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Sleep Patterns and Problems Among Army National Guard Soldiers

Sleep Patterns and Problems Among Army National Guard Soldiers Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 MILITARY MEDICINE, 183, 11/12:e396, 2018 Sleep Patterns and Problems Among Army National Guard Soldiers Lucas P. Hansen, MA*; Caroline Kinskey, BA†; Erin Koffel, PhD*‡§; Melissa Polusny, PhD*‡§; John Ferguson, PhD*║; Sonja Schmer-Galunder, MS¶; Christopher R. Erbes, PhD*‡§ ABSTRACT Introduction: Adequate sleep plays an integral role in the physical and mental health of individuals, while simultaneously influencing their cognitive and work performance. Having recognized this, the U.S. Army has focused efforts on improving soldiers’ healthy sleep behaviors. This study examines the extent to which mental health, alcohol use, and cer- tain sleep hygiene behaviors predict sleep problems within an Army National Guard sample (N = 438). Materials and Methods: This manuscript is part of a larger study approved through the Minneapolis Veterans Affairs Medical Center Institutional Review Board. Mailed surveys were sent to Minnesota Army National Guard soldiers collecting data on sleep hygiene behaviors, mental health symptoms (post-traumatic stress disorder and depression), and alcohol use. Predictors of sleep problems were evaluated with ordinary least squares multiple linear regression analyses, regressing Insomnia Severity Index total scores on demographic variables, post-traumatic stress disorder (PTSD), depression, alcohol use, sleep hygiene factors (routine and consumption activity; both derived from exploratory factor analysis), and technology use (multiple device use and use before bed). Results: Overall, the majority of participants did not endorse high levels of sleep impairment, while 16.4% screened positive for moderate or even severe levels of clinical insomnia. Bivariate correlations demon- strated that sleep problems were correlated with PTSD symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < 0.001), Sleep Hygiene Routine (r = −0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, 2 2 p = 0.002). The overall regression model predicting sleep problems was significant (R = 0.35, adj R = 0.34, F[8,408] = 27.58, p < 0.001). Independent predictors of sleep problems included gender (B = 0.99, β = 0.09, t = 2.10, p = 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depression (B = 1.53, β = 0.20, t = 7.56, p < 0.001), and Sleep Hygiene Routine (B = −0.88, β = −0.23, t = −5.473, p < 0.001). Alcohol use, Sleep Hygiene Consumption, and technology use did not emerge as independent predictors. Conclusion: Although most soldiers denied sleep problems, a sizeable minority met screening criteria for clinical insomnia. Greater numbers of sleep-related complaints were related to psychological dis- tress including depressive and PTSD symptoms, while adherence to a bedtime routine (Sleep Hygiene Routine) showed an inverse relationship. Alcohol use and sleep hygiene consumption activities were not predictive of sleep problems, suggesting that different sleep hygiene behaviors have differential relationships with sleep problems. Screening and intervention for specific sleep problems may be helpful even very early in Army National Guard service members’ careers. Particular focus may be needed for those showing signs of emotional distress, such as PTSD or depression. Future research examining the impact of individual sleep hygiene components is warranted. INTRODUCTION well-being of military personnel. Sleep is a necessary activity A large body of empirical work has demonstrated that sleep for the body and brain to function optimally. To date, sleep has has significant importance to the physical and psychological been linked to several different physical health outcomes such 1,2 3 as cardiovascular disease, inflammatory responses, and 4,5 excess weight gain, to name a few. Regarding mental health, *Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, 6–8 MN 55417. poor sleep has been further associated with depression, sui- 7 9 †Minnesota State University, Mankato, 103 Armstrong Hall, Mankato, cidal ideation, anxiety/stress, post-traumatic stress disorder MN 56001. 8,10 11–13 (PTSD), and memory. In addition, inadequate sleep has ‡Center for Chronic Disease Outcomes Research, 1 Veterans Drive, an impact on one’s ability to work effectively. In some cases, Minneapolis, MN 55417. these impacts are merely expressed through decreased cognitive §Department of Psychiatry, University of Minnesota Medical School, 11–13 14 2450 Riverside Ave South, Minneapolis, MN 55454. function, which results in a loss of productivity. However, ║Division of Rehabilitation Science, Department of Rehabilitation on military deployments service members are often subject to Medicine, University of Minnesota, 420 Delaware St. SE, MMC 297, operational demands that require prolonged periods of incon- Minneapolis, MN 55455. 7,15 sistent or insufficient sleep. Such sleep deficiencies can ¶Smart Information Flow Technologies, 319 1st Ave North, Suite 400, account for a substantial proportion of accidents and poten- Minneapolis, MN 55401. 