Sleep and Military Animation

Sleep & the Military:
Complete Guide to Sleeping for Soldiers & Veterans

“In peace and war, the lack of sleep works like termites in a house: below the surface, gnawing quietly and unseen to produce gradual weakening which can lead to sudden and unexpected collapse.”

— Major General Aubrey Newman [1]

The need to sleep is important for everyone but maybe even more so for those that protect their country. Falling asleep can be difficult enough, but add the stress of war, the sound of gunfire, or terrifying post-traumatic experiences, and catching a few hours of rest each night can feel next to impossible.

 

Authors of a military sleep evaluation proposed that “while the prevalence of sleepiness in the military is largely unknown, it is well established that short sleep duration is endemic. The reasons for this include: the demanding nature of their duties, shift work and 24-hour duty periods, deployments and exigencies of military service as well as sleep disorders.”

 

This study along with dozens of others, point toward evidence that strongly suggests that the vast majority of deployed military and veterans are not sleeping enough.

Studies show how military induced sleep deprivation makes soldiers and veterans more prone than the general population to underlying mental illnesses, many of which can lead to conditions like Post Traumatic Stress Disorder (PTSD), substance abuse, and even suicidal thoughts and actions.

The purpose of this guide is to help soldiers and veterans explore the root causes of these conditions, how prevalent they are, and the importance of seeking help with these struggles. One thing is for certain, if you have served in the military and are currently struggling with sleep, you are definitely not alone.

Soldiers and Vets Vs. The General Population
Sleep-Related Issues During Deployment
Coming Home to Sleep: Post-deployment Veterans
Treatment
Options
Why Do Many Soldiers and Vets Not Seek Treatment?
What Is a Good First Step to Achieving Sleep?

Soldiers and Vets Vs. The General Population:
Who Gets Less Sleep?

In a society that is continually moving and progressing, sleep often sits on the back burner. Most studies show that 1 in 3 Americans do not get enough rest. Compare this to a number of other studies that report that anywhere between 62% and 74% of military personnel were classified as poor sleepers.

Other research shows that 88% of the participating service members were diagnosed with some sort of sleep disorder.
Sleep Deprivation –
Military, Veterans vs General Population
Military, Veterans vs General Population -Sleep Chart

Sources: “Health of the Force” — [2] U.S. Army, “National Veteran Sleep Survey” — [3] My Vet Advisor, “Short Sleep Duration Among US Adults” — [4] Centers for Disease Control and Prevention

Soldiers in one self-assessed report averaged around 5.8 hours of shuteye in each 24 hour period. This demonstrated that 72% of military personnel were getting less than 6 hours of sleep, while in another study demonstrates that an alarming 42% were getting less than 5 hours of rest per day. To put this into perspective, roughly 65% of American adults say that they get more than 7 hours of sleep each night. 

 

The November 2015 Health and Force report found that only 15% of active duty soldiers in the army meet the national sleep standards, while an alarming 55% failed to reach any of the defined targets.

An online survey showed that many veterans are having the same problems as active service members. The results found that veterans from all branches were averaging 5.6 hours each night. Another found that 1 in 5 Veterans are getting less than 4.5 hours of rest per night. Between these studies, evidence suggests that anywhere between 76% and 89% of veterans are sleep deprived.

Sleep-Related Issues During Deployment

Impact of Deployment on Sleep

In one survey, before troops were deployed they reported that they get an average of anywhere between 7 and 8 hours of sleep. After deployment, the average decreases to between 5 and 6 hours.

 

A study performed by Madigan Army Medical Center found that 58% of nearly 800 military personnel were diagnosed with some type of sleep disorder. Those who were affected had the following.

Sleep Conditions in Military Sleep Study
Sleep Conditions in Military - Sleep Study Chart

Source: “Sleep Disorders and Associated Medical Comorbidities in Active Duty Military Personnel” — [5] National Center For Biotechnology Information

What is the Military Doing to Address These Issues?

Those serving their country often find themselves under immense pressure to perform in high-stress situations. They can have unprecedented demands tasked to themselves, as well as those they lead and serve with. It is little surprise that the majority of soldiers are sleep deprived.

