Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea.

STUDY OBJECTIVES: The aim of this study was to evaluate sex-related differences in symptoms of sleep disorders, sleep-related impairment, psychiatric symptoms, traumatic brain injury, and polysomnographic variables in treatment-seeking military personnel diagnosed with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA). METHODS: Participants were 372 military personnel (46.2% women, 53.8% men) with an average age of 37.7 (standard deviation = 7.46) years and median body mass index of 28.4 (5.50) kg/m2. Based on clinical evaluation and video-polysomnography, participants were diagnosed with insomnia (n = 118), OSA (n = 118), or COMISA (n = 136). Insomnia severity, excessive daytime sleepiness, sleep quality, nightmare disorder, sleep impairment, fatigue, posttraumatic stress disorder, anxiety, depression symptoms, and traumatic brain injury were evaluated with validated self-report questionnaires. Descriptive statistics, parametric and nonparametric t-tests, and effect sizes were used to assess sex differences between men and women. RESULTS: There were no significant differences between women and men with insomnia or OSA in sleep-related symptoms, impairment, or polysomnography-based apnea-hypopnea index. Military men with COMISA had a significantly greater apnea-hypopnea index as compared to military women with COMISA, but women had greater symptoms of nightmare disorder, posttraumatic stress disorder, and anxiety. CONCLUSIONS: In contrast to civilian studies, minimal differences were observed in self-reported sleep symptoms, impairment, and polysomnography metrics between men and women diagnosed with the most frequent sleep disorders in military personnel (ie, insomnia, OSA, or COMISA) except in those with COMISA. Military service may result in distinct sleep disorder phenotypes that differ negligibly by sex. CITATION: Mysliwiec V, Pruiksma KE, Matsangas P, et al. Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2024;20(1):17-30.

Digital CBTI hubs as a treatment augmentation strategy in military clinics: study protocol for a pragmatic randomized clinical trial.

BACKGROUND: Chronic insomnia is the most prevalent sleep disorder among military service members, and it compromises readiness, performance, and physical and mental health. Cognitive behavioral treatment for insomnia (CBTI) is the standard of care for the treatment of insomnia recommended by the VA/DoD Clinical Practice Guideline, the American Academy of Sleep Medicine, and the American College of Physicians. CBTI is highly effective but has limited scalability. It is often unavailable in clinical settings where service members receive sleep care. Digital technologies offer unique opportunities to scale and broaden the geographic reach of CBTI services and support increased patient access and engagement in behavioral sleep care. This study aims to evaluate the impact and acceptability of digital CBTI hubs to augment military treatment facilities' capabilities in behavioral sleep medicine. METHODS: This is a multi-site, non-inferiority randomized clinical trial designed to compare the effects of in-person (face-to-face or virtual) insomnia care as usual at three military sleep clinics versus CBTI delivered remotely and asynchronously through digital CBTI hubs. Digital CBTI hubs are led by licensed, certified clinicians who use NOCTEM's® evidence-based clinical decision support platform COAST™ (Clinician Operated Assistive Sleep Technology). Changes in insomnia severity and daytime symptoms of depression and anxiety will be compared at baseline, at 6-8 weeks, and at 3-month follow-up. Patient satisfaction with insomnia care as usual versus digital CBTI hubs will also be examined. We hypothesize that digital CBTI hubs will be non-inferior to insomnia care as usual for improvements in insomnia and daytime symptoms as well as patient satisfaction with insomnia care. DISCUSSION: Digital technology has a high potential to scale CBTI accessibility and delivery options required to meet the insomnia care needs of military service members. Digital CBTI hubs using COAST offer a novel approach to broaden service members' access to CBTI and to serve as an augmentation strategy for existing sleep services at military treatment facilities. The pragmatic approach leveraging technology in this trial has the potential to rapidly inform clinical practice within the Defense Health Agency as well as other healthcare systems. TRIAL REGISTRATION: ClinicalTrials.gov NCT05490550. Registered on 14 July 2023.

Survey of Resources in Behavioral Sleep Medicine Across the Department of Defense, Defense Health Agency.

