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. Author manuscript; available in PMC: 2025 Apr 1.
Published in final edited form as: J Sleep Res. 2023 Oct 1;33(2):e14063. doi: 10.1111/jsr.14063

Perpetuating and protective factors in insomnia across racial/ethnic groups of veterans

Sofia Rubi 1, J Kale Monk 2, Sydney Shoemaker 1, Colten Miller 1, Nivedita Prabhu 1, Lisa Y Flores 3, Donte Bernard 3, Christina S McCrae 4, Brian Borsari 5,6, Mary Beth Miller 1
PMCID: PMC10947959  NIHMSID: NIHMS1939674  PMID: 37778753

Summary

Few studies have examined racial/ethnic differences in rates and correlates of insomnia among veterans. This study compared rates of insomnia and interest in sleep treatment among veterans of diverse racial/ethnic backgrounds. Consistent with the 3P model, we tested racial discrimination as a predictor of insomnia, with post-traumatic stress disorder symptoms and romantic partners as perpetuating and protective moderators of this association, respectively. A total of 325 veterans (N = 236 veterans of colour; 12% Asian, 36% Black, 14% Hispanic/Latine) completed questionnaires online from remote locations. Descriptive statistics were used to compare patterns across racial/ethnic groups. Linear regression was used to test moderators of the association between racial discrimination and insomnia severity. Overall, 68% of participants screened positive for insomnia: 90% of Asian; 79% of Hispanic/Latine; 65% of Black; and 58% of White participants. Of those, 74% reported interest in sleep treatment, and 76% of those with partners reported interest in including their partner in treatment. Racial discrimination and post-traumatic stress disorder were correlated with more severe insomnia, while romantic partners were correlated with less severe insomnia. Only post-traumatic stress disorder moderated the association between racial discrimination and insomnia severity. Rates of insomnia were highest among Asian and Hispanic/Latine participants, yet these groups were among the least likely to express interest in sleep treatment. Racial discrimination may exacerbate insomnia symptoms among veterans, but only among those who do not already have disturbed sleep in the context of post-traumatic stress disorder. Romantic partners may serve as a protective factor in insomnia, but do not seem to mitigate the impact of racial discrimination.

Keywords: discrimination, partner, post-traumatic stress disorder, relationships, sleep

1 |. INTRODUCTION

One in three adults in the USA will experience insomnia at some point in their lives (Ohayon, 2011). Insomnia has been associated with higher risk for comorbid conditions, including post-traumatic stress disorder (PTSD), depression, and alcohol use disorder (Byrne et al., 2021) and trajectories of insomnia worsen with age (Kaufmann et al., 2016). Thus, insomnia is a prevalent and persistent public health concern. Unfortunately, insomnia disproportionally affects veterans in comparison to civilian populations (Mysliwiec et al., 2013). In addition to higher rates of insomnia, veterans and military personnel report worse sleep health; for example, shorter sleep duration, worse sleep quality and more daytime sleepiness (Faestel et al., 2013; Samuel et al., 2022). Health disparities also exist across racial/ethnic groups, such that Black, Hispanic/Latine and Asian adults tend to experience worse sleep health than non-Hispanic White individuals (Carnethon et al., 2016; Kaufmann et al., 2016; Petrov & Lichstein, 2016). However, few studies have investigated sleep disparities across racial/ethnic groups of veterans. This study examines rates of insomnia and interest in sleep treatment in a racially diverse sample of veterans. Consistent with the “3P” model of insomnia (Spielman et al., 1987), we propose racial discrimination as an acute precipitating event for insomnia among veterans of colour. We then examine current PTSD as a compounding perpetuator of insomnia severity, and romantic relationships as a protective factor within this population.

Spielman’s “3P” model (Spielman et al., 1987) has been widely adopted to explain the development of insomnia. Consistent with stress-diathesis frameworks, the 3P model posits that Predisposing, Precipitating and Perpetuating factors explain transitions from preclinical sleep to acute and then chronic insomnia (Ellis et al., 2021; Spielman et al., 1987). First, “predisposing” factors (e.g. biology, personality traits) leave some individuals more vulnerable to insomnia than others throughout their lives. In individuals with a predisposition for sleep disturbance, stressful life events (e.g. work demands, deployment) may then trigger or “precipitate” the onset of insomnia. For some people, stress-induced sleep problems resolve with the stressor. However, some people develop thought patterns or habits that then “perpetuate” their sleep problems over time (e.g. spending excessive time in bed, worrying about sleep). These three Ps explain the development and maintenance of insomnia (Bramoweth & Germain, 2013; Ellis et al., 2021; Pruiksma et al., 2018; Spielman et al., 1987). However, in clinical practice, a fourth P is often added to identify the strengths or supportive (“protective”) factors that mitigate the negative impacts of insomnia (Macneil et al., 2012). In prevention and intervention efforts, predisposing and precipitating factors are often not the focus because they tend not to be modifiable; however, perpetuating factors are often targeted because they can be changed (Bramoweth & Germain, 2013). Protective factors are similarly important because they foster resilience and may facilitate recovery.