 

The United States Department of Defense trains personnel to have good sleep hygiene and screens them for possible disorders. While they have taken steps in the right direction, one study by the RAND Corporation suggests that military leaders may be slightly uneducated on the subject and noted several places where sleep health training could be improved.

 

The study reads, “These policies generally focused on the initial phases of military training (i.e., basic training), and codified policies pertaining to sleep did not necessarily extend to subsequent training environments… There was a lack of specific guidance on how to implement these plans. We also found inconsistency in the amount of emphasis placed on sleep in each of the occupational areas within each Service.

Should Military Emphasize Attention Towards Sleep Education

The same study points out that there are several hurdles to achieving better rest for service members. Those in charge do not necessarily understand sleep-related behaviors and current policies pose a barrier to military leaders recognizing current sleep issues. To add to this problem, many of the sleep regulations in place are often taken as guidance and are not always seriously addressed.

 

A current issue the military faces is a lack of the necessary resources needed to understand sleep in a military context. This would include instruments used for screening and studying sleep, as well as other tools and training.

 

Science continues to show that humans need sufficient sleep to perform at their highest level. The complexity with soldiers is they sleep far less than most other groups of people and are expected to function at an excelled level, often under immense stress.

 

This raises the question: Could it not only be beneficial for the soldier but for the military as a whole to emphasize greater attention and funding towards sleep education and care? As the U.S. Defense budget is yet again increased, putting more money towards this issue could potentially be more useful than using those funds elsewhere.

Service members in general, and those who have deployed, specifically, are at high risk for insufficient sleep duration. This is particularly concerning, given the robust evidence linking short sleep duration with compromised mental and physical health and cognitive impairments, all of which can have a direct impact on operational readiness and servicemember resilience.


[6] National Center for Biotechnology Information

Lack of Sleep on a Soldier’s Body

The military lifestyle naturally leads to less rest. Days as well as nights for that matter, are often full of assignments and a whole lot of stress. If physical and mental fatigue were not enough, they are often forced to sleep on a cot, or worse, on the ground, making it feel near impossible to fall asleep.

 

Here a just a few ways these conditions can affect a soldier.

Soldier Icon
Decreased Performance and Fatigue
“As sleep debt accumulates, a person's mood, motivation, attention, alertness, short-term memory, ability to complete routines, task performance (errors of omission more than errors of commission) and physical performance will become more negatively affected.” — Defence Medical Research Institute Ministry of Defence [7]

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Heart Conditions and Cardiovascular Disease
“What many people don’t realize is that the amount of sleep you get and when you sleep directly affects your heart health…  One of the potentially most dire consequences of these effects is their contribution to heart disease. Poor sleep quality in general, and especially sleep apnea, is associated with an increased risk of high blood pressure.” — Joseph Hill, M.D., Ph.D. [8]

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MicroSleep

“Soldiers who routinely get less than 7 hours of sleep perform much like a person who is legally drunk. They lose their situational awareness, lose the ability to exercise good judgment and increase risky behaviors. They also are at risk of uncontrolled and unintentional sleeping. Micro-sleep can occur during critical events such as driving, speaking and even walking. Put simply, accidents increase when the total amount of sleep you get each night decreases over time.” — Army Performance Triad [9]

Note: These are only a few of many other conditions that can be caused by sleep deprivation. Others include headaches, obesity, as well as increased risks for conditions such as diabetes and some cancers.

Sleep Deprivation and Moral Reasoning/Decision Making

Illustration of a Soldier With an Angel and the Devil on His Shoulders

A sleep study was performed on officers at both the Norwegian Naval Academy and the Norwegian Army Academy. The experiment tested their moral reasoning under both rested, and severely unrested states. The findings of the experiment demonstrated that “the officers' ability to conduct mature and principally oriented moral reasoning was severely impaired during partial sleep deprivation compared to the rested state.”

 

The purpose of the experiment was to determine how rest affects moral justice judgments and, on a larger scale, how this could play into combat operations that directly influence the lives of both soldiers and civilians. As wartime decisions often take place in battle,  the results of this study show that sleep deprivation has the potential to sway life and death decisions.

