Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study

Insomnia Symptoms and Environmental Disruptors: A Preliminary Evaluation of Veterans in a Subacute Rehabilitation

OBJECTIVES

Evaluate insomnia symptoms and environmental disruptors at admission and discharge in a subacute rehabilitation care setting.

METHODS

Veterans (age ≥50) admitted to a Veterans Health Administration (VA) Hospital subacute rehabilitation between March and August 2022 completed baseline (N = 46) and follow up (N = 33) assessments with the Insomnia Severity Index (ISI), Sleep Need Questionnaire (SNQ), Epworth Sleepiness Scale (ESS), and an assessment of environmental sleep disruptors. Veterans were offered sleep resources after admission evaluations and outpatient referrals after discharge evaluations. Pearson correlation determined associations between length of stay (LOS), ISI, SNQ, and ESS scores at admission and discharge; chi-square and Wilcoxon Signed Rank Tests compared insomnia at admission and discharge.

RESULTS

One-half of participants reported clinically meaningful insomnia symptoms and sleep needs at baseline with no significant change at discharge. Almost all (89.1%) Veterans reported sleep was disturbed by environmental factors, primarily staff awakenings. LOS was correlated with ESS scores at discharge (r = .52, p = .002).

CONCLUSIONS

Environmental sleep disruption was common during a subacute rehabilitation admission and were not adequately addressed through sleep resources and treatment due to low uptake.

CLINICAL IMPLICATIONS

Providers should assess sleep at admission and lessen environmental sleep disruptors by reducing noise, light, and non-essential awakenings at night.

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

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.

Longitudinal associations between insomnia, cannabis use and stress among US veterans

Insomnia is highly prevalent among military veterans, with rates nearly double that of civilian populations. Insomnia typically co-occurs with other psychological problems, including substance use (e.g. cannabis) and perceived stress. Much of the research focused on insomnia, stress and cannabis use explores cannabis as a sleep aid and a mechanism for stress relief. However, recent theoretical and empirical evidence suggests a dynamic interplay between insomnia, cannabis use and perceived stress, yet few longitudinal studies exist. Using a sample of 1105 post-9/11 veterans assessed over four time points across 12 months, we used latent difference score modelling to examine proportional change between insomnia, perceived stress and cannabis use. Results revealed a complex interplay between all three constructs. In particular, we show that higher prior levels of insomnia are associated with greater increases in perceived stress, and greater prior levels of stress are associated with greater increases in cannabis use. Perhaps more importantly, our results also point to cannabis use as a catalyst for greater increases in both stress and insomnia severity. Our results suggest there may be both benefits and costs of cannabis use among veterans. Specifically, for veterans who experience chronic sleep problems, perceived stress may become overwhelming, and the benefit of stress reduction from increased cannabis use may come at the cost of increasing insomnia symptomology.

Guideline-concordant use of cognitive behavioral therapy for insomnia in the Veterans Health Administration

OBJECTIVE

To characterize guideline-concordant use of cognitive behavioral therapy for insomnia vs. sleep medications among Veterans Health Administration patients.

METHODS

Cognitive behavioral therapy for insomnia was identified from the text of psychotherapy notes within the Veterans Health Administration's electronic medical record. Patients that received first-line cognitive behavioral therapy for insomnia (ie, no prior insomnia treatment) were compared to those who first received a sleep medication in fiscal year 2021.

RESULTS

Among 5,519,016 patients, first-line cognitive behavioral therapy for insomnia was received by 9313 (0.2%) whereas 225,618 (4.1%) were newly prescribed a sleep medication without prior cognitive behavioral therapy for insomnia. Patients over 60 years old and those with substance use disorders were less likely to receive first-line cognitive behavioral therapy for insomnia compared to other patients.

CONCLUSIONS

Adherence to practice guidelines to provide cognitive behavioral therapy for insomnia as first-line treatment for insomnia disorder remains a challenge, highlighting the need to better integrate effective implementation strategies within therapist training programs. Targeted strategies may be needed for older patients or those with substance use disorders.

Efficacy of an Internet-Delivered Intervention for Improving Insomnia Severity and Functioning in Veterans: Randomized Controlled Trial

BACKGROUND

Despite a growing evidence base that internet-delivered cognitive behavioral therapy for insomnia (iCBT-I) is associated with decreased insomnia severity, its efficacy has been minimally examined in veterans.

OBJECTIVE

The objective of this study was to evaluate the efficacy of an unguided iCBT-I (Sleep Healthy Using the Internet [SHUTi]) among veterans.

