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MHS addresses sleep in the military through sleep studies

Image of a man sleeping in bed with alarm clock on side table. Click to open a larger version of the image. A good night’s sleep is essential to mission success in the military, but often hard to come by. The Military Health System offers a variety of sleep studies to diagnose problems with sleep and amplify sleep for better daytime performance. (8th Army photo)

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Sleep complications are common in the military, from the early-rise culture that can disrupt normal sleeping patterns to the bouts of insomnia resulting from night operations, early morning physical therapy workouts, sustained combat operations, and other such disruption. Researchers and doctors within the Military Health System work to address these concerns and improve the efficiency of service members suffering from sleep complications.

Army Lt. Col. (Dr.) Vincent Capaldi, sleep medicine consultant to the surgeon general and chief of behavioral biology at the Walter Reed Army Institute of Research in Silver Spring, Maryland, stressed the importance of the military perspective when addressing sleep concerns in service members. Capaldi pointed out that while proper sleep is necessary for mission effectiveness in the field, 62% of service members sleep less than six hours a night on average—resulting in chronic sleep deprivation and insomnia.

“When people are chronically sleep deprived and do a sleep study in the civilian sector, we found that they're being diagnosed with narcolepsy at significantly higher raters compared to those diagnosed in the Military Health System,” Capaldi said. “We're able to take a more nuanced approach in the MHS to evaluate what’s causing their difficulty and prevent a misdiagnosis that can result in a service member getting medically boarded.”

Doctors at the Walter Reed National Military Medical Center in Bethesda, Maryland, use a variety of techniques to diagnose sleeping problems. WRNMMC’s chief of sleep medicine, Lt. Col. (Dr.) Meagan Rizzo, stated that due to the COVID-19 pandemic, using respiratory sleep tests—such as positive airway pressure titration studies—have been temporarily halted to prevent the potential spread of COVID-19. Rizzo did note that WRNMMC’s Sleep Laboratory is still open for some in-lab diagnostic sleep studies. The laboratory also offers sleep tests that patients take home and bring back for further study.

“Home sleep tests can be good at picking up moderate and severe obstructive sleep apnea in high-risk patients,” Rizzo said. “It’s a good starting point, and something we can use while our labs are closed to still offer insight into sleep remotely.”

The home sleep tests can lead to further testing, like the multiple sleep latency test, administered through a medical device comparable to an activity tracking device that patients wear on their wrists at home to track sleep and check for signs of narcolepsy. Overnight pulse oximetry is also offered, which measures a patient’s pulse and the oxygen content in their blood to make sure that oxygen levels don’t drop too low during sleep.

Military medical professionals recognize that there are also military concerns that contribute to diagnosing sleep problems, like post-traumatic stress disorder and traumatic brain injury. Army Lt. Col. (Dr.) Scott Williams, director for medicine at Fort Belvoir Community Hospital in Virginia, explained the link between these conditions: “When you disrupt the brain either because of PTSD or TBI, it lowers a patient’s arousal threshold, making it easier to wake them up, so what someone might otherwise sleep through before their injury, like a snoring episode or a mild sleep apnea, now wakes them up.”

Gradually treating TBI and PTSD can have positive effects on the resulting sleep complications. But Carla York, who specializes in behavioral sleep medicine at WRNMMC, stated that treating one does not always eliminate the other.

“As we improve sleep, we can improve management of a psychiatric condition like PTSD, but we often find that even when there's an improvement in PTSD symptoms, sleep problems like insomnia can still persist,” York said. “So thinking about a psychiatric diagnosis and a sleep problem as being the same thing isn't helpful. We have to treat both conditions concurrently for optimal improvement.”

WRNMMC, FBCH, and other military medical treatment facilities use cognitive behavioral therapy for insomnia, or CBT-i, to treat patients with chronic insomnia. CBT-i uses stimulus control, sleep hygiene, sleep restriction, relaxation training, and cognitive therapy to provide patients with tools and resources to better manage their sleep. The U. S. Department of Veterans Affairs also offers a free mobile app called CBT-i Coach that walks patients through some of these techniques.

WRAIR’s sleep research has resulted in exploring treatment options like transcranial electrical stimulation, which Capaldi hopes will help patients get to slow-wave sleep faster and sleep more efficiently. Capaldi’s team is exploring the use of pharmacological treatments that target orexin, a protein-like molecule in the brain that regulates wakefulness. These efforts focus on the use of orexin receptor antagonists to allow service members to get to sleep quickly and wake without the grogginess of prescribed sleep aids. In 2004, WRAIR invented and subsequently licensed a caffeinated gum - Military Energy Gum. MEG is available in first strike rations for the military and sold commercially since 2012.

Capaldi hopes that through research and clinical efforts in the military medical community, proper sleep and the methods to get that sleep will be prioritized in military culture.

“Cognitive dominance is critical for success in the battlefield of today and tomorrow. Sleep is ammunition for the brain, necessary for the maintenance of sustained vigilance and cognitive dominance,” Capaldi said. “We would never send service members into the field and say they don't need to bring water along with them, so we have to reverse the culture within our military that views sleep as a liability instead of an asset to help service members keep their brains in the fight.”

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