“Given that most contemporary military operations involve long periods of partial sleep deprivation and fighting in highly complex environments, one possible consequence of moral decay may be disproportionate use of power.” — Olav Kjellevold Olsen, Ph.D. Ståle Pallesen, Ph.D. Eid Jarle, Ph.D [10]

Coming Home to Sleep:
Post-deployment Veterans

Tired Soldier Looking at His Bed

These veterans sacrifice their time and talents, often risking their lives to protect and defend their country. When they step back into their civilian shoes, their problems do not always end. Conditions like depression, anxiety, PTSD, and sleep disorders follow them into their homes.

 

Sleep deprivation is one of the steepest problems facing our veterans. Up to 89% are classified as poor sleepers. With more than 9.7 million U.S. military veterans surveyed, a study found that the age-adjusted prevalence of disorders had increased from less than 1 percent in 2000 to nearly 6 percent in 2010. Another survey found that 54% of respondents that were enrolled with the Department of Veteran Affairs had been diagnosed with some type of sleep disorder.

 

The subjects of both these analysis were veterans who had sought care, leaving out hundreds thousands to potentially millions who did not seek treatment. Authors of the first study project that these trends will continue to rise past 2010. In terms of treatment and management, these numbers emphasize how urgently veterans will need these resources in the years to come.

Common Sleep Disorders Among Vets

Sleep Disorders Among Vets Chart

Sources: “The National Veteran Sleep Disorder Study: Descriptive Epidemiology and Secular Trends, 2000–2010” — [11] National Center For Biotechnology Information

Insomnia

“Individuals with insomnia find it difficult to fall asleep or stay asleep. The effects can be devastating. Insomnia commonly leads to daytime sleepiness, lethargy, and a general feeling of being unwell, both mentally and physically. Mood swings, irritability, and anxiety are commonly associated symptoms.” — Peter Crosta; reviewed by Daniel Murrell, M.D. [12]

Sleep Apnea

“Sleep apnea is a common sleep disorder in which an individual's breathing repeatedly stops and starts during sleep. Symptoms include daytime sleepiness, loud snoring, and restless sleep.” — Kathleen Davis FNP; reviewed by University of Illinois-Chicago, School of Medicine [13]

Circadian Rhythm Disorders

“Circadian rhythm disorders are disruptions in a person’s circadian rhythm… The key feature of circadian rhythm disorders is a continuous or occasional disruption of sleep patterns… These are the more common circadian rhythm disorders: delayed sleep phase disorder, advanced sleep phase disorder, jet lag, shift work disorder, and narcolepsy.” — Cleveland Clinic [14]

Movement Disorders

“Periodic limb movement disorder is a condition characterized by repetitive movements of the limbs during sleep. It is the only movement disorder that occurs during sleep and, as such, is considered to be a sleep disorder as well.” — Jayne Leonard; reviewed by Suzanne Falck, M.D. [15]

Hypersomnia

“Hypersomnolence is a condition where a person experiences significant episodes of sleepiness, even after having 7 hours or more of quality sleep. Other terms used to describe hypersomnolence include excessive daytime sleepiness, excessive daytime somnolence, and hypersomnia.” — Rachel Nall, RN, BSN;  reviewed by Timothy J. Legg, Ph.D. [16]

Nightmares

“During a nightmare, the dreamer may experience a range of disturbing emotions, such as anger, guilt, sadness, or depression. However, the most common feelings are fear and anxiety. The person usually wakes up at least once during the dream.” — Hannah Nichols; reviewed by Timothy J. Legg, Ph.D. [17]

Night Terrors

“Night terrors, or sleep terrors, are common terms for episodes that cause fear at night, especially in children. They are different from nightmares. They can be distressing for the person who has them and for their family.” — Tim Newman; reviewed by Timothy J. Legg, Ph.D. [18]

REM Behavior Disorder/ Parasomnia

“REM sleep behavior disorder involves unusual actions or behaviors during the rapid eye movement sleep phase. The condition is a type of sleep disorder known as a parasomnia. These are sleep disorders in which strange or dangerous events occur that disrupt sleep… talking, shouting, screaming, lashing out physically, punching and kicking, cursing, a clear ability to recall dreams on waking, sleepwalking.” — Christian Nordqvist; reviewed by Nancy Hammond, M.D. [19]

