During this month’s Sleep Team takeover of the CDP website, I wanted to take a minute to talk about a particularly hard hit subset of military members, Special Duty personnel. Over my career I had many opportunities to work with these elite military members both as a clinician and as an embedded consultant. Sleep problems are endemic in this population, so let’s take a quick look at who they are and what types of issues are affecting their mission readiness related to sleep.
For the purposes of this blog let’s consider Special Duty personnel anyone who requires an extra level of medical readiness, either because they could deploy with only a moment’s notice, or because they regularly have access to highly sensitive information. I reached out to some behavioral health providers who are currently working with these populations to talk about what they see as the primary issues related to sleep and to discuss prevention and treatment options.
Adults are recommended to get between 7-8 hours of sleep per night. However, only 24% of military members get this amount, as compared to 64% of civilians. Most troops get around 6 hours of sleep per night. Not surprisingly, one main consequence of inadequate sleep is daytime fatigue. For example, Maj Michael Rath, Air Force Operational Social Worker with the 692nd Intelligence, Survey, & Reconnaissance (ISR) Group, noted that in his survey of of 165 special duty personnel, 45% experienced moderate fatigue. An additional 9% reported severe fatigue.
Shift work can exacerbate the impact of inadequate sleep. Maj. Rath noted that among night shift workers, 52% report moderate-to-severe fatigue in the preceding 24 hours as compared to 37% those on day shift. Additionally, fatigue among night shift personnel impacted most areas of their life; mood, work, social relations, and recreation. For day shift the main impact was only on mood.
Many assume that whatever level of sleepiness or fatigue builds up during work hours is resolved during off time. I’ve seen many sleep logs that show 5-6 hours Total Sleep Time (TST) during the work week, followed by 10 or more hours TST on off days. However, Maj. Rath found that even after their off days, a majority still experience at least a mild level of fatigue; 81% for day shift and 62% for night shift.
To help support special duty personnel with sleep or other mental health issues, some assets are embedded at the work center. For example, Maj. Joanne Ho, an Air Force psychologist, is part of a six-member Embedded Resiliency Team with Distributed Ground System-2 at Beale Air Force Base. Responsible for some 1,600 personnel, Maj. Ho and her team act primarily as coaches, consultants, and advisors to individual Service members, their supervisors, or commanders.
Healthy Sleep Habits - Prevention
Specific to sleep, Maj. Ho recommends that all special duty personnel follow sleep hygiene and stimulus control techniques – which she bills “healthy sleep habits”, as well as what she learned about circadian rhythms during her attendance at a recent CDP course. She noted that historically work shifts were inconsistent, with the result that a 12-hour shift could easily last 15 hours. While most providers know that a consistent schedule is a key factor in getting quality sleep, not all military personnel realize this. Majors Ho and Rath noted that some troops on night shift elect to follow the daytime schedule of their family and friends. This fluctuating pattern can disrupt the circadian rhythm resulting in short- or long-term sleep problems.
Dr. Ray King, an aviation psychologist who has worked with pilots, navigators, air traffic controllers and support crew over the last 20 years, noted that many troops do not have a sense of their circadian pattern and live out of sync with their body. Their body’s natural bed time may be 0100, but for the sake of their work schedule they feel they should get in bed by 2200 in order to assure they are up on time. They have no idea how to adjust their internal clock so as to fit with their occupational demands. Many troops end up relying or caffeine and/or nicotine to stay awake and “tough it out.” Dr. King discourages their use and sees sleep medication as a last resort. Maj. Ho echoed noted that within her community there are concerns with long-term use of sleep medication. Any personnel using it must see a clinical provider on a regular basis as a registered patient to ensure there is a plan to stop using it, and also to ensure there isn’t an underlying sleep disorder, such as obstructive sleep apnea, that should be managed differently.
Maj. Ho noted one of the more difficult aspects of her role when it comes to addressing troops’ concerns about sleep is how to distinguish an idiopathic sleep disorder from the accumulated effects of recurrent shift changes. In some career fields, members change shifts every two to six months and so they may experience a chronic impact. It can also be difficult to differentiate an acute sleep issue from the result of 10-year’s-worth of shift-work. This question can be further complicated by the fact that sleep issues can be a part of numerous health issues from chronic pain to anxiety.
Insufficient Sleep and Breathing Related Sleep issues
Polysomnography (PSG) results published in 2013 by Vincent Mysliwiec and his colleagues at Madigan Army Medical Center suggest just how important a sleep study is for correctly diagnosing sleep disorders in military personnel. Of the 725 PSGs conducted among the deployed (85%), male (93%) group referred by primary or behavioral health care providers, OSA was the most frequent diagnosis (51%). While this result compares with civilian samples, the rates for insomnia (25%) and behaviorally induced insufficient sleep syndrome (BIISS; 9%) in this military sample were, respectively, nearly 6 and 11 times higher than in the civilian sample.
In my experience with this population my motto was "When in doubt, refer out…" That was my approach with this population when they reported regularly getting less than 7 hours of sleep per night (while spending more than 7 hours in bed), along with other consequences such as repeatedly waking up anxious or feeling fatigued throughout the day.
A sleep study is not required in order to diagnose insomnia or BIISS. However, the implication of Mysliwiec’s analysis is that one in five military members with sleep complaints may not have received any diagnosis if they hadn’t had a PSG. Potentially they would have gone untreated. While all Service members and Veterans deserve a thorough sleep evaluation, to include consideration for a sleep study, this is especially important for those working in extremely stressful, dangerous, or sensitive career fields.
For more on sleep, be sure to visit our Sleep Spotlight page here, where we'll be adding sleep-related content and resources all month!
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
David J. Reynolds, Ph.D., is the Military Internship Behavioral Health Psychologist at Malcolm Grow Medical Clinics and Surgery Center located on Joint Base Andrews, Maryland.
Bray, R. M., et al. (2009). Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, Research Triangle Park, N.C.: RTI International, Report No. RTI/10940-FR, 2009.
Krueger, P. M., & Friedman, E. M. (2009). Sleep duration in the United States: a cross-sectional population-based study. American Journal of Epidemiology, 169(9), 1052-1063.
Luxton, D. D., Greenburg, D., Jenny, R., Alexander, N., Wheeler, G., & Mysliwiec, V. (2011). Prevalence and impact of short sleep duration in redeployed OIF Soldiers. Sleep, 34(9), 1189–1195.
Mysliwiec, V., Gill, J. G., Lee, H., Baxter, T., Pierce, R., Barr, T. L., Krakow, B., & Roth, B.J. (2013). Sleep disorders in U.S. military personnel: a high rate of comorbid insomnia and obstructive sleep apnea. CHEST, 144(2), 549-557.
RAND (2015). Sleep in the Military: Promoting Healthy Sleep Among U.S. Servicemembers.
RAND Health Quarterly, 5(2). Available at https://www.rand.org/content/dam/rand/pubs/research_reports/RR700/RR739/RAND_RR739.pdf