INTRODUCTION: Insomnia affects approximately 40% of active duty service members and adversely affects health, readiness, and safety. The VA/DoD Clinical Practice Guideline for the management of insomnia recommends cognitive-behavioral treatment of insomnia (CBTI) or its abbreviated version (brief behavioral treatment of insomnia [BBTI]) as the first-line insomnia treatment. The goal of this study was to assess CBTI/BBTI resources at MTFs, perceived facilitators and barriers for CBTI/BBTI, and gaps in these treatments across the Defense Health Agency. MATERIALS AND METHODS: Between July and October 2022, we conducted an electronic survey of CBTI/BBTI resources across Contiguous United States and the District of Columbia (CONUS) and Outside Continental United States (OCONUS) MTFs. The survey was distributed to 154 military sleep health care providers from 32 MTFs, and a link to the survey was posted on two online military sleep medicine discussion forums. Fifteen providers from 12 MTFs volunteered to complete a 30-minute qualitative interview to explore their perception of barriers and facilitators of CBTI/BBTI at their facility. RESULTS: Fifty-two of 154 providers (33.8%) at 20 MTFs completed the survey. A majority of providers indicated that hypnotics remain the most common treatment for insomnia at their facility. Sixty-eight percent reported that CBTI/BBTI was available at their facility and estimated that less than 50% of the patients diagnosed with insomnia receive CBTI/BBTI. The main facilitators were dedicated, trained CBTI/BBTI providers and leadership support. Referrals to the off-post civilian network and self-help apps were not perceived as significant facilitators for augmenting insomnia care capabilities. The primary barriers to offering CBTI/BBTI were under-resourced clinics to meet the high volume of patients presenting with insomnia and scheduling and workflow limitations that impede repeated treatment appointments over the period prescribed by CBTI/BBTI protocols. Four primary themes emerged from qualitative interviews: (1) CBTI/BBTI groups can scale access to insomnia care, but patient engagement and clinical outcomes are perceived as inferior to individual treatment; (2) embedding trained providers in primary or behavioral health care could accelerate access, before escalation and referral to a sleep clinic; (3) few providers have the time to adhere to traditional CBTI protocols, and appointment scheduling often does not support weekly or bi-weekly treatment visits; and (4) the absence of quality and/or continuity of care measures dampens providers' enthusiasm for using external referral resources or self-help apps. CONCLUSIONS: Although there is a wide recognition that CBTI/BBTI is the first-line recommended insomnia treatment, the limited scalability of treatment protocols, clinical workflow limitations, and scarcity of trained CBTI/BBTI providers limit the implementation of the VA/DoD clinical guideline. Educating and engaging health care providers and leadership about CBTI, augmenting CBTI-dedicated resources, and adapting clinical workflows were identified as specific strategies needed to meet the current insomnia care needs of service members. Developing protocols for scaling the availability of CBTI expertise at diverse points of care, upstream from the sleep clinics, could accelerate access to care. Establishing standardized quality measures and processes across points of care, including for external providers and self-help apps, would enhance providers' confidence in the quality of insomnia care offered to service members.

A comprehensive evaluation of insomnia, obstructive sleep apnea and comorbid insomnia and obstructive sleep apnea in US military personnel.

STUDY OBJECTIVES: The aim of this study was to characterize the sleep disorders of insomnia, obstructive sleep apnea (OSA), and comorbid insomnia and OSA (COMISA) in active duty military personnel. METHODS: Prospective observational study of 309 military personnel with a mean age of 37.17 years (SD = 7.27). Participants served in four branches of the U.S. military (47.9% Air Force, 38.8% Army, 11.3% Navy, and 1.9% Marines). Sleep diagnoses were rendered after video-polysomnography and a clinical evaluation. Validated self-report measures assessed insomnia severity, excessive daytime sleepiness, sleep quality, disruptive nocturnal behaviors, nightmare disorder, shift work disorder (SWD), sleep impairment, fatigue, posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, and traumatic brain injury (TBI). General linear models and Pearson chi-square tests were used for between-group differences in data analyses. RESULTS: Insomnia was diagnosed in 32.7%, OSA in 30.4% and COMISA in 36.9%. Compared to military personnel with OSA alone, those with insomnia only and COMISA had significantly greater insomnia severity, disruptive nocturnal behaviors, sleep-related impairment, rates of nightmare disorder, and poorer sleep quality (all Ps < .05). They also reported greater symptoms of fatigue, PTSD, anxiety, and depression (all Ps < .05). There were no significant differences among the three sleep disorder diagnostic groups on sleepiness, SWD, or TBI. CONCLUSIONS: Military personnel with insomnia only and COMISA overall report worsened symptoms of sleep disorders, sleep-related impairment, fatigue, and psychiatric disorders than those with OSA. Results highlight the importance of a comprehensive assessment for sleep-related impairment, sleep, and comorbid disorders in military personnel with clinically significant sleep disturbances.