Racial discrimination is an acute “precipitating” factor for insomnia in diverse racial/ethnic groups. Racial discrimination is defined as differential treatment and/or distribution of resources and opportunities based on someone’s race or ethnicity (Williams, 2018). Day-to-day experiences of discrimination have been recorded in institutional settings and individual interactions (Williams, 2018), making these encounters quite prevalent for people of colour. In one national survey, 61% of adults reported everyday discrimination due to their race or ethnicity (APA, 2016). In civilian populations, racial discrimination acts as a chronic stressor that has been linked to various negative long-term health outcomes, including higher risk for insomnia and PTSD (Cheng et al., 2020; Marshall et al., 2009; Williams, 1999). Race-related stressors have also been linked to higher risk for negative mental health outcomes in veteran populations (Loo et al., 2001; Loo et al., 2005). Thus, racial discrimination may precipitate (and rumination about discrimination may perpetuate) insomnia symptoms in diverse samples of veterans.

In military and veteran samples, one particularly relevant “precipitating” event for insomnia is exposure to trauma (e.g. combat; Bramoweth & Germain, 2013; Pruiksma et al., 2018), and ongoing struggles with PTSD symptoms (e.g. distressing memories, increased arousal) may “perpetuate” sleep difficulties. Trauma exposure has been linked to sleep disturbances and insomnia severity in veteran and civilian samples (Lee & Gabriele, 2018; Xie et al., 2021). In one study, more than half of the trauma-exposed veterans were diagnosed with clinical insomnia, and PTSD symptoms were strongly correlated with insomnia severity (Rosen et al., 2019). However, the impact of trauma on sleep may also vary across racial/ethnic groups. For example, Black and Hispanic/Latina women who reported childhood trauma were more likely than White women with this experience to report short sleep and delayed sleep onset (Gaston et al., 2021). Studies investigating the cause of higher susceptibility to trauma in diverse racial/ethnic groups suggest that race-related adversity during childhood (e.g. racial discrimination, racism, social injustices) may play a role (Bernard et al., 2021; Slopen et al., 2015; Williams, 1999). In particular, racial discrimination has been linked to both race/ethnicity and insomnia severity, with some investigators suggesting it may explain these associations across racial/ethnic civilian groups (Cheng et al., 2020). Other studies also indicate that experiences of racial discrimination may exacerbate risk for both PTSD (Loo et al., 2001; Marshall et al., 2009) and sleep disturbances (Xie et al., 2021).

In contrast to racial discrimination and PTSD, which precipitate and/or perpetuate insomnia symptoms, strong romantic partnerships may play a protective role. Veterans tend to report more interest in seeking treatment if interventions are family-focused (Khaylis et al., 2011), and many indicate that encouragement from friends and family would facilitate treatment-seeking (Warner et al., 2008). Consistent with recommendations to include partners in mental health treatment among veterans (Monk et al., 2018), multiple studies have theorised and tested the impact of romantic partners on sleep patterns (Troxel et al., 2022). Previous work has demonstrated that partners impact not only patients’ sleep (Arpin et al., 2018; Fillo et al., 2017), but also their response to sleep treatment (Ellis et al., 2015). However, few studies have reported veterans’ interest in including partners in sleep treatment, particularly across racial/ethnic groups.

This study aimed to compare rates of insomnia across racial/ethnic groups of veterans. Based on data in civilian samples (Chen et al., 2015; Grandner et al., 2010; Kaufmann et al., 2016), we hypothesised that Black, Hispanic/Latine and Asian veterans would demonstrate higher rates of insomnia than non-Hispanic White veterans. Our previous research found that veterans (as a group) demonstrate the concerning combination of high rates of sleep problems with comparatively low interest in treatment (Miller, Monk, et al., 2022). To inform future research in this area, we examined this discrepancy (rates of sleep problems versus interest in treatment) across racial/ethnic groups. Based on civilian research (Cheng et al., 2020; Xie et al., 2021), we hypothesised that racial discrimination would precipitate insomnia symptoms among veterans of diverse racial backgrounds. We then examined two theoretically relevant factors that might moderate this association: one perpetuating factor (PTSD symptoms) and one protective factor (romantic partners). Specifically, we hypothesised that racial discrimination would be: (a) more strongly associated with insomnia severity among those who also screen positive for current PTSD; and (b) less strongly associated with insomnia severity among those in romantic relationships.

2 |. MATERIALS AND METHODS

2.1 |. Participants and procedure

Eligible participants (N = 325) were adults (> 18 years) who served in the USA military. They were recruited using Qualtrics research panels in April and May 2021 to participate in a parent study examining attitudes toward health-related research among veterans (Miller, Flores, et al., 2022). Qualtrics sent panel members an invitation to participate, and those who clicked on the link and provided informed consent completed the online survey. The parent study aimed to recruit ~75% veterans of colour. All procedures were approved by the Institutional Review Board.

