Sleep in the Military

Abstract

Sleep disturbances are a common reaction to stress and are linked to a host of physical and mental health problems. Given the unprecedented demands placed on U.S. military forces since 2001, there has been growing concern about the prevalence and consequences of sleep problems for servicemembers. Sleep problems often follow a chronic course, persisting long after servicemembers return home from combat deployments, with consequences for their reintegration and the readiness and resiliency of the force. Therefore, it is critical to understand the role of sleep problems in servicemembers’ health and functioning and the policies and programs available to promote healthy sleep. This study provides the first comprehensive review of sleep-related policies and programs across the U.S. Department of Defense (DoD), along with a set of actionable recommendations for DoD, commanders, researchers, and medical professionals who treat U.S. servicemembers. The two-year multimethod study also examined the rates and correlates of sleep problems among post-deployed servicemembers, finding negative effects on mental health, daytime impairment, and perceived operational readiness. The research reviewed evidence-based interventions to treat sleep disturbances among servicemembers and veterans and exposed several individual- and system-level barriers to achieving healthy sleep. Implementing evidence-based treatments is just one step toward improving sleep across the force; as the research recommendations highlight, it is equally important that policies and programs also focus on preventing sleep problems and their consequences.

“In peace and war, the lack of sleep works like termites in a house: below the surface, gnawing quietly and unseen to produce gradual weakening which can lead to sudden and unexpected collapse.”

—Major General Aubrey Newman (Follow Me, 1981, p. 279)

Significance

Sleep disturbances are a common reaction to stress and are reliably and prospectively linked with a host of adverse mental and physical health outcomes, including increased risk of depression, suicide, posttraumatic stress disorder (PTSD), accidents and injuries, cardiometabolic disorders, and mortality (Bramoweth and Germain, 2013). Given the unprecedented demands placed on the U.S. military over the past 13 years of protracted overseas combat operations in Iraq and Afghanistan, increasing attention has focused on the prevalence and consequences of sleep problems among servicemembers returning from deployments in support of Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND). Perhaps not surprisingly, research suggests that sleep problems—particularly insomnia, short sleep duration, and nightmares—are highly prevalent during combat operations (Bray et al., 2009; McLay, Klam, and Volkert, 2010; Mental Health Advisory Team [MHAT] 9, 2013; Young-McCaughan, Peterson, and Bingham, 2011). Importantly, sleep disturbances are also core symptoms of PTSD, depression, anxiety, and traumatic brain injury (TBI), which are considered among the signature wounds of OIF/OEF deployments (Hoge, Castro, et al., 2004). Research further suggests that, for many servicemembers, sleep problems persist long after deployments have ended and can have a substantial impact on their ability to successfully reintegrate and rebuild their lives post-deployment (Pietrzak, Morgan, and Southwick, 2010; Plumb et al., 2014; Seelig et al., 2010; Swinkels et al., 2013). As the United States continues its drawdown from OIF, OEF, and OND and increasing numbers of servicemembers face the challenges of reintegration, the military health system is being tasked with identifying and treating the range of physical and mental health consequences of war, including sleep disturbances, that persist into the post-deployment period, and that impact subsequent force readiness. It is therefore critical to understand the role of sleep problems in servicemembers' health and functioning in the post-deployment period, the types of programs available to promote healthy sleep and treat sleep disorders, and the policy-level factors that may contribute to servicemembers' sleep. To date, however, there have been no comprehensive reviews of existing policies and programs across the U.S. Department of Defense (DoD) that affect sleep in the post-deployment period.

Approach

To comprehensively explore these issues and provide a set of actionable recommendations for DoD, researchers, and medical professionals, the RAND National Defense Research Institute (NDRI) conducted a two-year independent study using a multimethod approach. The study examined the prevalence and consequences of post-deployment sleep problems among U.S. servicemembers, current programs and policies related to sleep in the military, barriers to implementing those programs and policies, and evidence-based interventions to treat sleep disturbances in servicemember populations. Our study's conceptual model suggests that there is considerable continuity between sleep problems in the deployed setting and those in the post-deployment period. While research and policies to date have focused primarily on deployed settings (as reviewed in a recent report by Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury [DCoE] titled Overview of Sleep and Fatigue, 2012), we focused our analysis (where possible) on the post-deployed environment, because research suggests that chronic and enduring sleep problems (i.e., those that persist after a deployment has ended) are most likely to affect mental and physical health and may impact subsequent operational readiness.

