Hoge CW. Mild traumatic brain injury (concussion) during combat: lack of association of blast mechanism with persistent postconcussive symptoms. J Head Trauma Rehabil. 2010;25:9–14.PubMedCrossRefGoogle Scholar
  37. 37.
    Polusny MA, Kehle SM, Nelson NW, Erbes CR, Arbisi PA, Thuras P. Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in national guard soldiers deployed to Iraq. Arch Gen Psychiatry. 2011;68:79–89.PubMedCrossRefGoogle Scholar
  38. 38.
    Terrio H, Brenner LA, Ivins BJ, Cho JM, Helmick K, Schwab K, et al. Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team. J Head Trauma Rehabil. 2009;24:14–23.PubMedCrossRefGoogle Scholar
  39. 39.
    Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis. Sleep Med. 2012;13:898–905.PubMedCrossRefGoogle Scholar
  40. 40.
    Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest. 2012;142:622–30.PubMedCrossRefGoogle Scholar
  41. 41.
    Rao V, Spiro J, Vaishnavi S, Rastogi P, Mielke M, Noll K, et al. Prevalence and types of sleep disturbances acutely after traumatic brain injury. Brain Inj. 2008;22:381–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Bryan CJ. Repetitive traumatic brain injury (or concussion) increases severity of sleep disturbance among deployed military personnel. Sleep. 2013;36:941–6.PubMedGoogle Scholar
  43. 43.
    Kempf J, Werth E, Kaiser PR, Bassetti CL, Baumann CR. Sleep-wake disturbances 3 years after traumatic brain injury. J Neurol Neurosurg Psychiatry. 2010;81:1402–5.PubMedCrossRefGoogle Scholar
  44. 44.
    Worthington AD, Melia Y. Rehabilitation is compromised by arousal and sleep disorders: results of a survey of rehabilitation centres. Brain Inj. 2006;20:327–32.PubMedCrossRefGoogle Scholar
  45. 45.
    Makley MJ, English JB, Drubach DA, Kreuz AJ, Celnik PA, Tarwater PM. Prevalence of sleep disturbance in closed head injury patients in a rehabilitation unit. Neurorehabil Neural Repair. 2008;22:341–7.PubMedGoogle Scholar
  46. 46.
    Harvey AG. Insomnia: symptom or diagnosis? Clin Psychol Rev. 2001;21:1037–59.PubMedCrossRefGoogle Scholar
  47. 47.
    Germain A. Sleep disturbances as the hallmark of PTSD: where are we now? Am J Psychiatry. 2013;170:372–82.PubMedCrossRefGoogle Scholar
  48. 48.
    Bootzin RR. Stimulus control treatment for insomnia. Proc Am Psychol Assoc. 1972;7:395–6.Google Scholar
  49. 49.
    Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10:45–56.PubMedGoogle Scholar
  50. 50.
    Krakow B, Kellner R, Pathak D, Lambert L. Imagery rehearsal treatment for chronic nightmares. Behav Res Ther. 1995;33:837–43.PubMedCrossRefGoogle Scholar
  51. 51.
    •• Manber R, Carney C, Edinger J, Epstein D, Friedman L, Haynes PL, et al. Dissemination of CBTI to the non-sleep specialist: protocol development and training issues. J Clin Sleep Med. 2012;8:209–18. An introduction to the nationwide rollout of CBTI training in the VHA.PubMedGoogle Scholar
  52. 52.
    • Karlin BE, Trockel M, Taylor CB, Gimeno J, Manber R. National dissemination of cognitive behavioral therapy for insomnia in veterans: therapist- and patient-level outcomes. J Consult Clin Psychol. 2013 Apr 15. [Epub ahead of print]. Initial results of both providers and patients for the VHA's nationwide CBTI training program. Google Scholar
  53. 53.
    Lavie P. Sleep disturbances in the wake of traumatic events. N Engl J Med. 2001;345:1825–32.PubMedCrossRefGoogle Scholar
  54. 54.
    Neylan TC, Marmar CR, Metzler TJ, Weiss DS, Zatzick DF, Delucchi KL, et al. Sleep disturbances in the Vietnam generation: findings from a nationally representative sample of male Vietnam veterans. Am J Psychiatry. 1998;155:929–33.PubMedGoogle Scholar
  55. 55.
    Krakow B, Hollifield M, Johnston L, Koss M, Schrader R, Warner TD, et al. Imagery rehearsal therapy for chronic nightmares in sexual assault survivors with posttraumatic stress disorder: a randomized controlled trial. JAMA. 2001;286:537–45.PubMedCrossRefGoogle Scholar
  56. 56.
    Nappi CM, Drummond SP, Thorp SR, McQuaid JR. Effectiveness of imagery rehearsal therapy for the treatment of combat-related nightmares in veterans. Behav Ther. 2010;41:237–44.PubMedCrossRefGoogle Scholar
  57. 57.
    Germain A, Shear MK, Hall M, Buysse DJ. Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study. Behav Res Ther. 2007;45:627–32.PubMedCrossRefGoogle Scholar
  58. 58.
    • Ulmer CS, Edinger JD, Calhoun PS. A multi-component cognitive-behavioral intervention for sleep disturbance in veterans with PTSD: a pilot study. J Clin Sleep Med. 2011;7:57–68. Combined CBTI/IRT improves insomnia, nightmares, and PTSD severity in Veterans.PubMedGoogle Scholar
  59. 59.
    • Germain A, Richardson R, Moul DE, Mammen O, Haas G, Forman SD, et al. Placebo-controlled comparison of prazosin and cognitive-behavioral treatments for sleep disturbances in US Military Veterans. J Psychosom Res. 2012;72:89–96. Combined CBTI/IRT, and prazosin, improves insomnia and nightmares in Veterans; CBTI/IRT group maintained treatment gains better than prazosin group at follow-up.PubMedCrossRefGoogle Scholar
  60. 60.
    Epstein DR, Babcock-Parziale JL, Haynes PL, Herb CA. Insomnia treatment acceptability and preferences of male Iraq and Afghanistan combat veterans and their healthcare providers. J Rehabil Res Dev. 2012;49:867–78.PubMedCrossRefGoogle Scholar
  61. 61.
    Epstein DR, Babcock-Parziale JL, Herb CA, Goren K, Bushnell ML. Feasibility test of preference-based insomnia treatment for Iraq and Afghanistan war veterans. Rehabil Nurs. 2013;38:120–32.PubMedCrossRefGoogle Scholar
  62. 62.
    Troxel WM, Germain A, Buysse DJ. Clinical management of insomnia with brief behavioral treatment (BBTI). Behav Sleep Med. 2012;10:266–79.PubMedCrossRefGoogle Scholar
  63. 63.
    Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171:887–95.PubMedCrossRefGoogle Scholar
  64. 64.
    Germain A, Moul DE, Franzen PL, Miewald JM, Reynolds CF, Monk TH, et al. Effects of a brief behavioral treatment for late-life insomnia: preliminary findings. J Clin Sleep Med. 2006;2:403–6.PubMedGoogle Scholar
  65. 65.
    Lande RG, Gragnani C. Efficacy of cranial electric stimulation for the treatment of insomnia: a randomized pilot study. Complement Ther Med. 2013;21:8–13.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC)VA Pittsburgh Healthcare SystemPittsburghUSA
  2. 2.Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghUSA
  3. 3.Department of PsychologyUniversity of PittsburghPittsburghUSA

Personalised recommendations