by Bianca Garilli, ND, IFMCP, USMC Veteran
Sleep disorders in military veterans are common, yet their role in chronic illness is frequently overlooked. A study published in Sleep brings attention to this important subject: “The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000–2010” was a serial, cross-sectional study that reviewed sleep disorder trends in veterans who were treated in the Veterans Health Administration (VHA) over a period of 11 years.1 In total, 9,786,778 patient visits were included in this study; collected information included sleep disorder diagnosis, sex, race, combat experience, BMI, and comorbid diagnoses.1
Key results include:1
- In veterans with >1 diagnosed sleep disorder, prevalence of sleep apnea was 47% and insomnia was 26%, and 91% had been prescribed at least 1 sleep medication
- Over the 11 years:
- Total sleep disorder diagnoses increased ~6-fold
- Sleep apnea and insomnia prevalence increased by >7-fold
- Relative increases in less prevalent sleep disorder subtypes were also seen:
- Movement disorders: relative increase of 1,048%
- Hypersomnias: relative increase of 50%
- Parasomnias: relative increase of 750%
- Circadian rhythm disorders: relative increase of 900%
Various hypotheses attempt to explain the dramatic increases in veterans’ sleep issues over this time period include improved diagnostic criteria and vigilance, increased reporting by patients as sleep issues have become a more prominent component of healthcare conversations, greater visibility via marketing ads for sleep aids (both equipment and pharmaceutical), increased prevalence of obesity (which is associated with increased prevalence of sleep disorders), and higher rates of mental health disorders including PTSD and depression which are also associated with sleep disorders.1 It is unknown whether mental health issues increase sleep disorders or if sleep problems exacerbate mental health conditions.1
Sleep problems, particularly at such dramatically rising rates, are of major concern for a variety of reasons, one of the most important being their link to a greater risk of increased morbidity and mortality.1-2 In a review and meta-analysis of 16 studies with data from 1,382,999 participants, it was found that both short duration sleepers (i.e., <7 hours/night, frequently <5 hours/night) and long duration sleepers (i.e., >8 or 9 hours/night) had increased rates of mortality (increased mortality rates of 12% and 30%, respectively when compared to sleeping between 7 and 8 hours/night).2
Adequate, restorative sleep plays an important role in chronic disease risk. There is increasing evidence that, “…chronically restricted and disrupted sleep have significant health consequences. By dysregulating immune and endocrine pathways, sleep may contribute to increased risk of inflammatory mediated diseases, including cardiovascular disease, diabetes, metabolic syndrome, and depression.”3 Additionally, sleep disorders have been linked with PTSD, depression, anxiety, and traumatic brain injury.4
Due to the rising prevalence of mental health issues in both active military and veteran personnel, it is critical to determine how sleep and mental health intersect within these populations.4 Research has revealed the bidirectional impact between the stressors of military service, particularly during war operations, and service members’ sleep patterns:4-5
- Chronic sleep disturbances reduce an individual’s resiliency and adaptive capacity to function optimally in stressful situations
- Exposure to stressful events and environments can negatively impact sleep quality
Taking this one step further, chronic exposure to stressful events coupled with poor sleep patterns may increase detrimental physical and psychological health outcomes.5 Unfortunately, sleep problems and their associated health issues do not simply resolve after a service member leaves the military. In fact, research is showing that sleep problems experienced while on active duty frequently persist long after deployments and service are over.4
The VHA has designed a self-guided sleep program called the Path to Better Sleep which utilizes cognitive behavioral therapy for insomnia (CBT-i), a non-pharmaceutical program used as a first line approach for addressing insomnia and other sleep disorders.6 The RAND Corporation’s in-depth report “Sleep in the Military” identifies the need for further work to elucidate innovative approaches, in addition to CBT-i, to address the rising trend of sleep-related disorders and their associated health concerns in the military and veteran populations.4
A publication in Clinical Psychology brings together components of several behavioral medicine theories to present insomnia as a chronic, cyclical problem that is interrelated to stress, both as a predictor of and a consequence of stressful events and environments.5 Additionally, the dynamic, reciprocal relationship between sleep and pain adds another layer of complexity to this health issue, due to the rising prevalence of chronic pain rates in service members and veterans.7-8 In fact, 2010-2014 data demonstrates that veterans experience a higher prevalence and severity of pain than their non-veteran counterparts.8
A Journal of Clinical Sleep Medicine study suggests that, “sleep and pain are worst in veterans with traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD), and that sleep is similarly impaired in veterans with PTSD despite not having as much pain.”7 Study authors discuss the possibility that PTSD may be the trigger for sleep disturbances and, when added to a co-occurring TBI, may then increase pain in this group of veterans.7
Realizing the multitude of tightly interwoven and complex interactions between stressful events and environments, sleep disorders, chronic pain, TBI, mental health, and additional factors such as comorbid chronic health issues including obesity, it is imperative that individualized plans of treatment be considered for each veterans’ unique needs and history. Utilizing a system of diagnosing and treating the root cause (possibly multiple causes in many cases) will be key to unraveling the connections between these various conditions and appropriate treatment.
- Alexander M et al. The national veteran sleep disorder study: descriptive epidemiology and secular trends, 2000-2010. Sleep. 2016;39(7):1399–1410.
- Francesco P et al. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep. 2010;33(5):585-592.
- Okun M. Biological consequences of disturbed sleep: important mediators of health? Jpn Psychol Res. 2011;53(2):163–176.
- Rand Corporation. Sleep in the military: promoting healthy sleep among U.S. service members. https://www.rand.org/content/dam/rand/pubs/research_reports/RR700/RR739/RAND_RR739.pdf. Accessed November 26, 2018.
- Hughes J et al. Insomnia in United States military veterans: an integrated theoretical model. Clin Psychol Rev. 2018;59:118-125.
- Department of Veterans Affairs. Veteran Training; Insomnia. https://www.veterantraining.va.gov/insomnia/index.asp. Accessed November 26, 2018.
- Balba N et al. Increased sleep disturbances and pain in Veterans with comorbid traumatic brain injury and posttraumatic stress disorder. J Clin Sleep Med. 2018;14(11):1865–1878.
- NIH. Pain: US military and veterans. https://nccih.nih.gov/health/pain/veterans. Accessed November 30, 2018.
Bianca Garilli, ND, IFMCP, USMC Veteran is a former US Marine turned Naturopathic Doctor (ND). She works in private practice in Northern California as well as running a consulting company working with leaders in the natural and functional medicine world such as the Institute for Functional Medicine and Metagenics. She is passionate about optimizing health and wellness in individuals, families, companies and communities- one lifestyle change at a time. Dr. Garilli has been on staff at the University of California Irvine, Susan Samueli Center for Integrative Medicine and is faculty at Hawthorn University. She is the creator of the Veterans for Health Initiative and is the current Past-President of the Children’s Heart Foundation, CA Chapter.