Sleep Paralysis

“Sleep paralysis is a feeling of being unable to move, either at the onset of sleep or upon awakening. The individual's senses and awareness are intact, but they may feel as if there is pressure on them, or as if they are choking. It may be accompanied by hallucinations and intense fear.” — Kathleen Davis FNP; reviewed by University of Illinois-Chicago, School of Medicine [20]

Common Conditions That Can Affect Sleep

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Traumatic Brain Injury

11%-23% of deployed troops have suffered mild TBI

“Sleep disturbances after TBI are estimated to occur in 30–70% of head injured patients often impairing the resumption of normal activities.” — Nathaniel F. Watson, M.D. [21]
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Tinnitus
Over 150,000 veterans were diagnosed with tinnitus in 2015

“Veterans have higher rates of tinnitus than the general public due to the noise levels they encounter while in the service, including gunfire, machinery, aircraft, and much more… Tinnitus is defined as the perception of ringing, hissing, or other sounds in the ears or head when no external sound is present.” [22]

Headache Icon
Pain

65.5% of veterans reported having pain in the last three months

“For those who return home with physical wounds, pain management becomes a challenge. Even after injuries are treated, there are still other issues: headaches, neurological pain in ghost limbs, long-term painful conditions like arthritis. The term “painsomnia” refers to pain so intense it prevents one from falling asleep. Many veterans have to deal with painsomnia.” [23]
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Substance Abuse

36%-72% of substance abusers have insomnia

“Traumatic events such as combat exposure and multiple deployments can trigger drug or alcohol use, which all too often lead to addiction.” [24]
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PTSD

13.8% of veterans who served in Iraq and Afghanistan were diagnosed with PTSD

“Post-traumatic stress disorder is a mental health problem that can occur following the experience of a psychologically traumatic event like war, assault, or disaster. The estimated prevalence of PTSD in the general population is 1-9%, among victims with significant trauma the figure is 20–45% and among veterans, it is 15–20%.” — Sleep Disorders Research Center [25]
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Depression/ Anxiety

One study shows that 27%-30% of veterans have a triple combination of PTSD, anxiety, and depression

“In the group who have PTSD, depression is quite prominent, about 45 percent.” — Frank Schoenfeld, M.D., the director of the PTSD program at the Veterans Affairs Hospital

“In some studies, nearly half of the veterans who had PTSD were also depressed. The two conditions often go hand in hand, often with some overlap in symptoms.” [26]

Treatment Options

Psychiatrist Appointment for Veteran
Cognitive Behavioral Therapy

This is the most widely studied form of psychotherapy. It uses two schools of therapeutic approach, cognitive and behavior therapy. Patients work with a mental health counselor in order to be made aware of how their thoughts affect their behaviors and how they can respond to these obstacles in an effective manner.

Circadian Rhythm Adjustments

This can be done in correlation with light therapy by reteaching the mind when it should be asleep and when it should be awake.  This technique helps to re-establish the body’s internal clock in order to more successfully induce proper rest.

Addiction Rehabilitation

Addiction rehab often uses psychotherapeutic methods to help users quit or reduce substance use and abuse. Substance abuse is often influenced by or causes other issues like depression, anxiety, and PTSD. Addiction Rehab is designed to show veterans that they are in control of their lives so they can better control their addiction.

Therapy Dogs

Therapy dogs are great for all sorts of tasks. These can be especially good for veterans with PTSD. These animals can help reduce the trauma associated with triggering events. They do so by detailed training that enables them to recognize signs of pain, fear, and anxiety and provide comfort.

CPAP Therapy

These machines are used to treat people who have sleep apnea. This method increases air pressure in the trachea to prevent the airway from collapsing as the sleeper inhales. This therapy also helps to reduce nightmares and other key symptoms associated with PTSD.

Light Techniques

For those people who have Circadian Rhythm Disorders, this therapy can help re-establish the body’s internal clock through specialized lights. This could be beneficial for veterans who have severe jet lag, soldiers who work irregular shifts, night shifts, or soldiers and veterans who otherwise sleep when they should be awake and vice versa.