A total of 602 individuals responded to the initial Qualtrics invitation. Consistent with recommendations to ensure data integrity in online samples, data were screened meticulously (Griffin et al., 2021; Meyer et al., 2013). A total of 268 respondents were excluded for the following reasons: 101 only provided demographic data; 118 provided illogical responses (e.g. “hubba”); 13 reported implausible data (e.g. deployed before birth); and 36 failed random responding indicators. An additional four participants declined to disclose race/ethnicity, and five did not complete the Insomnia Severity Index (ISI), resulting in a final analytic sample of 325 participants (66% male, 73% person of colour; Table 1).

TABLE 1.

Participant demographics (N = 325)

Descriptive variable Total (N = 325) Insomnia screen
 χ2/t(df)
Negative (n = 104) Positive (n = 221)
Age, M (SD) 41.5 (14.8) 44.8 (16.7) 40.0 (13.6) 2.52 (168≠)*
Gender, n (%)
 Female 105 (32%) 30 (29%) 75 (71%) 0.84 (1)
 Male 214 (66%) 73 (34%) 141 (66%) 1.29 (1)
 Non-binary or other 6(2%) 1 (17%) 5 (83%) 0.66 (1)
Sexual orientation, n (%)
 Straight or heterosexual 284 (87%) 98 (35%) 186 (66%) 5.74 (1)*
 Lesbian or gay 13 (4%) 3 (23%) 10 (77%) 0.52 (1)
 Bisexual 19 (6%) 1(5%) 18 (95%) 6.71 (1)*
 Queer, pansexual or questioning 7 (2%) 2 (29%) 5 (71%) 0.04 (1)
 Prefer not to respond 2 (< 1%) 0 (0%) 2 (100%) -
Relationship status - - - 4.69 (1)*
 No partner, n (%) 118 (36%) 29 (25%) 89 (75%) -
 Partner, n (%) 207 (64%) 75 (36%) 132 (64%) -
  CSI, M (SD) 15.7 (4.6) 16.5 (4.5) 15.3 (4.5) 1.84 (205)
Race/Ethnicity, n (%)
 American Indian or Alaska Native 18 (6%) 6 (33%) 12 (67%) 0.02 (1)
 Asian or Asian American 38 (12%) 4 (11%) 34 (90%) 9.12 (1)*
 Black or African American 116 (36%) 41 (35%) 75 (65%) 0.93 (1)
 Hispanic, Latino/a, or Latine 47 (14%) 10 (21%) 37 (79%) 2.90 (1)
 Multiracial or Multi-ethnic 13 (4%) 6 (46%) 7 (54%) 1.25 (1)
 Native Hawaiian or Pacific Islander 4 (1%) 0(0%) 4 (100%) 1.91 (1)
 White, Caucasian or European 89 (27%) 37 (42%) 52 (58%) 5.16 (1)*
 Other 0 (0%) 0 (0%) 0(0%) -
Military affiliation, n (%)
 Active duty 68 (21%) 18 (27%) 50 (74%) 1.21 (1)
 Reserves/guard 60 (19%) 17 (28%) 43 (72%) 0.46 (1)
 Separated/discharged/retired 197 (61%) 69 (35%) 128 (65%) 2.10 (1)
Branch of service, n (%)
 Air Force 54 (17%) 18 (33%) 36 (67%) 0.05 (1)
 Army 168 (52%) 60 (36%) 108 (64%) 2.21 (1)
 Coast Guard 19 (6%) 9 (47%) 10 (53%) 2.19 (1)
 Marines 42 (13%) 7 (17%) 35 (83%) 5.21 (1)*
 Navy 42 (13%) 10 (24%) 32 (76%) 1.49 (1)
Symptoms of PTSD, M (SD) 4.5 (6.3) 1.3 (3.5) 6.0 (6.8) 8.27 (321≠)*
 Positive PTSD screen, n (%) 76 (23%) 4(5%) 72 (95%) 32.59 (1)*
 Military-related trauma, n (%) 55 (17%) 3(6%) 52 (95%) 21.44 (1)*
Racial discrimination, M (SD) 13.3 (12.8) 8.1 (9.3) 15.7 (13.5) 5.17 (270≠)*
Insomnia severity, M (SD) 12.5 (6.9) 4.4 (3.1) 16.3 (4.5) 27.70 (276≠)*
 Positive insomnia screen, n (%) 221 (68%) - - -
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Abbreviations: ≠, equal variance not assumed; CSI, Couples Satisfaction Index; M, mean; N, number; PTSD, post-traumatic stress disorder; SD, standard deviation.

*

p < 0.05.

2.2 |. Measures

2.2.1 |. Demographics

Participants selected their race from a list (see options in Table 1), and all participants were then asked to specify via open text box the subgroup that best fit their ethnicity (e.g. Creek, Navajo, Chinese, Vietnamese, Haitian). Participants were only asked to specify their gender, not their sex assigned at birth. Demographics variables (with response options) are depicted in Table 1.