Guided by the conceptual framework and in collaboration with our sponsor, DCoE, we employed a multimethod approach that included literature reviews and quantitative and qualitative research methods to answer the following five research questions:

1. What are the correlates and consequences of sleep problems among servicemembers in the post-deployment period?

2. What are the current programs and policies related to sleep in the military?

3. What are the evidence-based interventions to treat sleep disorders among servicemembers?

4. What are the barriers to achieving healthy sleep for servicemembers?

5. What actions can be taken to promote sleep health among servicemembers?

Specifically, we reviewed the literature pertaining to the prevalence and consequences of sleep disturbances in servicemember populations in the post-deployment period, as well as evidence-based strategies for treating sleep disturbances in servicemember populations. We also sought sources and strategies with a particular focus on veterans of OEF/OIF, a population found to be at heightened risk for stress-related sleep disturbances.

In addition, we conducted a cross-sectional survey to inform an in-depth analysis of the types of sleep problems and behaviors that are characteristic of servicemember populations, identify specific subgroups of servicemembers who may be at greater risk for sleep problems, and determine whether sleep problems are independently associated with mental and physical health and operational readiness. The survey offered a broad assessment of sleep problems and associated consequences in a large and diverse sample of deployable servicemembers across all four branches of the U.S. armed forces (N = 1,957). We focused on the associations between sleep symptoms or behaviors and several important indicators of servicemember health and readiness. We also included a rich assessment of covariates (e.g., depressive symptoms, presence of traumatic brain injury, shift work, and a host of deployment and sociodemographic characteristics) that are known to covary with sleep problems, well-being, and readiness.

Although deployments may be a precipitating factor in the onset of sleep disturbances for many servicemembers (as highlighted in the study's conceptual model), from a policy perspective, it is important to consider more broadly the system-level factors that may contribute to increased vulnerability to sleep problems across the deployment cycle. Therefore, we reviewed existing DoD and Service-level policies and programs related to sleep in training, operational, and clinical contexts, regardless of deployment status.

To supplement our review of codified policies and programs related to sleep and the barriers to implementation, we conducted a series of 40 interviews with line leaders and clinicians from all Service branches and convened an expert panel consisting of 31 clinicians, line leaders, and researchers with expertise in sleep in the military. In the following section, we summarize our findings for each of the five study questions.

Findings

What Are the Correlates and Consequences of Sleep Problems Among Servicemembers in the Post-Deployment Period?

Evidence from the reviewed published literature and our survey data suggest that sleep problems are prevalent, debilitating, and persistent in servicemember populations in the post-deployment period. Consistent with the civilian population, the most commonly diagnosed sleep disorders among servicemembers seeking evaluation include insomnia and obstructive sleep apnea (OSA; Capaldi, Guerrero, and Killgore, 2011; Collen et al., 2012; McLay, Klam, and Volkert, 2010; Mysliwiec, Gill, et al., 2013; Mysliwiec, McGraw, et al., 2013). Servicemembers in general, and those who have deployed, specifically, are at high risk for insufficient sleep duration (i.e., sleeping six hours or less on average; Luxton, Greenburg, et al., 2011; Seelig et al., 2010). This is particularly concerning, given the robust evidence linking short sleep duration with compromised mental and physical health and cognitive impairments, all of which can have a direct impact on operational readiness and servicemember resilience (Wesensten and Balkin, 2013). Perhaps as a consequence of insufficient sleep duration and poor sleep quality, servicemembers are also at high risk for daytime sleepiness and fatigue (Hoge et al., 2008; Toblin, Riviere, et al., 2012). The prevalence of sleep disorders and symptoms in the post-deployment period is higher among servicemembers with comorbid deployment-related injuries or mental health problems than it is for those without such conditions (Bramoweth and Germain, 2013). Our conceptual model and prior research with veterans further indicate that, once initiated, sleep disturbances may follow a persistent course, lasting for years after deployment.

