Sleep solutions: What docs are doing to help troops get some shut-eye

Sleep disorder

Having trouble sleeping?

You are not alone. A 2013 study of 726 active-duty soldiers at Madigan Army Medical Center, Washington, found that more than half had moderate or severe obstructive sleep apnea and one in four suffered from insomnia.

The average amount of time the troops spent asleep was 5.74 hours — well below the seven to eight hours of quality sleep considered optimal by the National Sleep Foundation and under the minimum 6.5 hours stressed by many military physicians.

Without a decent night’s sleep, service members are more prone to poor decision-making, accidents and symptoms of depression. Both sleep deprivation and excessive sleep — considered to be more than nine hours — can make a person vulnerable to weight gain, heart conditions and stroke.

It’s been thought that military sleep problems are related to combat exposure or post-traumatic stress. But new research shows that deployment itself may play a major role in both developing sleep disorders and retaining them after deployment.

“In one study, 100 percent of veterans with PTSD had sleep problems and 90 percent without PTSD reported them, and many who deploy don’t return to predeployment sleep levels when they come back,” says Dr. Christopher Nelson, a Naval Hospital Camp Lejeune, North Carolina, psychiatrist.

Short of knocking back an Ambien or Lunesta — both which have side effects that pose a risk to troops — is there a way to work toward getting a good night’s sleep?

Defense and Veterans Affairs department experts weighed in May 4 during a seminar at the American Psychiatric Association annual meeting in New York City.

“This is far and away the biggest complaint our patients have. Everyone has problems with sleep,” said Lt. Cmdr. Paul Sargent, division officer of the Navy’s Overcoming Adversity and Stress Injury Support, or OASIS, residential combat-related PTSD program.

With the high incident rate of sleep apnea in a population that does not have the weight issues or advanced age normally associated with apnea, Dr. David FitzGerald, a neurologist at the Malcolm Randall VA Medical Center in Gainesville, Florida, sends his patients to the sleep clinic for testing. He has found that for many, a continuous positive airway pressure machine, or C-PAP, provides nearly instant relief.

“If it was just PTSD that was causing these problems with sleep, how is that that so many people benefit from using a C-PAP? … It’s not just PTSD,” FitzGerald says.

If the problem is not apnea or nightmares associated with PTSD that keep troops awake at night, other factors may be at play, including mild traumatic brain injury, anxiety or body clocks gone haywire.

Fortunately, technology can help develop good sleep habits, experts say.

Among the top recommendations is a mobile application developed by VA, DoD and others called CBT-I Coach (CBT stands for cognitive behavioral therapy).

While the app is supposed to be used in conjunction with professional treatment for insomnia, it can be downloaded and followed by anyone who wants to improve their sleep, says Rachel Markwald, a sleep researcher at the Naval Health Research Center.

The app includes a sleep diary, information on quieting the mind and establishing an optimal sleep environment, reminders to follow, and sleep assessments.

“I highly recommend this product, and it’s available for free,” Markwald says.

Other technological advancements include body-monitoring devices such as Jawbone Up and Fitbit One, activity trackers that register movement, rest and sleep.

The devices can monitor how long a person stays in bed, when they go to sleep and the time they wake.

“It can tell whether you are asleep or awake … they say they can differentiate between deep and light sleep, but that’s not true, based on 20-plus years of research in the field. But I look at it as assessing whether I am asleep or not … it’s information available to me,” says Markwald, who wears a Jawbone Up.

Other downloadable apps for smartphones include Sleep Cycle for iOS and Sleepbot for Android. Both use a phone’s accelerometer to determine activity and sleep. They also claim to differentiate between light or deep sleep, dreaming or REM (rapid eye movement).

But again, Markwald says, while they document sleep, the cool graphics showing sleep levels and cycles aren’t necessarily accurate.

“Still, they do provide a good overview,” she says.

Those seeking a less state-of-the-art solution may find it in acupuncture, an alternative therapy with growing popularity among troops, Navy researchers say.

In a study conducted at the Naval Medical Center San Diego, sailors found that acupuncture on the ear improved sleep quality and daytime focus as well as decreased pain.

“This population is very interested in alternatives to medications. I used to think acupuncture was voodoo and didn’t want to have anything to do with it. … Now I study it,” says Cmdr. Heather King, a Navy researcher.

Even when the basics — which include maintaining a steady sleep schedule, sleeping in a darkened room, avoiding caffeine or other stimulants late in the day and eliminating screen time at least an hour before bedtime — as well as these other solutions don’t work, medication can help.

Nelson says he often prescribes Rozerem, a sedative, to his Marine patients. Rozarem is not addictive and works with the brain’s suprachiasmatic nucleus, or master clock, to regulate sleep.

Many physicians prescribe Remeron, an antidepressant commonly given at low doses for sleep, although it can cause weight gain and should be used cautiously, Nelson says.

Other options include muscle relaxants — often prescribed for service members’ musculoskeletal strain that can serve a dual purpose, easing pain and causing drowsiness — and low doses of the anti-psychotic medication queitapine, or Seroquel.

Sleep-deprived individuals sometimes turn to alcohol or over-the-counter medications such as Benadryl, which contains diphenhydramine, the same ingredient found in Tylenol PM, Advil PM, Unisom and Sominex, but these should be avoided, experts say.

While these medications can knock a person out cold, they wreak havoc on sleep quality, and patients often wake up feeling worse than they did the day before.

“I get a hangover from Benadryl. Find something else that works,” FitzGerald says.

Ambien and Lunesta remain popular options, but many military docs avoid prescribing these medications because of potential side effects, which include such bizarre sleep behaviors as sleep-eating, sleep-driving and sleep sex.

“I used to think Lunesta wasn’t as bad as Ambien, but I did have a patient that woke up in Wal-Mart after having driven there,” Nelson says.

Finally, one natural solution — favored by travelers to reset their circadian rhythms when moving between time zones — may help, sleep researcher Markwald says.

“I take melatonin, and that’s it. I’ll take a little tiny bit, a half a gram, three hours before I want to go to bed, and then right before, I take a five milligram pill, and it works for me,” she says.

Troops facing troubled nights should consult their physicians about steps they can take to improve their sleep, the researchers says. Without it, patients risk developing symptoms of depression, anxiety, fatigue, PTSD and worse.

“Poor sleep can be a real predictor for suicide, and with suicide prevention at the forefront of our minds, sleep needs to very much be our priority,” Nelson says.

Patricia Kime is the health reporter for Military Times. She can be reached at pkime@militarytimes.com.

Patricia Kime

Patricia Kime is a health writer for Military Times. Reach her at pkime@militarytimes.com.

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