2.2.2 |. Racial discrimination

The 9-item Everyday Discrimination Scale (EDS; Williams et al., 1997) prompted participants to identify how often they experience discrimination in their day-to-day lives (e.g. “people act as if they’re better than you are”). Participants in this study were asked to identify discrimination due specifically to their race/ethnicity, which is compatible with the one-stage attribution version of the measure (Shariff-Marco et al., 2011). Participants indicated their responses on a scale from 0 (never) to 5 (almost every day), and a total score (range 0–45) was created by summing their responses. This scale has shown validity in the prediction of future negative emotions, such as anger or distress, and overall discrimination (Gonzales et al., 2016; Krieger et al., 2005; Shariff-Marco et al., 2011). In this sample, internal consistency was good (α = 0.96).

2.2.3 |. Sleep variables

This study included measures of insomnia symptoms, sleep duration, nightmares, bed partners and sleep treatment preferences. The 7-item ISI (Morin et al., 2011) was used to measure insomnia symptoms. Participants responded to questions about problems staying/falling asleep and the level of distress associated with these problems over the past 2 weeks. Total scores ≥ 10 indicate a positive screen for insomnia (Morin et al., 2011), and reliability in this sample was good (α = 0.89). The Pittsburgh Sleep Quality Index (Buysse et al., 1989) “sleep duration” subscale was used to assess hours of sleep per night; specifically, participants were asked to indicate how many hours of actual sleep they got on a typical night in the past month (noting that hours of actual sleep may differ from hours spent in bed). Lifetime history of nightmares was assessed as part of a checklist of potential medical conditions; participants indicated (yes/no) if they had ever experienced nightmares. This item was included as a covariate in regression models. Finally, participants indicated how often they currently share a bed with another person (0 = never, 1 = rarely, 2 = sometimes, 3 = usually, 4 = always).

Veterans’ preferences for sleep treatment were assessed using three different items. Participants responded to the item, “Are you interested in treatment for your sleep?” (yes/no). Participants who reported having a partner (Table 1) were asked two additional questions: “If you were to seek treatment for your sleep, would you want your partner to be involved?” (yes/no), and “Do you think your partner would want to be involved in treatment for your sleep?” (yes/no/I have no idea).

2.2.4 |. PTSD symptoms

Participants were asked if they had ever experienced, witnessed or had to deal with “any event involving actual or threatened death, serious injury, or sexual violence to you or someone else.” Those who said yes were asked if any of those traumatic events were related to their military experience in any way (yes/no), and then asked to complete the 4-item version of the PTSD Checklist for DSM-5 (PCL; Price et al., 2016). Participants rated how troubled they had been by four symptoms of PTSD (having distressing memories, needing to avoid external reminders, having strong negative beliefs, and feeling jumpy or easily startled) in the past month. Responses ranged from 0 (not at all) to 4 (extremely), and were summed to create a symptom severity score ranging from 0 to 16. Scores ≥ 10 indicate a positive screen for PTSD (Price et al., 2016). When compared with the full-scale PCL-5, the 4-item version has demonstrated similar diagnostic utility. It has also shown validity in identifying PTSD in adults and combat veterans (Price et al., 2016). Reliability in this sample was good (α = 0.90).

Although it is not part of the total score, participants with PTSD also indicated how much they had been bothered by “repeated, disturbing dreams” of their traumatic event(s) in the past month. For descriptive purposes, the number of participants in each racial/ethnic group reporting at least moderate distress related to PTSD-related nightmares is depicted in Table 2.

TABLE 2.

Sleep patterns and treatment preferences in the full sample (N = 325), and those who screened positive for insomnia (N = 221)