METHODS

We conducted a single-blind, randomized controlled trial in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn veterans eligible for Veterans Health Administration care. Participants were randomly assigned (1:1) to receive SHUTi (a self-guided and interactive program) or an Insomnia Education Website (IEW) that provided nontailored and fixed insomnia information. Web-based assessments were administered at baseline, postintervention, 6 months postintervention, and 1 year postintervention. The primary outcome was self-reported insomnia severity (Insomnia Severity Index [ISI]). Secondary outcomes were self-reported mental and physical health functioning (Veterans RAND 36-item Health Survey). Exploratory outcomes comprised sleep diary parameters.

RESULTS

Of the 231 randomized participants (mean age 39.3, SD 7.8 years; 170/231, 73.5% male sex; 26/231, 11.3% Black; 172/231, 74.5% White; 10/231, 4.3% multiracial; and 17/231, 7.4% other; 36/231, 15.6% Hispanic) randomized between April 2018 and January 2019, a total of 116 (50.2%) were randomly assigned to SHUTi and 115 (49.8%) to the IEW. In intent-to-treat analyses, SHUTi participants experienced significantly larger ISI decreases compared with IEW participants at all time points (generalized η2 values of 0.13, 0.12, and 0.10, respectively; all P<.0001). These corresponded to estimated larger differences in changes of -3.47 (95% CI -4.78 to -2.16), -3.80 (95% CI -5.34 to -2.27), and -3.42 (95% CI -4.97 to 1.88) points on the ISI for the SHUTi group. SHUTi participants experienced significant improvements in physical (6-month generalized η2=0.04; P=.004) and mental health functioning (6-month and 1-year generalized η2=0.04; P=.009 and P=.005, respectively). Significant sleep parameter improvements were noted for SHUTi (all P<.05), though the pattern and magnitude of these reductions varied by parameter. No adverse events were reported.

CONCLUSIONS

Self-administered iCBT-I was associated with immediate and long-term improvements in insomnia severity. Findings suggest that leveraging technology to meet insomnia treatment demands among veterans may be a promising approach.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03366870; https://clinicaltrials.gov/ct2/show/NCT03366870.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.

The association between long-term exposure to outdoor artificial light at night and poor sleep quality among Chinese veterans: A multi-city study

BACKGROUND

A handful of previous studies have reported the association between exposure to outdoor artificial light at night (ALAN) and sleep problems. However, evidence for such association is limited in low- and middle-income countries. This study aimed to examine the association between outdoor ALAN exposure and sleep quality in veterans across different regions of China.

METHODS

Within the network of the Chinese Veteran Clinical Research Platform, we selected 7258 participants from 277 veteran communities in 18 cities across China during December 2009 and December 2011, using a multi-stage stratified cluster sampling strategy. Face-to-face interviews with the participants were conducted by trained investigators. We used the Pittsburgh Sleep Quality Index (PSQI) to assess participants' sleep quality. We defined poor sleep quality as a PSQI global score >7. The 3-year average exposure to outdoor ALAN prior to the baseline interview was calculated using satellite imagery data, according to participants' geolocation information. The association of ALAN exposure with sleep quality was examined using the mixed-effects logistic regression models with natural cubic splines.

RESULTS

The exposure-response curve for sleep quality associated with ALAN exposure was nonlinear, with a threshold value of 49.20 nW/cm2/sr for the 3-year average exposure to outdoor ALAN prior to the baseline interview. Higher ALAN exposure above the threshold was associated with increased risk of poor sleep quality. After adjusting for potential confounders, the odds ratios (and 95%CI, 95% confidence intervals) were 1.15 (0.97, 1.36) and 1.45 (1.17, 1.78) at the 75th and 95th percentiles of ALAN against the threshold. The association of ALAN exposure with poor sleep quality was more pronounced in veterans with depression than those without. Higher OR of poor sleep quality at the 75th percentile of ALAN against the threshold was observed in veterans with depression than those without [2.09 (1.16, 3.76) vs. 1.09 (0.92, 1.30)].

CONCLUSIONS

Long-term exposure to outdoor ALAN was associated with higher risk of poor sleep quality in Chinese veterans. Effective outdoor ALAN management may help to reduce the burden of sleep disorders in Chinese veterans.

Race and Socioeconomic Status: Interlinked Drivers of Sleep Health Disparities

The effect of race and socioeconomic status on sleep disorders has significant effects on the availability of healthcare and health outcomes. This paper examines how race and SES contribute to sleep health disparities, emphasizing the importance of understanding their impact on sleep disorders and treatment particularly in minority populations and veterans.

Early detection of mandible osteoradionecrosis risk in a high comorbidity veteran population

OBJECTIVE

Osteoradionecrosis (ORN) of the mandible is a devastating complication of external beam radiation therapy (EBRT) for head and neck squamous cell carcinoma (HNSCC). We sought to ascertain ORN risk in a Veteran HNSCC population treatment with definitive or adjuvant EBRT and followed prospectively.