Relaxation Therapy

Teaching the mind to relax can take time, but with time meditation therapies can help veterans and soldiers clear their heads of troubling thoughts. These can take several weeks or even months to get used to and do not necessarily need to be performed on a daily basis, though this would likely . improve results. This technique can be done at any point during the day or week, but taking 20 to 30 minutes to relax right before bed might be most beneficial.

Correlation between Pre-Deployment Insomnia and PTSD/Suicide For Military Personnel and Veterans

When people think of PTSD and suicide, correlating conditions like anxiety and depression might be at the front of your mind. But new studies actually show that disorders like sleep apnea and insomnia have a closer relationship to this haunting conditions.

 

In a 2012 study, researchers analyzed a group of U.S. Army soldiers 1 to 2 months before they were deployed to Afghanistan. Overall, 15% reported that they had experienced insomnia within the thirty days before deployment. After their return, soldiers who had reported insomnia within this time frame were two times more likely to experience suicidal thoughts and twice as likely to have PTSD than those who had not reported insomnia.

 

After the team accounted for and eliminated other factors that may have affected the experiment’s results, they still determined that pre-deployment insomnia was related to a 43% higher chance of suicide and a 50% higher risk of PTSD.

Insomnia and Suicide

So, if all this military sleep deprivation was not bad enough. It gets worse.

 

Another study found similar results to the one mentioned above, the research relating to suicide among active duty soldiers. The authors noted that “Insomnia symptoms were unique predictors of suicide attempt longitudinally when only baseline self-reported insomnia symptoms, depressive symptoms, and hopelessness were controlled.”

Veterans Suicides Linked with Sleep Disturbance

Another analysis in 2012 observed that 45% of veterans suicides were also linked with some kind of night-time disturbance. If this study were to hold true for all veterans, that would mean that nearly half of all veteran suicides were linked with sleep deprivation.

Suicide Rates 2016 –
Veterans and General Population

In the United States, veteran suicides account for 14% of the national suicide rate, with veterans only accounting for 8% of the population.

 

To put that into perspective, the veteran suicide rate in 2016 was 1.5 times higher than the general population, with just over 6,000 death by suicide. That’s more military that died in seven years during Operation Iraqi Freedom (4,423 U.S. military casualties 2003-2010).

Suicide Rates for 2016 - Veterans vs General Population Chart

If we were to theoretically apply that 45% of veteran suicides from that one study into roughly 6,000 troops, that would total 2,700 suicide deaths related to sleep deprivation.

These studies and the results of many others like them indicate how the implementation of practical sleep education and resources within the military could begin to save hundreds to thousands of lives.

Science shows us that good rest is just as important as diet, nutrition, and exercise, but yet, hardly anyone seems to be getting enough. This is a huge problem with greater implications than the general population might realize.

A rapidly growing body of literature demonstrates that insomnia is a reliable risk factor of poor clinical outcomes, including PTSD, depression, and/or suicidality, and impedes the recovery process. Thus, efforts for early identification and timely intervention are important goals in order to attenuate the impact of deployment on sleep, accelerate recovery from insomnia, and ultimately prevent the onset of psychiatric comorbidities including suicide.


[27] National Center for Biotechnology Information

Why Do Many Soldiers and Vets Not Seek Treatment?

The support of family, friends, and medical professionals is important, especially to a soldier or veteran with PTSD or a related condition. The sad truth is that so many of these men and women do not feel that they have this support.

 

Researchers Adam D. Bramoweth, Ph.D. and Anne Germain, Ph.D. agree that soldiers need encouragement. They wrote in their report,  “In addition, family and social support are critical elements of successful reintegration and/or recovery. Thus, research and clinical efforts directed at military family members may be important components in providing the care needed and promoting health and recovery among service members and their families.”

 

Here is another major problem. Veterans often recognize something is wrong but they do not completely understand what is happening to their minds or bodies, so they do nothing about it. A University of Minnesota study observed over 7,600 veterans and found that when attentive care is delayed, individuals often fail to seek help in time.