Am. Indian/Al. Native Asian/Asian American Black or African Am. Hispanic or Latine Native haw./Pac. Islander Multi-racial/multi-ethnic White
Full sample (N = 325) n = 18 n = 38 n = 116 n = 47 n = 4 n = 13 n = 89
ISI total score 12.3 (7.3) 15.1 (5.3) 12.2 (7.1) 14.0 (6.8) 15.0 (2.6) 12.6 (9.1) 11.0 (6.7)
 ISI ≥ 10 12 (67%) 34 (90%) 75 (65%) 37 (79%) 4 (100%) 7 (54%) 52 (58%)
Sleep duration 5.1 (2.5) 5.2 (1.5) 5.3 (2.0) 5.9 (1.4) 4.6 (1.7) 4.9 (1.6) 5.7 (1.7)
Lifetime nightmares 9 (50%) 21 (55%) 56 (48%) 23 (49%) 1 (25%) 5 (39%) 29 (33%)
 PTSD nightmaresa 5 (28%) 11 (29%) 33 (28%) 15 (32%) 1 (25%) 3 (23%) 19 (21%)
Romantic partner 7 (39%) 24 (63%) 69 (60%) 28 (60%) 2 (50%) 12 (92%) 65 (73%)
Bed partner
 Never 3 (17%) 2 (5%) 32 (28%) 6 (13%) 1 (25%) 0 (0%) 18 (20%)
 Rarely 7 (39%) 7 (18%) 13 (11%) 11 (23%) 2 (50%) 3 (23%) 9 (10%)
 Sometimes 3 (17%) 11 (29%) 23 (20%) 6 (13%) 0 (0%) 1 (8%) 11 (12%)
 Usually 1 (5%) 6 (16%) 16 (13%) 5 (11%) 0 (0%) 2 (15%) 19 (21%)
 Always 4 (22%) 12 (32%) 32 (28%) 19 (40%) 1 (25%) 7 (54%) 32 (36%)
Insomnia (N = 221) n = 12 n = 34 n = 75 n = 37 n = 4 n =7 n = 52
Interest in treatment 8 (67%) 23 (68%) 58 (77%) 25 (68%) 2 (50%) 5 (71%) 42 (81%)
 + romantic partner 3/8 (38%) 14/23 (61%) 32/58 (55%) 15/25 (60%) 1/2 (50%) 4/5 (80%) 31/42 (74%)
Want partner involvedb 2/3 (67%) 10/14 (71%) 26/32 (81%) 13/15 (87%) 1/1 (100%) 2/4 (50%) 22/31 (71%)
Partner wants to be involvedb
 No 1/3 (33%) 4/14 (29%) 6/32 (19%) 0/15 (0%) 0/1 (0%) 1/4 (25%) 8/31 (26%)
 Yes 1/3 (33%) 8/14 (57%) 23/32 (72%) 13/15 (87%) 1/1 (100%) 2/4 (50%) 17/31 (55%)
I have no idea 1/3 (33%) 2/14 (14%) 3/32 (9%) 2/15 (13%) 0/1 (0%) 1/4 (25%) 6/31 (19%)
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Abbreviations: Am, American; Al, Alaska; Haw, Hawaiian; ISI, Insomnia Severity Index; Pac, Pacific; PTSD, post-traumatic stress disorder; Tx, treatment.

a

Moderately, quite a bit, or extremely bothered by nightmares in the past month.

b

Only administered to participants with a romantic partner (denominators listed).

2.2.5 |. Relationship variables

Response options for marital status included: (1) never married; (2) engaged to be married; (3) married; (4) domestic partnership or civil union; (5) divorced or separated; and (6) widowed. Response options for relationship status included: (1) single, not dating; (2) casually dating or talking to partners, but no exclusive partner at this time; (3) in a committed relationship with a single, exclusive partner; and (4) in a committed relationship with multiple partners. Participants who indicated that they were married, engaged to be married, or in a committed relationship (with single or multiple partners) were categorised as having a “partner”. For descriptive purposes, those with a partner completed the 4-item Couples Satisfaction Index (CSI), which asks participants to evaluate their romantic relationship (Funk & Rogge, 2007). Participants first ranked the “degree of happiness (all things considered) of your relationship” on a scale from 0 (extremely unhappy) to 6 (perfect). The remaining three items assessed warmth/comfort, reward and satisfaction with their relationship on a scale from 0 (not at all) to 5 (completely). Higher summed scores indicate higher couple satisfaction, with scores below 13.5 indicative of relationship distress. The CSI has demonstrated strong convergent and construct validity (Funk & Rogge, 2007). Reliability in this sample was good (α = 0.85).

2.3 |. Data screening and analysis plan

Data were screened for invalid and missing responses prior to analysis. No outliers were identified, and all outcome variables were normally distributed. Descriptive statistics and analysis of variance were used to characterise rates of insomnia and interest in sleep treatment across racial/ethnic groups. To reduce the likelihood of misrepresentation, these descriptions focused on the racial/ethnic groups with at least 30 participants: Asian, Black, Hispanic and non-Hispanic White. Two separate hierarchical linear regressions were then conducted among all veterans of colour (N = 236). In the hypothesised “perpetuating” model, PTSD screen (0 = PCL total score < 10; 1 = PCL total score ≥ 10) was tested as a moderator of the association between racial discrimination (EDS score) and insomnia severity (ISI score), controlling for romantic partnership. In the hypothesised “protective” model, romantic partner (0 = no, 1 = yes) was examined as a moderator of the association between racial discrimination (EDS score) and insomnia severity (ISI score), controlling for positive PTSD screen (CSI was not used as the moderator because it was only administered to participants who reported having partners; however, results were consistent when using total CSI score as the moderator in place of the “partner” variable). Age and gender (0 = female, non-binary, or other; 1 = male) were included as covariates in both models due to age- and gender-related variations in insomnia and PTSD (given the small number of non-binary and “other” gender participants, we ran models both excluding and including these participants – results did not differ, so all were included; Ford et al., 2015; Marshall et al., 2009). Both models also controlled for lifetime history of nightmares, as nightmares may contribute to sleep disturbance. Regression coefficients were used to estimate effect size. In the case of significant moderation, tests of simple slopes (Cohen et al., 2003) were used to evaluate the association between racial discrimination and insomnia severity at high and low levels of each moderator (i.e. PCL total scores < versus ≥ 10; with versus without romantic partner).