Clinical and polysomnographic features of trauma associated sleep disorder.

STUDY OBJECTIVES: Trauma associated sleep disorder is a proposed parasomnia that develops after trauma with clinical features of trauma related nightmares, disruptive nocturnal behaviors, and autonomic disturbances. The purpose of this case series is to better characterize the clinical and video-polysomnographic features of patients meeting clinical criteria for this proposed parasomnia. METHODS: Semistructured clinical interview and detailed video-polysomnography review of 40 patients. Movements and vocalizations in rapid eye movement sleep were quantified according to the rapid eye movement sleep behavior disorder severity scale. RESULTS: Patients (n = 40, 32 males) were service members and veterans with a median age of 38.9 years (range 24-57 years) who reported trauma related nightmares and disruptive nocturnal behaviors at home. On video-polysomnography, 28 (71.8%) patients had disruptive nocturnal behaviors in rapid eye movement sleep consisting of limb, head, and axial movements; vocalizations were present in 8 (20%). On the rapid eye movement sleep behavior disorder severity scale, most (n = 28, 71.8%) had a low rating but those with greater severity (n = 11, 28.2%) had a higher prevalence of posttraumatic stress disorder (P = .013) and markedly less N3 sleep (P = .002). The cohort had a high rate of insomnia (n = 35, 87.5%) and obstructive sleep apnea (n = 19, 47.5%). Most patients were treated with prazosin (n = 29, 72.5%) with concomitant behavioral health interventions (n = 25, 64.1%); 15 (51.7%) patients receiving prazosin reported improved symptomatology. CONCLUSIONS: Disruptive nocturnal behaviors can be captured on video-polysomnography during rapid eye movement sleep, although they may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-polysomnographic correlations are invaluable in assessing patients with trauma associated sleep disorder to document objective abnormalities. This case series provides a further basis for establishing trauma associated sleep disorder as a unique parasomnia. CITATION: Brock MS, Matsangas P, Creamer JL, et al. Clinical and polysomnographic features of trauma associated sleep disorder. J Clin Sleep Med. 2022;18(12):2775-2784.

OSA and cardiorespiratory fitness: a review.

The effects of untreated obstructive sleep apnea (OSA) on cardiopulmonary function remain unclear. Cardiorespiratory fitness (CRF), commonly reflected by VO2 max measured during cardiopulmonary exercise testing, has gained popularity in evaluating numerous cardiopulmonary conditions and may provide a novel means of identifying OSA patients with the most clinically significant disease. This emerging testing modality provides simultaneous assessment of respiratory and cardiovascular function with results helping uncover evidence of evolving pathology in either organ system. In this review, we highlight the current state of the literature in regard to OSA and CRF with a specific focus on changes in cardiovascular function that have been previously noted. While OSA does not appear to limit respiratory function during exercise, studies seem to suggest an abnormal cardiovascular exercise response in this population including decreased cardiac output, a blunted heart rate response (ie, chronotropic incompetence), and exaggerated blood pressure response. Surprisingly, despite these observed changes in the cardiovascular response to exercise, results involving VO2 max in OSA remain inconclusive. This is reflected by VO2 max studies involving middle-aged OSA patients showing both normal and reduced CRF. As prior studies have not extensively characterized oxygen desaturation burden, we propose that reductions in VO2 max may exist in OSA patients with only the most significant disease (as reflected by nocturnal hypoxia). Further characterizing this relationship remains important as some research suggests that positive airway pressure therapy or aerobic exercise may improve CRF in patients with OSA. In conclusion, while it likely that severe OSA, via an abnormal cardiovascular response to exercise, is associated with decreased CRF, further study is clearly warranted to include determining if OSA with decreased CRF is associated with increased morbidity or mortality. CITATION: Powell TA, Mysliwiec V, Brock MS, Morris MJ. OSA and cardiorespiratory fitness: a review. J Clin Sleep Med. 2022;18(1):279-288.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

The Military Service Sleep Assessment: an instrument to assess factors precipitating sleep disturbances in U.S. military personnel.

