Medical Experts Look Beyond Drugs for Sleep Solutions

FALLS CHURCH, Va. — One in 20 active-duty Soldiers are on sleep medications, according to the Army Office of the Surgeon General, or OTSG, "Health of the Force" report released this month.

"These Soldiers are less likely to be medically ready to deploy," the report cautions.

Lt. Col. Jacob Collen, a sleep-medicine physician, who also specializes in pulmonary issues on Joint Base San Antonio, Texas, said physicians usually prescribe Ambien to Soldiers suffering from insomnia.

He and others spoke at the OTSG-sponsored Performance Triad Sleep Summit, Dec. 9.

Ambien - a commonly prescribed brand of zolpidem - is a sedative and it's also known as a hypnotic, said Lt. Col. Ingrid Lim, sleep lead for Performance Triad, OTSG.

While it does work in getting Soldiers to fall asleep, zolpidem "may impair your thinking or reactions," she said. It's something "you don't want to over prescribe."

Cognitive Therapy

Collen said that since there are only 24 sleep specialists in the Army, serving some 1 million troops, the attending physician may not realize that besides Ambien, there are non-prescriptive treatments that are effective for sleep issues.

Currently, the most effective treatment is cognitive behavioral therapy for insomnia, or CBTi, he said.

In addition, BBTi, or brief behavioral therapy for insomnia, is not only effective with sleeping problems, but can also be used with patients who have medical and psychiatric conditions and it can be delivered in a primary care setting, Lim said.

CBTi treatments last several weeks and BBTi less, she said. Both involve encouraging change to thought patterns and behaviors that are the underlying causes contributing to poor sleep.

While CBTi and BBTi are evidence based and clinically proven to be effective, there are, unfortunately, "watered-down versions" of those therapies that are out there, Collen said. These pseudo-versions cherry-pick from the manual rather than using the full approach.

"We want Soldiers to get the rigorous, evidence-based version," he said. "It would be better to have no treatment at all than to get the wrong one.

"There are a lot of dissatisfied people who've taken the watered-down version," he continued. "When they find it doesn't work, they tell others about their experience and they quit going to the MTF," or medical treatment facility.

The solution, Collen said, is to provide more physicians - not just the 24 sleep specialists - training in CBTi and BBTi. Mobile training teams could be used to educate health care providers, including integrated behavioral health consultants.

Sleep Apnea

Lim said that besides insomnia, the second sleep-related issue Soldiers have is obstructive sleep apnea.

Sleep apnea occurs when breathing stops and then starts in cycles. She said the treatment for that is a Continuous Positive Airway Pressure, or CPAP device, which pumps oxygen into the nasal passage to restore normal breathing.

Inadequate Sleep

Lim said the third sleep-related issue Soldiers have is inadequate sleep, meaning less than seven or eight hours.

The Health of the Force report notes that one-third of Soldiers get five hours or less of sleep per night and 62 percent of Soldiers get less than seven. The report lists possible effects of inadequate sleep:

• Increased musculoskeletal injuries
• Risk of behavioral health disorders
• Greater susceptibility to illnesses
• Likelihood of developing symptoms of anxiety, depression and post-traumatic stress

And finally, the report notes that "individuals who routinely get five to six hours of sleep perform much like a person with a blood alcohol content of 0.08."

Proactive Measures

Lim said that besides getting medical help, there are steps Soldiers can take themselves.

Researchers who study sleep, activity and nutrition - the three prongs of what the Army calls Performance Triad - have found that all three interact with each other, meaning that a weakness in one negatively impacts the others, she said.

Limiting junk food and not taking caffeinated beverages before going to sleep are two examples of how to positively impact sleep, she said.

If Soldiers are not eating right or exercising, sleep quality suffers, so they might want to change what they're doing, she said.

Lim then offered another suggestion: ArmyFit.

There are a lot of good health and fitness apps out there, but a good starting place is ArmyFit, a free resource offered by the Army that can be accessed after taking the Global Assessment Tool 2.0, she said. Army civilians and their Families can also access it.

The website directs Soldiers to helpful resources within the physical, spiritual, emotional, Family and social resilience categories, as well as Performance Triad, said Capt. Kristin Saboe, who oversees the site's content.

Cautionary Notes

The Health of the Force report posted some dire warnings concerning poor sleep.

"In training and on the battlefield, inadequate sleep impairs essential abilities such as reaction times, the ability to detect and engage the enemy, and squad tactic coordination."

The report goes on to note that "despite mission degradation resulting from sleepiness, a culture of suboptimal sleep and a perception that lack of sleep is "the Army way" prevails in the force."

Finally, Lim said "sleep needs to be a Soldier's resource like ammo. Are you going to go across the line without adequate fuel for your vehicle, ammo and food? Why are we going to cross the [line of departure] without sleep?"