Sleep problems and disorders, in turn, have both short-term and lasting negative effects on physical health, cognitive functioning, and operational readiness. For example, physical health problems, such as obesity and high body mass index (BMI), are particularly prevalent among servicemembers with sleep-related breathing disorders (Brundage, Wertheimer, and Clark, 2010; Engel et al., 2000; Mysliwiec, McGraw, et al., 2013; Seelig et al., 2010). In fact, elevated BMI is a significant risk factor for developing sleep-related breathing disorders (e.g., OSA) in civilian populations (Patel and Hu, 2008; Yu and Berger, 2011). PTSD, depression, and TBI are common disorders associated with sleep problems, but longitudinal evidence further shows that sleep problems can presage the onset of these disorders (Gehrman et al., 2013; Hoge, McGurk, et al., 2008; McLay, Klam and Volkert, 2010; Wallace et al., 2011; Wright et al., 2011b; van Liempt et al., 2013). Beyond increasing the risk of developing a subsequent mental health condition, sleep problems are known to be among the most intractable symptoms of other mental health conditions, such as depression. Moreover, even with successful treatment for a co-occurring mental health condition (e.g., depression), sleep problems can predict poor treatment response or relapse (Manber, Edinger, et al., 2008; Troxel, Kupfer, et al., 2012). Findings from the military's research laboratories have demonstrated the significant effects of sleep deprivation and fatigue on cognition, attention, reaction time, and moral reasoning, all of which are critically important for operational effectiveness (Wesensten and Balkin, 2013).

As mentioned, the existing literature provides suggestive evidence that sleep problems are a prevalent and salient issue among servicemembers and that military deployments may be associated with an increased risk of sleep problems. These findings are generally based on studies that included single or few-item assessments of isolated sleep symptoms (e.g., trouble sleeping or sleep duration). However, sleep is a multidimensional state, including both nocturnal characteristics (e.g., quality, duration, nightmares) and associated daytime consequences (e.g., sleepiness, fatigue). No study to date has examined multiple dimensions of sleep and associated daytime impairments in a large sample of servicemembers across all Service branches and components. In addition, only a handful of studies have examined sleep problems according to servicemembers' deployment history or characteristics of the deployment that may increase the risk of stress-related sleep disturbances (e.g., exposure to combat). Moreover, the existing literature has generally focused on a single Service branch, which may limit the generalizability of the findings. Finally, given that sleep problems are known to covary with sociodemographic and military characteristics, as well as overall well-being (Bramoweth and Germain, 2013), questions remain about whether sleep is merely a proxy for these co-occurring factors or an independent correlate of key indicators of mental and physical health and operational readiness.

We also conducted a cross-sectional survey to address these gaps and to inform an in-depth analysis of the types of sleep problems and behaviors that characterize servicemember populations, identify specific subgroups of servicemembers who may be at greater risk for sleep problems, and determine the extent to which sleep problems are independently associated with mental and physical health and operational readiness. The survey offered a broad assessment of sleep problems and associated consequences in a large and diverse sample (N = 1,957) of servicemembers across all four branches of the U.S. armed forces.

The survey results showed a high prevalence of insufficient sleep duration, poor sleep quality, daytime sleepiness, fatigue, and nightmares in our sample. Approximately 18 percent of the sample reported using sleep medications, which is important to consider given the known side effects of these medications, which may compromise operational effectiveness, and the limited evidence of efficacy or safety in military settings.