3 |. RESULTS

Descriptive statistics for the full sample and those with and without insomnia are depicted in Table 1, and descriptive statistics across racial/ethnic groups are depicted in Table 2. Overall, 68% of participants screened positive for clinically significant insomnia: 90% of Asian, 79% of Hispanic/Latine, 65% of Black and 58% of White participants. Rates of insomnia were significantly higher among Asian versus White (χ2(1) =11.74, p < 0.001), Asian versus Black (χ2(1) = 8.53, p = 0.004) and Hispanic/Latine versus White participants (χ2(1) = 5.60, p = 0.02). Group differences between White and Black (χ2(1) =0.83, p = 0.36), Asian and Hispanic/Latine (χ2(1) =1.77, p = 0.18), and Black and Hispanic/Latine participants (χ2(1) =3.08, p = 0.08) were not statistically significant.

Of the 221 who screened positive for insomnia, 163 (74%) reported interest in sleep treatment: 68% of Asian, 68% of Hispanic/Latine, 77% of Black and 81% of White participants (Table 2). Group differences in treatment interest were not significant (all p ≥ 0.16). Of the 163 with insomnia who expressed interest in treatment, 100 (61%) had a partner. Satisfaction with partners was high (M = 15.7, SD = 4.6), with 74% scoring below the cut-off for relationship distress. Of those with romantic partners, 76% agreed that they would want their partner involved in sleep treatment and 65% indicated that their partner would want to be involved (rates across race/ethnicity in Table 2).

Linear regression was used to examine positive PTSD screen as a moderator of the association between everyday racial discrimination and insomnia severity among veterans of colour, controlling for age, gender, nightmares and romantic partners. Bivariate correlations are depicted in Table 3, and main effects and interaction terms are presented in Table 4. Racial discrimination and PTSD screen were both significantly associated with insomnia severity; however, this was qualified by a significant interaction (B = −0.19, SE = 0.08, p = 0.01 [95% CI: −0.34, −0.04]). Follow-up tests of simple slopes indicated that racial discrimination was positively associated with insomnia severity among those who screened negative for PTSD (B = 0.18, SE = 0.04, p < 0.001 [95% CI: 0.09, 0.26]), but was not associated with insomnia severity among those who screened positive for PTSD (B = −0.02, SE = 0.07, p = 0.81 [95% CI: −0.14, 0.11]; see Figure 1). In terms of covariates, nightmares were linked to worse insomnia severity, and partners were linked to less insomnia severity within this model. Age and gender were not significantly associated with insomnia severity.

TABLE 3.

Bivariate correlations among veterans of colour (N = 236)

Age Male EDS PTSD NM Partner
Age -
Male gender 0.23* -
Racial discrimination (EDS) −0.25* −0.07 −
Positive PTSD screen −0.08 −0.06 0.34* -
Nightmares (NM) −0.03 0.10 0.20* 0.52* -
Romantic partner 0.05 0.07 0.02 −0.05 −0.08 -
Insomnia severity (ISI) 0.02 0.03 0.29* 0.38* 0.33* −0.16*
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Abbreviations: EDS, Everyday Discrimination Scale; ISI, Insomnia Severity Index; NM, nightmares; PTSD, post-traumatic stress disorder.

*

p < 0.05.

TABLE 4.

Main effects and interactions in the prediction of insomnia severity among veterans of colour (n = 236)

B SE P 95% CI
Lower Upper
Perpetuating factor model: PTSD
 Intercept 7.55 1.75 < 0.001 4.10 11.01
 Age 0.05 0.04 0.16 −0.02 0.13
 Male gender (Y/N) 0.58 0.85 0.49 −1.10 2.26
 Nightmares (Y/N) 1.93 0.95 0.04 0.06 3.81
 Romantic partner (Y/N) −1.68 0.82 0.04 −3.31 −0.06
 Discrimination 0.18 0.04 < 0.001 0.09 0.26
 Positive PTSD screen (Y/N) 7.28 1.87 < 0.001 3.60 10.96
 Discrimination x PTSD −0.19 0.08 0.01 −0.34 −0.04
Protective factor model: Romantic partners
 Intercept 7.21 1.93 < 0.001 3.41 11.00
 Age 0.06 0.04 0.13 −0.02 0.13
 Male gender (Y/N) 0.65 0.86 0.45 −1.05 2.34
 Nightmares (Y/N) 1.90 0.97 0.05 −0.0004 3.80
 Positive PTSD screen (Y/N) 3.71 1.14 0.001 1.46 5.96
 Discrimination 0.18 0.06 0.003 0.06 0.30
 Romantic partner (Y/N) −0.46 1.33 0.73 −3.09 2.17
 Discrimination x partner −0.10 0.07 0.18 −0.24 0.04
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Abbreviations: CI, confidence interval; PTSD, post-traumatic stress disorder; Y/N = yes (coded 1) versus no (coded 0).