STUDY DESIGN

Retrospective analysis of prospective cohort.

SETTING

Tertiary care Veterans Health Administration (VHA) medical center.

METHODS

Patients with HNSCC who initiated treatment at the Michael E. DeBakey Veterans Affairs Medical Center (MEDVAMC) are prospectively tracked for quality of care purposes through the end of the cancer surveillance period (5 years post treatment completion). We retrospectively analyzed this patient cohort and extracted clinical and pathologic data for 164 patients with SCC of the oral cavity, oropharynx, larynx, and hypopharynx who received definitive or adjuvant EBRT (2016-2020).

RESULTS

Most patients were dentate and 80 % underwent dental extractions prior to EBRT of which 16 (16 %) had complications. The rate of ORN was 3.7 % for oral cavity SCC patients and 8.1 % for oropharyngeal SCC patients. Median time to ORN development was 156 days and the earliest case was detected at 127 days post EBRT completion. All ORN patients were dentate and underwent extraction prior to EBRT start.

CONCLUSION

ORN development can occur early following EBRT in a Veteran population with significant comorbid conditions but overall rates are in line with the general population. Prospective tracking of HNSCC patients throughout the post-treatment surveillance period is critical to early detection of this devastating EBRT complication.

Pre-deployment threat learning predicts increased risk for post-deployment insomnia: Evidence from the Marine Resiliency Study

Insomnia is a common and impairing consequence of military deployment, but little is known about pre-deployment risk factors for post-deployment insomnia. Abnormal threat learning tendencies are commonly observed in individuals with insomnia and maladaptive responses to stress have been implicated in the development of insomnia, suggesting that threat learning could be an important risk factor for post-deployment insomnia. Here, we examined pre-deployment threat learning as a predictor of post-deployment insomnia and the potential mechanisms underlying this effect. Male servicemembers (N = 814) completed measures of insomnia, psychiatric symptoms, and a threat learning task before and after military deployment. Threat learning indices that differentiated participants with versus withoutinsomnia at post-deployment were tested as pre-deployment predictors of post-deployment insomnia. Post-deployment insomnia was linked to elevations on several threat learning indices at post-deployment, but only higher threat conditioning, as indexed by higher threat expectancy ratings to the danger cue, emerged as a pre-deployment predictor of post-deployment insomnia. This effect was independent of combat exposure levels and partially mediated by greater post-deployment nightmares. The tendency to acquire stronger expectations of aversive events following encounters with danger cues may increase risk for post-deployment insomnia, in part due to the development of more severe nightmares.

The association of polysomnographic sleep on posttraumatic stress disorder symptom clusters in trauma-exposed civilians and veterans

Study Objectives

Self-reported sleep disturbance has been established as a risk factor and predictor for posttraumatic stress disorder (PTSD); however, less is known about the relationship between objective sleep and PTSD symptom clusters, and the specific role of hyperarousal. The present study examined the relationships between sleep continuity and architecture on PTSD symptom clusters.

Methods

Participants underwent two in-laboratory sleep studies to assess sleep continuity and architecture. They also completed the Clinician-Administered PTSD-IV scale and the Structured Clinical Interview for the DSM-IV to assess for PTSD diagnosis and other psychiatric disorders.

Results

Sleep continuity (i.e. total sleep time, sleep efficiency percent, wake after sleep onset, sleep latency) was significantly related to PTSD Cluster B (reexperiencing) symptom severity (R ² = .27, p < .001). Sleep architecture, specifically Stage N1 sleep, was significantly associated with PTSD Cluster B (t = 2.98, p = .004), C (Avoidance; t = 3.11, p = .003), and D (Hyperarosual; t = 3.79, p < .001) symptom severity independently of Stages N2, N3, and REM sleep. REM sleep variables (i.e. REM latency, number of REM periods) significantly predicted Cluster D symptoms (R ² = .17, p = .002).

Conclusions

These data provide evidence for a relationship between objective sleep and PTSD clusters, showing that processes active during Stage N1 sleep may contribute to PTSD symptomatology in civilians and veterans. Further, these data suggest that arousal mechanisms active during REM sleep may also contribute to PTSD hyperarousal symptoms.This paper is part of the War, Trauma, and Sleep Across the Lifespan Collection. This collection is sponsored by the Sleep Research Society.

Prevalence and predictors of insomnia and sleep medication use in a large tri-service US military sample

OBJECTIVE

The presence of insomnia in the general military population is not well known. This study aimed to determine the prevalence of probable clinical insomnia and identify factors leading to new-onset insomnia and/or sleep medication use in a large military population.

