Sleep: key to understanding mental health problems in the military?

15 June 2015 (Last Updated June 15th, 2015 18:30)

The importance of sleep in the armed forces is often forgotten, with early wake-up calls during basic training and the complexities of missions depriving members of healthy sleep. A study has found that such problems could predict the onset of mental health conditions, including post-traumatic stress disorder. Gary Peters speaks to the researchers to find out more.

Sleep: key to understanding mental health problems in the military?

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Getting seven to eight hours' sleep each night is a necessity to many. Healthy sleep helps people function, keeping them alert to what the day may throw their way. But how does this work in the military environment, where many barriers prevent members of the armed forces from attaining such a goal? Now, a new study has shone a light on the lack of sleep in the military and its consequences.

With combat operations in Iraq and Afghanistan now winding down and more veterans returning home to civilian life, the number of troops seeking help for mental health problems is rising.

In March, the UK-based charity Combat Stress reported a 26% increase in one year alone, with six new veterans asking for help every day; this adds up to 2,264 veterans.

According to figures from the U.S. Department of Veterans Affairs' National Center for PTSD [Post-Traumatic Stress Disorder], updated in November 2014, approximately eleven to 20 out of every 100 veterans who served in Operation Iraqi Freedom and Operation Enduring Freedom have PTSD in a given year.

While treatment may be focused on dealing with the issue after it has been diagnosed, one area that has received relatively little attention is the importance of healthy sleep in military environments and its impact on mental health.

A study by RAND, a non-profit research organisation, entitled 'Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers', has found that sleep problems are common among troops and are linked to an increased risk of PTSD, depression, suicide, cardiovascular disease, obesity, accidents and injuries.



The US Government is investing $107 million to establish two consortia to research the diagnosis and treatment of post-traumatic stress disorder .


Commissioned by the U.S. Department of Defense's Defense Centers of Excellence on Psychological Health and Traumatic Brain Injury, RAND's study aims to identify the correlates and consequences of sleep problems among servicemembers, highlight the current programmes and policies related to sleep in the military and suggest evidence-based interventions to treat sleep disorders. It also contemplates the barriers to achieving healthy sleep and recommends ideas to improve the situation.

Predicting the onset of PTSD?

One of the sparks for the RAND study was a literature review that showed that in a previous study of 15,204 servicemembers pre-deployment insomnia was followed by the onset of PTSD, anxiety and depression post-deployment.

It also claimed that those getting less than six hours of sleep pre-deployment were more likely to develop PTSD and anxiety following deployment, and those suffering from pre-deployment insomnia and only a few hours' sleep were at the greatest risk for PTSD and anxiety.

"Our literature review showed that sleep disturbances can often precede the onset of PTSD and other mental health problems," says Wendy Troxel, a clinical psychologist and behavioural scientist at RAND.

"So, screening for, and treating, sleep problems may be one way to identify those at risk for mental health problems."

RAND's own survey included approximately 2,000 US servicemembers across all service branches and components.

"Our literature review showed that sleep disturbances can often precede the onset of PTSD and other mental health problems."

The sample of army troops included "sufficient numbers in the sample to analyse the prevalence of sleep problems in those who had never deployed, currently deployed or previously deployed".

"For [the] navy, we were able to analyse data in those who had never deployed or previously deployed," adds Troxel.

RAND's findings claim that only 37% of servicemembers sleep the recommended seven to eight hours per night, while approximately 31% of those surveyed said they slept for five hours or less.

Other key findings include a particularly high prevalence of poor sleep among those who have deployed to conflict zones, with this possibly compromising operational effectiveness.

Barriers: is military culture to blame?

The two-year study also looked at post-deployed servicemembers, with Troxel adding that sleep problems were prevalent "regardless of deployment history".

"This suggests that sleep may be endemic to military culture and that cultural barriers to achieving sufficient, good quality sleep must be addressed to promote physical health, mental health and operational readiness in the military," she adds.



The treatment of post-traumatic stress disorder (PTSD) in military veterans is challenging for both the patient and health service personnel.


This can be linked to the 'mission first' attitude among troops. The research states that sleep deprivation can be seen as a badge of honour, with weakness associated to those who acknowledge they need sleep.

"Mission first is the creed of every servicemember," explains Troxel. "Therefore, operational demands and manpower limitations, as well as cultural attitudes that have traditionally undermined the need for sleep, can serve as barriers that make it challenging for servicemembers to get the sleep they need.

"Our report identified several factors that serve as barriers to achieving healthy sleep in the military, including cultural barriers, knowledge barriers, operational barriers, and medical and treatment system barriers."

For example, sleep can be seen as a luxury rather than a necessity or priority, while others may not recognise the importance of sleep health - a clear knowledge barrier. A lack of knowledge as to the risk of sleep medications was also reported among those using them.

Not having enough manpower also inhibits commanders from allowing every servicemember adequate sleep. Of course, the enivornment in which they operate can also have a negative effect, with noise and conditions not conducive to sleep.

According to Troxel and her team, those suffering from sleep disturbances may also be hesitant to seek help via military health care professionals for fear of the potential consequences, such as the reaction of peers or the effect on their career because of prolonged treatment.

Changing policies and attitudes

RAND's findings suggest that more needs to be done to promote sleep within the military environment. RAND's handbook, 'Improving Sleep Health for U.S. Servicemembers', which was part of the wider study, claimed that no codified prevention policies are in place, although "each military service has at least one programme...in which healthy sleep is identified as an important component of resilience", and includes recommendations encouraging healthy sleep behaviours.

"Troxel also believes that "the role of sleep and fatigue on mishaps" should be evaluated."

One such programme is the Performance Triad, an army initiative which focuses on sleep, activity and nutrition. Other U.S. Department of Defense recommendations focus on managing sleep during post-deployment and improving awareness of poor sleep.

Researchers also found that in the US Navy and Marine Corps, personnel are given sleep rights permitting them eight hours of sleep per night, except in certain conditions. For the US Army, trainees are given tips on how to manage sleep and recognise problems.

"Some of our recommendations include preventing sleep problems through increased education about sleep-related behaviours," says Troxel.

"[In addition we should] improve screening for sleep disturbances in primary settings, enhance the dissemination of evidence-based practices, improve continuity of care of treatments across the deployment cycle [and] revise training and operational policies regarding sleep to align with current clinical guidelines about optimal sleep duration."

Troxel also believes that "the role of sleep and fatigue on mishaps" should be evaluated, and positive messages about sleep should be promoted as an "operational imperative".

In 2009, sleep guidelines by the U.S. Army Medical Command said that soldiers require seven to eight hours of "good quality" sleep to remain at peak performance, and any less would result in "some level of performance degradation".

It also highlighted that sleep should be seen in a similar light to water, food, fuel and ammunition.

However, the military environment, with its mission first imperative, is unlikely to transform into a haven for sleep overnight, despite the best of intentions.