FIGURE 1.

FIGURE 1

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Strength of associations between racial discrimination and insomnia severity in the context of positive versus negative post-traumatic stress disorder (PTSD) screen.

A second linear regression was conducted to test romantic partner as a moderator of the association between everyday racial discrimination and insomnia severity, controlling for age, gender, nightmares and positive PTSD screen (Table 4). Again, racial discrimination was associated with worse insomnia severity (B = 0.18, SD = 0.06, p = 0.003). However, partners were not significantly linked to insomnia severity in this model (B = −0.46, SE = 1.33, p = 0.73), and there was no significant interaction (B = −0.10, SE = 0.07, p = 0.18 [95% CI: −0.24, 0.04]). Nightmares and positive PTSD screen were significant covariates (Table 4).

4 |. DISCUSSION

This study compared insomnia rates across racial/ethnic groups of veterans. Although existing literature has examined racial/ethnic health disparities in insomnia (Chen et al., 2015; Gaston et al., 2021; Grandner et al., 2010; Kaufmann et al., 2016; Lee & Gabriele, 2018; Xie et al., 2021), few have examined these trends in veteran populations. Consistent with findings in civilian populations (Chen et al., 2015; Gaston et al., 2021; Grandner et al., 2010; Kaufmann et al., 2016; Xie et al., 2021), Asian (90%) and Hispanic/Latine (79%) veterans demonstrated the highest rates of insomnia of all racial/ ethnic groups. Unfortunately, they also demonstrated the least interest in sleep treatment (both at 68%). In contrast, White veterans demonstrated relatively low rates of insomnia (58%) and relatively high interest in treatment (80%). Complementing our findings that veterans as a group are least willing to seek treatment for the conditions that are most prevalent in their communities (Miller, Monk, et al., 2022), these data indicate that participants from racial/ethnic groups with the highest need for insomnia treatment are also among the least interested. Given these findings, providers are especially encouraged to screen for sleep problems and offer sleep treatment among veterans of colour, as these minoritised groups may not share sleep issues spontaneously or request sleep treatment unprompted. Though we cannot be certain why rates of insomnia were highest among Asian veterans, Asian Americans are especially at risk for discrimination following the COVID-19 pandemic (Huang & Tsai, 2023), which may explain why they had the greatest rates of insomnia in this sample (data collected in early 2021). Individuals with marginalised racial/ethnic identities may also be more reluctant to seek treatment due to experiences of discrimination in healthcare settings, stigma surrounding mental health, less access to adequate facilities or culturally informed care, or the inability to find providers who understand their racialised experiences (Shim, 2021).

Consistent with hypotheses and previous research (Cheng et al., 2020), racial discrimination was associated with insomnia severity among veterans of colour. However, this association was only significant among those who screened negative for PTSD. We speculate that racial discrimination may not be linked to insomnia severity in the context of PTSD because veterans with PTSD have such high rates of sleep disturbance to begin with (i.e., a ceiling effect). Indeed, in this sample, all but four of those who screened positive for PTSD (95%) also screened positive for insomnia. As such, discrimination may not be linked to insomnia among veterans with PTSD because their sleep is already so disturbed.

In contrast to hypotheses, having a romantic partner did not moderate the association between racial discrimination and insomnia severity. Similarly, although rates of insomnia were higher among those who were not partnered (relative to those who were partnered), having a romantic partner was only linked to lower insomnia severity in one of the two models. This may be due to relatively high relationship satisfaction among all those with partners (regardless of insomnia status). Indeed, three out of four veterans who expressed interest in sleep treatment also expressed interest in involving their partner. This finding aligns with the research on broader mental health treatment preferences among veterans, who report that they would prefer services that are family oriented (Khaylis et al., 2011; Warner et al., 2008). In line with biopsychosocial models, which highlight covariation between relationship functioning and sleep (Troxel et al., 2022), studying and treating sleep as a dyadic (rather than individual) experience may facilitate recovery because partners influence sleep onset, quality and duration as well as response to sleep treatment (Arpin et al., 2018; Ellis et al., 2015; Fillo et al., 2017; Troxel et al., 2022). Extending data pointing to the effectiveness of including partners in sleep interventions, our findings indicate that many veterans – across most racial/ethnic groups – also prefer their partner’s inclusion.