We also had a unique opportunity to examine whether the prevalence of sleep problems differed according to deployment history or combat exposure; to date, only a handful of studies have done so. Somewhat surprisingly, we found few statistically significant differences in sleep according to deployment history, though we did find differences according to combat exposure. Specifically, we found only one significant difference according to deployment history. In the Navy sample, those with prior deployments had greater sleep-related daytime impairment than those without a prior deployment. In the Army sample—in which we were able to compare soldiers who had never deployed, those who were currently deployed, and those who had previously deployed—we found no significant differences among the three subgroups on any sleep measure. In contrast to these generally non-significant findings for deployment history, and consistent with the prior literature, we found that higher levels of combat exposure were associated with poorer sleep quality and greater frequency of reporting repeated, disturbing dreams among those who experienced a traumatic event (Plumb et al., 2014; Luxton, Greenburg, et al., 2011; Wright et al., 2011b). These results suggest that it may not be deployment, per se, that is associated with an increased risk of sleep problems; however, exposure to combat may increase the risk, perhaps as a result of conditioned vigilance and hyperarousal that stems from sustained high operational tempo (OPTEMPO) environments.

As for our survey analyses of outcomes associated with poor sleep, we found that poor sleep quality and sleep-related daytime impairment are associated with poor physical health, probable depression, probable PTSD, and lower perceived unit readiness. These findings are consistent with previous military sleep studies documenting the association between sleep problems and mental health problems, such as depression and PTSD; however, we are not aware of any prior study that included an assessment of perceived readiness. Our findings also extend this work to highlight the robust associations between sleep quality and health outcomes. Collectively, these findings attest to the high prevalence of a myriad of sleep problems, including insufficient sleep duration, poor sleep quality, nightmares, daytime fatigue, and the use of sleep medications among servicemembers. They also add further support to the notion that sleep problems are not merely a proxy for other co-occurring symptoms, but they may confer an independent increased risk of adverse mental and physical health outcomes and compromised operational effectiveness.

What Are the Current Programs and Policies Related to Sleep in the Military?

In our review of DoD-wide and Service-specific policies and programs, we found a range of sleep-related prevention, medical, training, and operational strategies. DoD recognizes sleep as an important contributor to physical and mental health and operational readiness, and it has established several programs and policies to treat and prevent sleep disorders and to promote healthy sleep practices.

DoD medical policies related to sleep include screening for troubled sleep using the Post Deployment Health Assessment (PDHA) and Post Deployment Health Re-Assessment (PDHRA) programs, setting and adhering to medical standards, applying qualifications for initial military service, referring medical conditions to a medical evaluation board, and treating sleep disorders.

We found that service-specific and U.S. Department of Veterans Affairs (VA) medical policies on treating sleep disorders primarily mention sleep as a symptom of other conditions rather than as a primary disorder. Because sleep problems may precede the onset of other psychological and medical conditions, handling sleep as a byproduct of other conditions in medical treatment policies can lead to underdiagnosis and insufficient treatment of sleep problems.

In general, medical policies related to sleep were included in military programs on resiliency and stress management rather than explicitly addressing sleep management. An advantage of this approach is that sleep-related policies and programs are directed at the whole individual from a broader wellness perspective. But a disadvantage is that the lack of a specific focus on sleep in these stress management programs may undermine the importance of sleep, given that many sleep problems present independently of or even precede the development of mental health problems. This lack of emphasis on sleep may lead to inconsistent guidance on how to help servicemembers achieve optimal sleep duration and quality.

One example of a promising prevention program that puts sleep on equal footing with other key indicators of health is the Army Performance Triad. Perhaps the most comprehensive program to date that promotes sleep health from a prevention perspective, the Performance Triad provides systematic messages about the importance of sleep as a health behavior on par with nutrition and physical activity and promotes the use of objective tools to facilitate sleep monitoring (e.g., actigraphy). To date, however, the program's efficacy has not been evaluated, though research efforts are under way. The program may be a useful platform for other Service branches to develop similarly comprehensive sleep health programs.

Overall, we found that training policies were generally consistent in recommending sleep duration of seven to eight hours per night. However, these policies generally focused on the initial phases of military training (i.e., basic training), and codified policies pertaining to sleep did not necessarily extend to subsequent training environments.