STUDY OBJECTIVES: Military personnel frequently experience sleep difficulties, but little is known regarding which military or life events most impact their sleep. The Military Service Sleep Assessment (MSSA) was developed to assess the impact of initial military training, first duty assignment, permanent change of station, deployments, redeployments, and stressful life events on sleep. This study presents an initial psychometric evaluation of the MSSA and descriptive data in a cohort of service members. METHODS: The MSSA was administered to 194 service members in a military sleep disorders clinic as part of a larger study. RESULTS: Average sleep quality on the MSSA was 2.14 (on a Likert scale, with 1 indicating low and 5 indicating high sleep quality), and 72.7% (n = 140) of participants rated their sleep quality as low to low average. The events most reported to negatively impact sleep were stressful life events (41.8%), followed by deployments (40.6%). Military leadership position (24.7%) and birth/adoption of a child (9.7%) were the most frequently reported stressful life events to negatively impact sleep. There were no significant differences in current sleep quality among service members with a history of deployment compared with service members who had not deployed. CONCLUSIONS: The MSSA is the first military-specific sleep questionnaire. This instrument provides insights into the events during a service member's career, beyond deployments, which precipitate and perpetuate sleep disturbances and likely chronic sleep disorders. Further evaluation of the MSSA in nontreatment-seeking military populations and veterans is required.

Diagnosing narcolepsy in the active duty military population.

PURPOSE: Narcolepsy type I and type II are central hypersomnias characterized by excessive daytime sleepiness and nocturnal sleep disruptions. These rare disorders make the diagnosis complex, as multiple sleep disorders are known to cause false-positive results on testing. There is a high incidence of sleep disorders in the military, and the diagnosis of narcolepsy can have serious career implications. This study looked to assess for the presence of confounding disorders in patients previously diagnosed with narcolepsy. METHODS: We conducted a retrospective analysis of patients aged 18-65 previously diagnosed with narcolepsy at an outside facility, referred for repeat evaluation at the Wilford Hall Sleep Disorders Center. Previous test results from the time of original diagnosis were reviewed if available and compared with repeat evaluation which included actigraphy, in-laboratory polysomnography, and multiple sleep latency testing. RESULTS: Of the 23 patients, 2 (9%) retained a diagnosis of narcolepsy after repeat testing. Ten patients (43%) had insufficient sleep syndrome, five (22%) had significant circadian rhythm sleep-wake disorders, and nine (39%) patients were diagnosed with mild obstructive sleep apnea (OSA). Four of the nine patients with OSA (44%) had supine predominant OSA. CONCLUSION: Diagnostic testing for narcolepsy may be influenced by the presence of comorbid sleep disorders including sleep-disordered breathing, insufficient sleep duration, and circadian misalignment which are common in active military personnel. This study emphasizes the importance of excluding these comorbid diagnoses in this population.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

Description: In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea: Synopsis of the 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines.

Description: In September 2019, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) approved a new joint clinical practice guideline for assessing and managing patients with chronic insomnia disorder and obstructive sleep apnea (OSA). This guideline is intended to give health care teams a framework by which to screen, evaluate, treat, and manage the individual needs and preferences of VA and DoD patients with either of these conditions. Methods: In October 2017, the VA/DoD Evidence-Based Practice Work Group initiated a joint VA/DoD guideline development effort that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline panel developed key questions, systematically searched and evaluated the literature, created three 1-page algorithms, and advanced 41 recommendations using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Recommendations: This synopsis summarizes the key recommendations of the guideline in 3 areas: diagnosis and assessment of OSA and chronic insomnia disorder, treatment and management of OSA, and treatment and management of chronic insomnia disorder. Three clinical practice algorithms are also included.

Posttraumatic Stress Disorder, Traumatic Brain Injury, Sleep, and Performance in Military Personnel.