16,17 The views expressed here are those of the authors and not of the tially dangerous behaviors (e.g., sleeping while on guard Department of Defense, Department of Veteran Affairs, or the U.S. duty). In these cases, what may be simply an inconvenience in Government. the civilian sector may have severe consequences in a combat- doi: 10.1093/milmed/usy107 related environment. Published by Oxford University Press on behalf of the Association of The military has acknowledged the importance of sleep and Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. the role it plays in maintaining soldier readiness to execute e396 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 18–20 military operations. There are currently active programs sleep problems. Given the increasing availability of handheld such as the Comprehensive Soldier Fitness initiative, designed electronic devices, and the accompanying potential for increased to enhance sleep education in an effort to improve unit readiness engagement across multiple electronic devices prior to sleep and resilience. The military population is incredibly diverse, (e.g., texting while watching TV or playing games), we also however, and the effectiveness of intervention strategies is likely examined multiple device usage prior to sleep-onset as a poten- to be constrained by the characteristics of service members and tial predictor of sleep problems. the environment and context in which they operate. Since the events leading to the Global War on Terror, MATERIALS AND METHODS approximately 850,000 National Guard soldiers have been mobilized and deployed throughout the world in support of mil- Participants itary operations. Currently, the National Guard provides the This sample is composed of 438 Minnesota Army National Army with 39% of its operational forces and is responsible for Guard soldiers who filled out and returned a mailed survey as managing 42% of its manned and unmanned aircraft. part of a larger study. The soldiers were identified by expres- Furthermore, the director of the Army National Guard, sing interest in future research while completing their enlist- Lieutenant General Timothy Kadavy, recently stated that mobi- ment contract. All soldiers have an enlistment date within the lizations will increase and combat center rotations will double last three years. Of those soldiers, 295 (67.4%) identified as in 2018. The prominence and activity of National Guard and male, 134 (30.6%) female, 2 (0.5%) as “other,” and data on Reserve (NGR) Component troops brings with it questions gender were missing for 7 (1.6%) participants. Ages ranged about the specific environmental context and demands faced by from 17 to 54 (M = 22.8, SD = 5.274). The majority of partici- these “citizen soldiers.” Unlike regular component service pants (325, or 74.2%) identified as White, 37 (8.4%) identified members, NGR personnel are required to make regular trans- as African-American or Black, 27 (6.2%) identified as Asian or ition from civilian roles and functioning to military contexts. Pacific Islander, 2 (0.5%) identified as American Indian or Simply to maintain unit readiness, National Guard soldiers Alaskan Native, and 39 (8.9%) as Other or Multiracial. Data on interrupt their established, civilian routines for military duty on race were missing for 8 (1.8%) participants. Thirty-two partici- a monthly basis, at minimum. When mobilized for an extended pants identified as of Hispanic origin (7.3%). Regarding rela- period, soldiers must acclimate to specific sleep patterns dic- tionship status, 180 (41.1%) identified as single, 63 (14.4%) tated by the requirements of the mission and the environmental married, 72 (16.4%) were in a relationship and living their part- hazards in which those soldiers operate. Often, when returning ner, and 116 (26.5%) were in a relationship, but not living home from an extended mobilization, soldiers are not subject to together. the same demands and are forced to again acclimate to previous sleep patterns. The unique needs and environmental demands Measures faced by NGR personnel are demonstrated in part by elevated All participants completed questionnaires assessing sleep and rates of mental health disorders, including PTSD, within the sleep difficulties, mental health difficulties, sleep-related beha- context of military deployments. It is, therefore, essential that viors, and the use of technology before going to sleep. levels of sleep impairment and predictors of that impairment within NGR populations be investigated so that intervention Insomnia Severity Index efforts can be evaluated and, if needed, tailored, for this critical component of today’smilitary. TheInsomniaSeverity Index(ISI) is abrief self-report instru- ment of people’s perception of their sleep. The measure includes both objective and subjective symptoms of insomnia, Study Rationale and Hypotheses as well as their perceptions of negative consequences that may The purpose of this study is to examine sleep patterns among occur due to poor sleep. The ISI is made up of seven items that Army National Guard (NG) soldiers and predictors of sleep assess problems with sleep onset, sleep maintenance difficulties, problems within this population. This specificworkispartofa level of satisfaction with sleep, level of noticeable impairment larger study of sleep-related behaviors and interventions. due to sleep problems, and level of distress due to the sleep Following prior findings in military and civilian samples, we problem. Items are rated on a 0–4 scale; total scores range from hypothesized that sleep problems would be predicted by psy- 0 to 28. A higher score is indicative of more sleep problems. chiatric distress (PTSD and depressive