Operational policies—the most common type of policies we identified—relate to sleep during combat operations or exercises. These operational policies focus on prescribing shift-work cycles and the duration of rest periods. These policies also mandate sleep plans, which are part of the process of establishing operational plans and associated risk assessments. However, there was a lack of specific guidance on how to implement these plans. We also found inconsistency in the amount of emphasis placed on sleep in each of the occupational areas within each Service.

What Are the Evidence-Based Interventions to Treat Sleep Disorders Among Servicemembers?

A review of the peer-reviewed academic literature showed that both pharmacologic and non-pharmacologic (i.e., behavioral or cognitive-behavioral) interventions have demonstrated efficacy in treating insomnia in civilian studies. Specifically, meta-analytic studies have found that pharmacologic and non-pharmacologic interventions have comparable efficacy in treating insomnia, with effect sizes in the moderate to large range for reducing insomnia for both types of interventions (Morin, Culbert, and Schwartz, 1994; Irwin, Cole, and Nicassio, 2006; Mitchell et al., 2012). However, the effects of non-pharmacologic interventions tend to be more durable (National Institutes of Health, 2005; i.e., treatment gains persist after active treatment has terminated). Nevertheless, pharmacologic approaches remain the front-line treatment in military and civilian populations, despite the fact that there is a notable lack of evidence supporting the efficacy or safety of pharmacologic approaches in treating insomnia in military settings (Brown, Berry, and Schmidt, 2013; DCoE, 2012). Key informants and expert panelists noted that this lack of systematic evidence is concerning because the safety issues pertaining to medication side effects may be particularly germane to servicemember populations, given operational demands and occupational hazards (Brown, Berry, and Schmidt, 2013). In contrast, there is a sizable and growing evidence base supporting the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) and imagery rehearsal therapy (IRT) for insomnia, specifically within servicemember populations (see, e.g., Talbot et al., 2014; Margolies, 2011; Gellis and Gehrman, 2011; Koffel and Farrell-Carnahan, 2014; Perlman et al., 2008).

The dissemination of efficacious cognitive-behavioral therapies for sleep disturbances has been limited, partly because of a critical shortage of trained providers in behavioral sleep medicine techniques and a lack of provider awareness of the efficacy of these programs in both civilian and military settings (Siebern and Manber, 2011). Training or hiring a greater number of qualified behavioral health specialists and creating more clinical training opportunities could help decrease this shortage, and efforts are underway both through VA and the Center for Deployment Psychology. Further research using robust randomized controlled trials in military contexts is also greatly needed to establish best-practice guidelines for treating servicemembers and veterans, because the nature of sleep problems and the efficacy of specific treatment strategies may differ for servicemember or veteran populations versus civilian populations. There is also a critical need to develop and validate evidence-based identification and prevention programs, including the use of objective sleep- and fatigue-monitoring devices, to promote healthy sleep behaviors and to provide opportunities for intervention before acute sleep disturbances become chronic and debilitating.

What Are the Barriers to Achieving Healthy Sleep for Servicemembers?

Even with evidenced-based practices and programs to prevent and treat sleep problems in servicemembers and codified policies related to sleep in place, we found cultural, operational, knowledge-related, and medical system barriers across the military context that may impede efforts to promote sleep health and treat sleep disorders in servicemember populations.

Expert panel attendees and interviewees highlighted the importance of military culture as a potential barrier to the promotion of healthy sleep practices. Specifically, they suggested that military cultural attitudes have historically tended to undermine the importance of sleep, which serves as an ongoing challenge to the adoption and implementation of effective sleep policies and programs. For instance, stigma associated with expressing a greater need for sleep may deter servicemembers from self-identifying or seeking help before a sleep problem becomes chronic and debilitating. Screening for sleep disturbances within military contexts is also limited, with sleep being perceived as a low institutional priority in military communities or simply “behind other areas” of war-related health issues.