Why Veterans Fail In Seeking Help

Dr. Michele Spoont, is a clinical and research psychologist at the Minneapolis VA Health Care System, said that “Part of what we're doing at VA with initial screening is to address this. If we can get a Veteran into a specialist that same day, it enhances their chance of success.”

 

She also indicated that having the belief that they can actually get help is a huge determining factor. “Veterans have to believe they can get better, that the treatment works,” Spoont said. “and they need to believe that they can do it.”

 

Veterans and soldiers are accountable for their own health, but it is increasingly important that family, friends, and medical providers help them find the help they need to achieve better rest and mental health. These conditions are not merely physical but often have psychological and social effects. This makes it increasingly important for loved ones to frequently reach out to see how their veteran is doing.

“Given the multiple health concerns these soldiers face, and the rise in suicides in returning veterans, it is critical that we look for viable strategies to improve their overall health.” — Jacob Collen, M.D., Critical Care and Sleep Medicine, Walter Reed National Military Medical Center [28]

What Is a Good First Step to Achieving Sleep?

First, it helps to realize that you are not alone. There are many resources and treatments available to you as well as trained medical professionals who specialize in working with soldiers and vets with these issues.

“For many people, simply improving their sleep habits will help. Try to avoid caffeine, nicotine, and exercise in the hours leading up to sleep; avoid using alcohol as a sleep aid; don’t go to bed hungry; try to keep your bedroom dark and quiet; use sleep masks and/or earplugs if needed; and keep your smartphone/devices out of bed.” — Captain Jeffrey Osgood

Establishing a good bedtime routine could be a great place to start. According to the National Sleep Foundation, a well-practiced routine is key. Develop a nightly routine that helps prepare both the body and mind to fall asleep.

 

This routine could include bathing, brushing your teeth, turning on some relaxing music, and doing some light reading, or maybe even an audiobook before turning out the lights. That’s just what I do, but you should make this pattern your own, making sure it includes good habits and things that help you relax.

If these solutions do not help the situation, please do not hesitate to reach out and seek medical attention from credible sources. You don’t have to be alone with this struggle, and there are many people trained to help you.

Resources

01

First, it helps to realize that you are not alone. There are many resources and treatments available to you and medical professionals who specialize in working with soldiers and vets with these issues.

02

The White House VA Hotline is not a crisis line. This helps to provide extensive training on VA programs and services. This line works with the before mentioned Veterans Crisis Hotline for at-risk veterans.

03

The National Veterans Foundation is staffed by veterans for veterans. This service provides crisis management and general direction for veterans and their families.

04

The VA offers an online course for Insomnia:

[1] Follow Me, 1981, p. 279


[2] Health of the Force, U.S. Army


[3] National Veteran Sleep Survey, My Vet Advisor


[4] Short Sleep Duration Among US Adults, Centers for Disease Control and Prevention


[6] Sleep in the Military – Promoting Healthy Sleep Among U.S. Servicemembers, National Center for Biotechnology Information


[7] Effects of Sleep Deprivation with Reference to Military Operations., National Center for Biotechnology Information


[8] To Sleep, Perchance to Lower Your Heart Disease Risk, US Southwestern Medical Center


[9] What to Know about Sleep Deficiency, Army Public Health Center


[12] Insomnia: Everything You Need to Know, Medical News Today


[13] What You Need to Know about Sleep Apnea, Medical News Today


[14] Circadian Rhythm Disorders, Cleveland Clinic




[17] Dreams and Nightmares: What Are They?, Medical News Today




[21] Traumatic Brain Injury and Sleep Disorders, National Center for Biotechnology Information

[23] Why Our Veterans Can’t Sleep, American Sleep Apnea Association


[24] Why Veterans Turn to Drugs and Alcohol, Addiction Center


[25] Sleep disturbances in veterans with chronic war-induced PTSD, National Center for Biotechnology Information


[26] Depression and PTSD in Veterans, Health Day


[27] Deployment-Related Insomnia in Military Personnel and Veterans, National Center for Biotechnology Information


[28] Vets with PTSD and sleep apnea less likely to use CPAP, Sleep Education

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