DESIGN

Cross-sectional and longitudinal analyses of a prospective cohort study.

PARTICIPANTS

A tri-service US military and veteran cohort (sample range 99,383-137,114).

MEASUREMENTS

Participants were surveyed in 2013 (Time 1 [T1]) and 2016 (Time 2 [T2]) using the clinically validated Insomnia Severity Index. The prevalence of insomnia and sleep medication use was quantified at both times. Multivariable models identified military factors associated with new-onset insomnia and/or sleep medication use while adjusting for covariates.

RESULTS

The prevalence of insomnia at T1 and T2 was 16.3% and 11.2%, respectively. New-onset insomnia at T2 was reported by 6.0% of participants screening negative at T1; risk factors included Army service, combat deployment experience, and separation from military service. The prevalence of sleep medication use at T1 and T2 was 23.1% and 25.1%, respectively. Sleep medication use at T2 was newly-reported by 17.1% of participants not reporting sleep medication use at T1; risk factors included number of deployments and having a healthcare occupation.

CONCLUSIONS

The prevalence of probable clinical insomnia in this large general military population is within the range of previous reports in military and civilian populations. Certain military factors that predict new-onset insomnia and/or sleep medication use should be considered when designing and implementing sleep interventions in military populations.

Self-rated sleep quality predicts incident suicide ideation in US military veterans: Results from a 7-year, nationally representative, prospective cohort study

Sleep disturbance is a risk factor for future suicidal behaviours (e.g. suicidal ideation, suicide attempt, death by suicide), and military veterans are at increased risk for both poor sleep and death by suicide relative to civilians. The purpose of this study was to evaluate whether self-reported sleep quality was associated with risk of new-onset suicidal ideation in a 7-year prospective nationally representative cohort study of US military veterans. Multivariable logistic regression analyses were conducted to identify the relation between self-rated sleep quality and incident suicidal ideation in 2,059 veterans without current suicidal ideation or lifetime suicide attempt history at baseline. Relative importance analyses were then conducted to identify the relative variance explained by sleep quality and other significant determinants of incident suicidal ideation. A total of 169 (weighted 8.9%, 95% confidence interval =7.7%-10.3%) veterans developed suicidal ideation over the 7-year study period. Poor self-rated sleep quality was associated with a more than 60% greater likelihood of developing suicidal ideation (relative risk ratio = 1.62, 95% confidence interval = 1.11-2.36), even after adjustment for well-known suicide risk factors such as major depressive disorder. Relative importance analysis revealed that poor self-rated sleep quality accounted for 44.0% of the explained variance in predicting incident suicidal ideation. These results underscore the importance of assessing, monitoring and treating sleep difficulties as part of suicide prevention efforts in military veterans.

New-onset and exacerbated insomnia symptoms during the COVID-19 pandemic in US military veterans: A nationally representative, prospective cohort study

The COVID‐19 pandemic has had a negative impact on physical and mental health worldwide. While pandemic‐related stress has also been linked to increased insomnia, scarce research has examined this association in nationally representative samples of high‐risk populations, such as military veterans. We evaluated pre‐ and pandemic‐related factors associated with new‐onset and exacerbated insomnia symptoms in a nationally representative sample of 3,078 US military veterans who participated in the National Health and Resilience in Veterans Study. Veterans were surveyed in the USA in 11/2019 (pre‐pandemic) and again in 11/2020 (peri‐pandemic). The Insomnia Severity Index was used to assess severity of insomnia symptoms at the pre‐ and peri‐pandemic assessments. Among veterans without clinical or subthreshold insomnia symptoms pre‐pandemic (n = 2,548), 11.5% developed subthreshold (10.9%) or clinical insomnia symptoms (0.6%) during the pandemic; among those with subthreshold insomnia symptoms pre‐pandemic (n = 1,058; 26.0%), 8.0% developed clinical insomnia symptoms. Pre‐pandemic social support (21.9% relative variance explained), pandemic‐related stress related to changes in family relationships (20.5% relative variance explained), pre‐pandemic chest pain (18.5% relative variance explained) and weakness (11.1% relative variance explained), and posttraumatic stress disorder (8.2% relative variance explained) explained the majority of the variance in new‐onset subthreshold or clinical insomnia symptoms during the pandemic. Among veterans with pre‐pandemic subthreshold insomnia, pandemic‐related home isolation restrictions (59.1% relative variance explained) and financial difficulties (25.1% relative variance explained) explained the majority of variance in incident clinical insomnia symptoms. Taken together, the results of this study suggest that nearly one in five US veterans developed new‐onset or exacerbated insomnia symptoms during the pandemic, and identify potential targets for prevention and treatment efforts.