Operational environments themselves are often barriers to healthy sleep, because of noise, crowded conditions, and the need for vigilance in threatening settings. Furthermore, we found that sleep policies are generally interpreted as “guidance” in operational contexts and, thus, secondary to operational demands. Although efforts to promote healthy sleep behaviors are important, such efforts must be carefully balanced against the realities of the dynamic, high-risk, and demanding military environment. Also, even where sleep policies are in place, leaders may not have sufficient manpower to allow for proper sleep—threats that are particularly salient given the high OPTEMPO of recent years. However, recent efforts to promote healthy sleep by optimizing crew shift schedules have shown that such strategies actually promote performance. Thus, perceived “trade-offs” may be balanced by improvements in servicemember performance and overall satisfaction.

Our qualitative research informed by expert panel attendees and interviewees suggested that the lack of knowledge about the importance of sleep behaviors and sleep-related policies was a barrier to recognizing and addressing sleep problems. This lack of knowledge or awareness is partly the result of limited education and training among leadership about the importance of sleep and the lack of a centralized DoD-wide resource on sleep policies. A centralized DoD repository could supplement some Service-specific websites that do provide sleep resources* to include guidance on the identification and management of sleep problems, as well as how to develop and implement at sleep plan.

Finally, medical and treatment system challenges create barriers. There is a lack of adequate screening tools, procedures, and systems for detecting sleep problems in military contexts. In addition, both continuity of care and shortages in the number of sleep providers and clinics were noted as barriers to promoting sleep health in servicemember populations during our interviews and focus groups.

Understanding these barriers is critical to making well-informed and robust policy recommendations related to preventing, identifying, and clinically managing sleep problems and promoting sleep health in both operational and training settings.

What Actions Can Be Taken to Promote Sleep Health Among Servicemembers?

Based on the findings above, we provide recommendations for filling gaps and overcoming barriers to achieving healthy sleep in servicemembers. To some extent and in certain contexts (e.g., in the combat environment), it is accepted that the unique role and demands of the military will necessarily restrict the opportunity for sufficient sleep duration and quality. Thus, we put forth a set of actionable recommendations that take into account these exigencies while at the same time identifying opportunities for programs and policies to promote sleep health in multiple contexts, including both operational and medical or clinical settings and across a continuum of care from prevention to identification and intervention.

In terms of preventing sleep problems, our study found no evidence-based practices to prevent sleep disorders in military or civilian populations, with the possible exception of weight loss and management strategies that also reduce the risk of OSA. This dearth of prevention efforts is consistent with the history of sleep medicine and medicine in general, which has tended to focus on physical illnesses or disorders rather than promoting health. Thus, we provide several recommendations to support prevention efforts, with the ultimate goal of promoting sleep health.

As for increasing the identification and diagnosis of sleep problems, our study identified several factors that may facilitate the detection of sleep disturbances, including the family as a key mechanism for detection, primary care as a key setting for detection, and the use of objective assessments to quantify insufficient sleep and associated daytime impairment.

In terms of clinically managing sleep disorders and promoting sleep health, our study also suggests a need to improve the education of health providers on the assessment, diagnosis, and treatment of sleep problems and disorders; to improve education of servicemembers on healthy sleep-related behaviors, including the appropriate use of stimulants and sleep medications; and to systematically evaluate promising programs and intervention approaches, including the use of technology to monitor and treat sleep disturbances. Policies that support provider training and that offer incentives for specialized sleep medicine training are needed to fill gaps in provider capabilities and the shortage of providers able to confidently deliver care to prevent, identify, and treat sleep disorders among military populations. Moreover, to enhance the dissemination of sleep treatments, trained providers are needed in a variety of contexts, including primary care, rather than in specialty sleep clinics only, where fewer patients are likely to present initially. Although several of these efforts to disseminate evidence-based sleep treatments by providing training for providers are under way within both the VA and DoD, there still is a need for systematic evaluation of the efficacy of these programs in terms of increasing provider knowledge and improving patient outcomes.