Sleep disturbances, posttraumatic stress disorder, and traumatic brain injury are highly prevalent in military personnel and veterans. These disorders can negatively impact military performance. Although literature evaluating how posttraumatic stress disorder and traumatic brain injury directly impact military performance is limited, there is evidence supporting that these disorders negatively impact cognitive and social functioning. What is not clear is if impaired performance results from these entities individually, or a combination of each. Further research using standardized evaluations for the clinical disorders and metrics of military performance is required to assess the overall performance decrements related to these disorders.

Unexpected Finding of Idiopathic REM Sleep Behavior Disorder in a Young Healthy Male With Snoring: A Case Report.

None: Idiopathic rapid eye movement sleep behavior disorder is characterized by vocalizations and complex motor behaviors during sleep. We report a case of a 44-year-old male with a 20-year history of dream enactment behavior that was incidentally captured on a polysomnogram during an evaluation for obstructive sleep apnea. Genetic testing found the patient had a homozygous deletion for one of the five tandem repeats in exon 18 of the PER3 gene. This case highlights a potential genetic basis for idiopathic rapid eye movement sleep behavior disorder. CITATION: Brock MS, Shirley S, Rohena L, Moore BA, Mysliwiec V. Unexpected finding of idiopathic REM sleep behavior disorder in a young healthy male with snoring: a case report. J Clin Sleep Med. 2019;15(9):1369-1371.

Trauma Associated Sleep Disorder: Clinical Developments 5 Years After Discovery.

PURPOSE OF REVIEW: We review recent and growing evidence that provides support for a novel parasomnia, trauma associated sleep disorder (TASD). Based on these findings, we further develop the clinical and polysomnographic (PSG) characteristics of TASD. We also address factors that precipitate TASD, develop a differential diagnosis, discuss therapy, and propose future directions for research. RECENT FINDINGS: Nightmares, classically a REM phenomenon, are prevalent and underreported, even in individuals with trauma exposure. When specifically queried, trauma-related nightmares (TRN) are frequently associated with disruptive nocturnal behaviors (DNB), consistent with TASD. Capture of DNB in the lab is rare but ambulatory monitoring reveals dynamic autonomic concomitants associated with disturbed dreaming. TRN may be reported in NREM as well as REM sleep, though associated respiratory events may confound this finding. Further, dream content is more distressing in REM. Therapy for this complex disorder likely requires addressing not only the specific TASD components of TRN and DNB but comorbid sleep disorders. TASD is a unique parasomnia developing after trauma. Trauma-exposed individuals should be specifically asked about their sleep and if they have nightmares with or without DNB. Patients who report TRN warrant in-lab PSG as part of their evaluation.

The Epworth Sleepiness Scale in Service Members with Sleep Disorders.

INTRODUCTION: Excessive daytime sleepiness affects an estimated 20% of the general population. 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. The Epworth Sleepiness Scale (ESS) is the most widely used sleep questionnaire and provides a self-assessment of daytime sleepiness. To date the clinical utility of this questionnaire in differentiating sleep disorders in military patients with sleep disorders has never been evaluated. MATERIALS AND METHODS: The primary aim of this manuscript was to assess if Epworth Sleepiness Scale (ESS) scores differed between military personnel with insomnia, obstructive sleep apnea (OSA), comorbid insomnia/obstructive sleep apnea (COMISA), and a group with neither insomnia nor obstructive sleep apnea (NISA). This study assessed the clinical utility of the ESS in differentiating sleep disorders amongst a sample (N = 488) of U.S. military personnel with insomnia (n = 92), OSA (n = 142), COMISA (n = 221), and a NISA group (n = 33) which served as the control population. RESULTS: In the present sample, 68.4% of service members reported excessive daytime sleepiness (EDS) with an ESS > 10. ESS scores differed between military personnel with COMISA (13.5 ± 4.83) and those with OSA only (11.5 ± 4.08; p < 0.001) and the NISA group (9.46 ± 4.84; p < 0.001). Also, ESS scores differed between patients with insomnia only (13.0 ± 4.84) and the NISA group (p < 0.01). CONCLUSIONS: Overall, the ESS had poor ability to differentiate sleep disorders. In military personnel, the ESS appears elevated in the most common sleep disorders, likely due to their insufficient sleep, and does not help to differentiate OSA from insomnia. Further studies are required to validate this questionnaire and determine an appropriate threshold value for abnormal sleepiness in the military population.