WASHINGTON, DC—Asking servicemembers and veteran patients about sleep can serve as a segue to conversations about other post-deployment issues that these patients might be experiencing, said Paula Domenici, PhD. Domenici is a licensed counseling psychologist who heads the Division of Training Programs at the Center for Deployment Psychology. “They are going to be more apt to go to a primary care doctor and complain about sleep then they are [about] that traumatic event that is weighing on their shoulders.”
Domenici spoke on sleep as part of a workshop held at Howard University Hospital last month. The workshop was designed to teach civilian psychiatry residents and other behavioral health specialists about the cultural and clinical concerns of military servicemembers. While Domenici referred to sleep as a “less stigmatizing” problem for servicemembers to discuss, it is a significant problem for those returning from deployment.
Sleep Problems are Common
Domenici said statistics from the Air Force Post Deployment Health Reassessment through July 2010 showed that of the 94,000 active duty Air Force personnel who were surveyed, 14,000 reported having a deployment-related concern or problem after returning. Of these personnel reporting problems, not sleeping or feeling tired after sleeping was the number one deployment-related concern or condition.
Another study conducted by the Army’s Mental Health Advisory Team-V (MHAT-V), which surveyed servicemembers in theater, found that 52.1% reported some degree of sleep deprivation.
That survey also noted that soldiers who report being sleep deprived are at significant risk of reporting mental health problems. In the MHAT-V data, only 11.7% of male El-E4 soldiers in theater for nine months who reported no sleep deprivation were positive for depression, anxiety, or acute stress. In contrast, 23.1% of the soldiers who reported two hours of sleep deprivation screened positive for depression, anxiety, or acute stress.
Helping Patients with Sleep-Related Problems
Providers can utilize a sleep questionnaire when a patient complains of sleep problems to find out about the quality of the patient’s sleep patterns. Another instrument that can help the patient and the provider understand the patient’s sleep habits is a sleep diary.
Domenici said that the Center for Deployment Psychology promotes Cognitive Behavioral Treatment of Insomnia (CBT-I) to treat insomnia patients. The treatment focuses on sleep hygiene, relaxation therapies, cognitive strategies, stimulus control, and sleep restriction.
Sleep hygiene entails encouraging the patient to avoid caffeine four to six hours before bedtime, avoiding alcohol after dinner, and avoiding daytime napping, among other things. By giving patients a copy of sleep hygiene guidelines and reviewing it with them, it can help patients “take more ownership” of the problem.
Because patients with insomnia often complain of not being able to “shut their mind off” when it is time to sleep, the treatment uses cognitive strategies to help reduce the patient’s need to engage in “thinking” in bed. This involves having the patient set aside a 15-20 minute time each day for focused planning and worrying so they are not doing this in bed.
Stimulus control involves teaching patients with insomnia to not pay bills or do other activities in the bedroom, but to use the bedroom for sleep. “Stimulus control is the idea that individuals who develop something like an insomnia, they unfortunately link up bedtime and the bedroom and sleepiness with all sorts of other things: anxiety, watching the TV, worrying, et cetera, such that they have a response to those sleep stimuli that doesn’t focus on sleepiness and falling asleep,” said Domenici. “So you are going to teach your patient to only go in the bedroom when they need to fall asleep.”
Sleep restriction involves having the patient with insomnia restrict the time spent in bed to the time that they actually sleep. A patient who typically spends seven hours in bed, but only sleeps five hours, would be asked to go to bed two hours later so that they are in bed for five hours, rather than seven hours. Gradually the amount of time in bed is increased as the patient begins to sleep better.
In addition to CBT-I, a therapy for patients with nightmares is Imagery Rehearsal Therapy (IRT). With this therapy, patients identify a recurring nightmare and then brainstorm and write out a new script for the dream. “What you are thinking about in close proximity to bedtime indeed is what you think about in your dreams and nightmares,” said Domenici.
Despite the common nature of sleep problems, many behavioral health providers have never had in-depth training in how to treat these issues, according to Domenici. “I want to inform you that the trend these days is to make sleep problems, like insomnia, primary diagnoses that are not running just secondary to the pain issue or the PTSD issue.”
The Center for Deployment Psychology also offers providers training in treating sleep problems.
Speakers from the Center of Deployment Psychology presented lectures at the one-day workshop at Howard University Hospital that taught the providers about military culture and the mental health issues facing returning servicemembers and veterans. “We are concerned about their safety, and especially the high suicide rates that they have,” said Donna Barnes, PhD, director of the Suicide Prevention Program in Howard University’s Department of Psychiatry.
Air Force Maj John Bowers, who gave a presentation on military culture, told the attendees that more than ever there is a need for culturally competent providers to take care of servicemembers and their families. “When you know as much as you can about the culture of your patients it does several things,” he said. “It allows you to communicate more effectively with your patients, it makes for a stronger patient-provider model, and research shows that it actually improves clinical outcomes.”
Bowers said that 62% of those who are or have deployed to Iraq or Afghanistan are under age 30. They joined the military knowing they would be sent into theater. Sometimes, however, servicemembers feel they must sacrifice their psychological health, a perception that the military is trying to change.
Bowers also shared some military jargon with the providers and said that it helps for civilian providers to be familiar with some military terminology that servicemembers may use. However, he said it is also important for providers to be honest about what they do and do not know.
Providers should also reinforce the courage it takes for the servicemember to seek help.
Domenici reminded the audience in her presentation that servicemembers may also be dealing with “moral” injuries. Servicemembers often have to make quick decisions in theater that may have unintended consequences. “When I see veterans or active duty Marines, it is those moral injuries that weigh on their souls so dramatically that you can’t just keep talking to them and say, ‘It’s not your fault. You did your best,’ because they are carrying it with them.”