Finally, in terms of improving sleep in training and operational contexts, our study found that policies related to sleep are generally Service-specific and sometimes inconsistent in the degree of emphasis placed on sleep in each of the occupational areas within each Service. To a certain extent, these observed variations are expected and necessary, given each Service's mission focus (e.g., Air Force air operations) and the associated sleep policy for that military community. Nevertheless, such variation can create challenges for leaders trying to integrate work schedules or manage shift work in a diverse occupational specialty or joint environment. There are clearly unique challenges to achieving quality sleep in the post-deployment setting, and it is in this context that chronic and debilitating sleep disorders are likely to manifest. Thus, efforts are needed—most likely at the DoD level—to communicate overarching guidance to the Services regarding sleep in terms that are consistent with, and coherent within, an operational framework. Our recommendations in this area are geared toward this end.

Table 1 summarizes the recommendations in the four areas.

Table 1.

Recommendations to Promote Sleep Health

Prevent Sleep Problems 1. Increase servicemember and line leader education about healthy sleep behaviors to increase self-awareness and knowledge about the factors that inhibit or promote adequate, restful sleep. 2. Fund or conduct research to perform longitudinal studies on sleep and effects on operational readiness and resilience. Increase Identification and Diagnosis of Sleep Problems 3. Educate families on signs and symptoms of sleep disturbances as a way to bolster sleep detection efforts. 4. Improve screening for sleep disturbances in primary care settings, including the routine use of validated screening tools to identify those at high risk for the broad range of sleep disorders. Clinically Manage Sleep Disorders and Promote Sleep Health 5. Develop provider education programs on preventing, identifying, and treating sleep disorders, with a focus on giving providers the latest findings in the field of sleep science to effectively advise patients on sleep issues and a focus on prevention as well as treatment. 6. Develop a clinical practice guideline for sleep disorders that specifically addresses sleep and discusses prevention, identification, and treatment of sleep disorders. 7. Increase the use of mobile technology for assessing and clinically managing sleep disorders, in particular to monitor sleep and alertness and to identify and manage sleep disorders before they become chronic or debilitating. 8. Continue to research evidenced-based practices for aadvancing healthy sleep in military populations (e.g., mindfulness, teletherapy) and establish guidelines for treating servicemembers and veterans. 9. Enhance dissemination of evidence-based sleep treatments (e.g., CBT-I, IRT) by training providers in primary care settings as well as behavioral health clinics. 10. Improve continuity of care of sleep disorder treatments, such as through the use of electronic medical records that link records across the deployment cycle. Improve Sleep in Training and Operational Contexts 11. Make appropriate revisions to existing training and operational policies to minimize inconsistencies and align with current clinical guidelines about optimal sleep duration that recommend that the amount of sleep required among civilians is eight hours. 12. Educate line leaders on creating sleep plans that align with current research on circadian rhythms, consider the physical sleeping environment, and factor in shift schedules of roommates or tentmates when assigning duty. 13. Create standardized operational and training policies across DoD to increase sleep duration and quality and reduce fatigue-related impairment. 14. Link sleep-related surveillance data on mishaps to evaluate the role of sleep and fatigue. 15. Prioritize sleep in reintegration policies to offer servicemembers a period of recuperation during which they might be able to begin to return to normal sleep habits and potentially prevent the onset of chronic sleep problems that develop well after the initial reintegration period. 16. Disseminate positive messaging about sleep as an operational imperative (a vital sign, such as blood pressure) to increase awareness and reduce cultural barriers.

Final Words

Given the recent drawdown from combat operations in Iraq and Afghanistan, increasing attention has focused on the factors that promote or hinder servicemembers' ability to reintegrate and rebuild their lives post-deployment. This study offers 16 policy recommendations to promote sleep health in the domains of prevention, identification, treatment, and training/operations. These recommendations should be addressed collectively by individual servicemembers, unit leaders, the military health system, training and operational commands, military health researchers, and DoD at large. Implementing these recommendations must go hand in hand with better messaging about the biological and operational necessity of sleep to overcome cultural, environmental, medical, and operational barriers to achieving healthy sleep among servicemembers. Carrying out such an integrated approach is critical for improving sleep, which is an important contributor to resilience and operational readiness in the U.S. military.