4.1 |. Clinical implications

This study was designed to inform clinical practice. The first and perhaps most important implication is that providers working with veterans can expect at least half of their patients to report clinically relevant sleep disturbance; and these rates are even higher (closer to three out of four) among veterans of colour. Often, veterans’ sleep problems are long-standing and may even predate military service, resulting in the belief that they are intractable. Thus, clinical training in how to screen for and/or diagnose sleep disorders will enhance providers’ abilities to have effective conversations that increase veterans’ intrinsic motivation to engage in available treatments. Even brief interactions (e.g. in primary care settings) can be enhanced by knowing when to provide patients with relevant resources and referrals for evidence-based sleep treatment. The Department of Veterans Affairs and US Department of Defence have published guidelines for the diagnosis and management of insomnia and obstructive sleep apnea (Mysliwiec et al., 2020). Although sleep hygiene and pharmacotherapy are the most frequently offered treatments for insomnia, cognitive behavioural therapies for insomnia (CBT-I) should be offered first (Mysliwiec et al., 2020) and can be delivered effectively inperson, via telehealth (Arnedt et al., 2021) and even by phone (Arnedt et al., 2013). The cognitive and behavioural components of CBT-I have also demonstrated efficacy independently in dismantling studies (Harvey et al., 2014), and the behavioural components alone have demonstrated efficacy in veteran populations (Maguen et al., 2021). Although evidence is weaker, self-help books exist (e.g. Quiet Your Mind and Get to Sleep; Carney & Manber, 2009) and have improved insomnia symptoms in at least one randomised controlled trial (Jernelöv et al., 2012). Mobile apps such as Insomnia Coach (Kuhn et al., 2021) and CBT-I Coach (Miller et al., 2019) have also been developed, and online treatments are available (Bernstein et al., 2017; Ritterband et al., 2017). In line with our findings of veteran preferences for the inclusion of partners, romantic partners can influence the efficacy of CBT-I (Ellis et al., 2015), which further highlights the importance of their consideration (Troxel et al., 2022).

The prevalence of insomnia among veterans with PTSD in this sample was also striking and has clear clinical implications. Sleep disturbance was the rule (not the exception) among veterans with PTSD, meaning the above-mentioned sleep diagnostic and treatment resources are especially needed among veteran providers who specialise in PTSD. Moreover, racial discrimination was linked to insomnia severity among those who screened negative for PTSD, and veterans of colour reported the lowest rates of interest in sleep treatment. Based on these data, targeted outreach and engagement is especially needed in these communities.

4.2 |. Limitations

This work should be reviewed with limitations in mind. First, responses were collected using a single (cross-sectional), retrospective survey. This makes it impossible to know if racial discrimination, PTSD or partners are impacting insomnia severity or vice versa (e.g. perhaps people with insomnia are more vulnerable to symptoms of PTSD). All measures were also self-report, which may contribute to shared method variance and overestimation of parameters (Cole & Maxwell, 2003) and may capture different dimensions of the sleep experience than objective measures (Aili et al., 2017). Future work is needed to replicate these findings using prospective sleep monitoring (e.g. sleep diaries) and objective measures, such as actigraphy. However, we can conclude that these conditions co-occur, and racial discrimination seems to play a stronger role in insomnia outside the context of PTSD. Although the screening measures used in this study have all been validated, it is also important to acknowledge that “screening positive” for insomnia or PTSD is not the same as being diagnosed with chronic insomnia or PTSD via clinical interview with a trained professional, so true rates of Insomnia Disorder and PTSD are uncertain.

Given the plurality of men in this sample, it is also unclear if/how findings would generalise to women; and we did not recruit sufficient numbers of Native American, Alaska Native, Native Hawaiian, Pacific Islander or multiracial/multi-ethnic veterans to draw strong conclusions about these racial/ethnic groups. Given the prevalence of insomnia and PTSD among veterans, we strongly encourage multicultural work examining the unique roles of PTSD and racial discrimination in various racial/ethnic groups. Research examining unique patterns among veterans of various sexual orientations and gender identities is also encouraged to inform and help resolve health disparities in these minoritised groups as well (Carey et al., 2022).

5 |. CONCLUSION

Veterans as a group report high rates of insomnia. However, rates are even higher among veterans of colour, particularly Asian and Hispanic/Latine veterans. Although rates varied across racial/ethnic groups, three out of four veterans expressed interest in sleep treatment, and the majority indicated that they would want their partner involved in treatment. This indicates promise for sleep treatment as a gateway to mental health, but it also means that providers must be trained and prepared to connect veterans with the sleep resources that they need. Everyday experiences of racial discrimination were only associated with more severe symptoms of insomnia outside the context of PTSD, presumably because veterans with PTSD already report such high rates of insomnia. In contrast, partners may be protective against insomnia, but do not seem to mitigate the negative impact of racial discrimination on insomnia severity. Research and clinical training to improve access to sleep treatment among veterans is needed, and targeted outreach is needed for veterans of colour.

FUNDING INFORMATION

Investigator contributions to this project were supported by the National Institute on Alcohol Abuse and Alcoholism (K23AA026895, PI Miller), and the National Institute of Minority Health and Health Disparities Grant K23MD016168 (PI D. L. Bernard). The National Institutes of Health had no role in study design; data collection, analysis or interpretation; manuscript preparation; or the decision to submit for publication. The parent project was registered on Open Science Framework prior to data collection (https://osf.io/dxhj6), and data will be made available upon request.

Footnotes

CONFLICT OF INTEREST STATEMENT

The authors have no conflicts of interest to report. This work has not been previously disseminated.

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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