Sleep issues continue to torment military personnel, and the military is increasingly concerned, because insufficient sleep from chronic insomnia poses a direct threat to military operational readiness. Soldiers in the Army have been most effected. Still, a recent study pointed out that clinical guidelines on treating the issues aren’t always being followed.
U.S. Army soldiers slept in a hasty fighting position on a cold morning in the mountains near Sar Howza, Paktika province, Afghanistan, in September 2009. Photo by Staff Sgt. Andrew Smith
WASHINGTON, DC — Chronic insomnia is a persistent issue for active-duty servicemembers and recommended treatment guidelines aren’t always followed to appropriately deal with the problem, according to a recent study.
The retrospective cohort study called “Incidence and Management of Chronic Insomnia, Active Component, U.S. Armed Forces, 2012 to 2021” estimated the incidence of chronic insomnia in active component military members from 2012 through 2021. The study, which also assessed the percentage of servicemembers receiving VA/DoD Clinical Practice Guideline-recommended insomnia treatments, was published recently in the military’s Medical Surveillance Monthly Report.1
The study population included all individuals who served in the active component of the Army, Navy, Air Force or Marine Corps at any time between January 2012 and December 2021. Researchers from the Uniformed Services University of the Health Sciences and the Armed Forces Health Surveillance Division gathered data for the study from the Defense Medical Surveillance System (DMSS), which contains comprehensive medical encounter and pharmacy data for active component servicemembers, as well as self-reported health data from annual Periodic Health Assessments (PHAs).
Insomnia, the most common sleep disorder in the United States, is characterized by a subjective perception of difficulty initiating or maintaining sleep, dissatisfaction with sleep quantity or quality despite adequate opportunity and subsequent daytime impairment. Chronic insomnia is defined as insomnia symptoms that last for at least three months and occur at least three days per week, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the International Classification of Sleep Disorders, Third Edition.
Among U.S. adults, 20% to 30% of adults report at least one symptom of insomnia, and an estimated 6% to 10% meet diagnostic criteria for chronic insomnia. Studies on military personnel have reported much higher prevalence and suggest that insomnia is a growing health threat to servicemembers. For instance, during Operation Iraqi Freedom, Operation Enduring Freedom and Operation New Dawn, diagnosis rates of insomnia increased dramatically in all branches of service.
Click to Enlarge Source: Medical Surveillance Monthly Report
The military is increasingly concerned, because insufficient sleep from chronic insomnia poses a direct threat to military operational readiness, resulting in impaired decision-making and reaction time, decreased cognitive performance, increased musculoskeletal injury and decreased anaerobic and endurance performance.
Nearly 150,000 active-duty servicemembers were diagnosed with chronic insomnia between 2012 and 2021, and the annual incidence rate did not change much throughout the 10-year period, with an overall rate of 116.1 per 10,000 person-years, researchers from the Armed Forces Health Surveillance Division told U.S. Medicine.
The highest annual rate was in 2016 at 134.0 cases per 10,000 person-years, and the lowest annual rate was in 2020 at 99.8 cases per 10,000 person-years. The Army’s rates of chronic insomnia were consistently the highest among the military services, with an incidence rate more than twice the rate of any other service each year, peaking at 242.8 cases per 10,000 person-years in 2016, the study reported.
About two years ago, the Pentagon issued a report, “Study on Effects of Sleep Deprivation on Readiness of Members of the Armed Forces,” which detailed how critical adequate sleep is for optimal military function.
“Sleep may be the most important biological factor that determines Service member health and combat readiness,” according to the report. “U.S. military personnel across settings tend to self-report significantly higher rates of sleep deprivation than the general national population. The majority of service members report they receive less sleep than needed to perform their military duties well.”
Physical Injury Risk Increased
Click to Enlarge Source: Medical Surveillance Monthly Report
While the report concedes that intermittent, short-term sleep deprivation might be a necessary cost of operational and training demands, “it is likely that prolonged and chronic sleep deprivation has the opposite effect on the readiness of the U.S. Armed Forces. Impairment from sleep deprivation can be equivalent to the effects of alcohol intoxication and significantly increases the risk of physical injury.”
The Pentagon study reviewed recent research, finding that sleep deprivation has significant effects on the physical, cognitive and emotional functioning needed for readiness, occupational and operational mission fulfillment in the military.”
The 2019 VA and DoD joint Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea offers an evidence-based management pathway to help navigate the treatment of chronic insomnia. The recent USU-led study found, however, that implementation of these recommendations has been limited, according to the researchers.
“Chronic insomnia is a persistent problem among our servicemembers,” the Armed Forces Health Surveillance Division researchers wrote in an email. “There is a gap between what the Clinical Practice Guideline recommends for management of chronic insomnia and what is being done in clinical practice throughout the Military Health System. While behavioral therapy is recommended as first line treatment, especially for those with co-occurring mental health conditions, we found that 54% of individuals with chronic insomnia received behavioral therapy, while 73% received pharmacotherapy. We were also surprised to find that medications recommended against use for chronic insomnia in the Clinical Practice Guideline are still prescribed for this purpose.”
Incidence of chronic insomnia increased with age, with rates highest among the oldest servicemembers. Incidence also differed by sex and racial/ethnic group, being 51% higher among females than males and 69% to 89% higher for non-Hispanic Black servicemembers compared to those of non-Hispanic white, Hispanic or other/unknown race/ethnicity. Servicemembers with a history of prior deployment had an incidence rate 108% higher than those without prior deployment.
As case ages increased, the proportion of servicemembers who received therapy decreased. Co-existing mental health conditions increased the likelihood of receiving therapy for insomnia cases, according to the study.
Insomnia is associated with higher rates of numerous physical and mental health conditions, poor job performance, and increased work-related injuries and accidents. This sleep disorder also poses a threat to military operational readiness and can have devastating effects, such as two separate fatal collisions of U.S. Navy ships in 2017 where fatigue was cited as a contributing factor, the study authors advised.
The evidence-based management pathways outlined in the VA and DoD Clinical Practice Guideline “should be promoted to mitigate the negative consequences of chronic insomnia and to enhance the health and well-being of our servicemembers,” the Armed Forces Health Surveillance Division researchers recommended.
The researchers added that the MHS needs to promote awareness of the Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea to enhance the implementation of recommendations among clinicians caring for servicemembers.
- Hsu NM, Stahlman SL, Fan MT, Wells NY. Incidence and Management of Chronic Insomnia, Active Component, U.S. Armed Forces, 2012 to 2021. MSMR. 2023 Jan 20;30(1):2-10. PMID: 36881546.