symptoms), poor sleep Prior studies have demonstrated acceptable levels of internal 6–10 hygiene behaviors, and heightened alcohol use. Given that consistency and validity through concurrence with other mea- 24,25 there are many distinct types of behaviors discussed as influenc- sures of sleep impairment. Established cutoffs for the ISI ing sleep quality, this study also investigated the dimensionality demonstrate that a score from 0 to 7 indicates no sleep pro- of a sleep hygiene questionnaire containing commonly men- blems, 8 to 14 indicates subthreshold insomnia, 15 to 21 indi- tioned sleep-related behaviors to facilitate analyses. In addition, cates moderate clinical insomnia, and 22 to 28 suggests severe we examined the relationship between electronic usage (i.e., clinical insomnia. Internal consistency (Cronbach’s alpha) within screen time) immediately before bed and amount of sleep and the present sample was 0.86. MILITARY MEDICINE, Vol. 183, November/December 2018 e397 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 subject to a principal components factor analysis with promax Alcohol Use Disorders Identification factor rotation. Three factors produced eigenvalues greater than Test-Consumption one, accounting for a total of 49.41% total item variance, and Alcohol Use Disorders Identification Test-Consumption the scree plot confirmed a three-factor solution. The first factor (AUDIT-C) is a three-item measure that is used to measure (eigenvalue = 2.64, 24.03% total variance accounted for) potential heavy and/or hazardous drinking. Items in the involved items related to sleep routine including “go to bed the AUDIT-C address frequency of drinking in the last year, how same time each night,”“get up at the same time each day,” much alcohol on average is consumed on a day where the “create a sleep environment that is dark, quiet, comfortable, and individual does drink alcohol, and frequency of binge drinking cool,”“reserve your bed for sleep or sex,” and “haveabedtime episodes (6 or more drinks on one occasion). Total scores range routine.” The second factor (eigenvalue = 1.69, 15.36% vari- from 0 to 12. A higher score suggests that alcohol abuse is ance accounted for) contained items relating to consumption likely a problem for that individual. A score of 3 or more is con- behaviors involving food, drink, or chemicals prior to bed sidered a positive screening for hazardous drinking in women, including “avoid caffeine within 4 h of bedtime,”“avoid spicy and a score of 4 or more is a positive screening for men. There foods within 4 h of bedtime,”“avoid alcohol within 4 h of bed- is strong evidence for the use and interpretation of this instru- time,” and “avoid nicotine within 4 h of bedtime.” Two items ment, specifically in younger, OIF/OEF veterans. Internal with low commonalities loaded on a final factor (eigenvalue = consistency (Cronbach’s alpha) within this sample was 0.84. 1.10, 10.01% variance accounted for): “exercise” and “get out of bed if you have been awake for more than 20 minutes”.As Primary Care-Post-traumatic Stress Disorder the resulting factor had only two items and a reliability of 0.19, Screen these items were excluded from further analysis. Mean scores The Primary Care-Post-Traumatic Stress Disorder Screen is a were calculated for the two remaining factors: Sleep Hygiene four-item screening tool for PTSD that is commonly used in Routine and Sleep Hygiene Consumption. primary care settings and considered an acceptable screening method within the VA system. The screen addresses symp- Screen Use Before Bed toms of re-experiencing a traumatic event, numbing, avoidance, This section consisted of two questions regarding electronic and hyperarousal. The items are answered with either “Yes” or device usage within 1 h of going to sleep. Multiple device usage “No.” Total scores range from 0 to 4. A cutoff score of 3 was measured on a five-point Likert scale ranging from “never” demonstrated a strong sensitivity (0.78) and specificity to “all the time,” asking how often in a given week multiple (0.87) in VA general medical settings. Prior studies have devices (e.g., computers, cell phones, tablets, game consoles, demonstrated acceptable levels of internal consistency and 29,30 television, or electronic reading devices) were used. Any device validity through concurrence with other measures of PTSD. usage was measured by asking (with the same response format) Internal consistency (Cronbach’s alpha) within the present sample how often any devices were used in the bedroom in the hour was 0.80. before going to bed. Patient Health Questionnaire-2 Procedures The Patient Health Questionnaire-2 is a two-item depression A standard survey protocol was followed in which potential screening tool. The items address depressed mood and anhe- participants were first sent a pre-notification postcard explaining donia over the past 2 wk. Both items are scored from 0 the study. Two weeks later they were sent the survey along (“not at all”)to3(“nearly every day”). The total score (the with a cover-letter detailing the study and a modest ($2) pay- sum of both items) ranges from 0 to 6. A score of ≥3or ment. Non-responders were sent, at 2-wk intervals, a reminder higher is considered a positive initial screening for depres- postcard, a second survey, and then a third survey (this time via sion. These items demonstrated a 0.76 pooled sensitivity and priority mail). Of 2,063 surveys mailed out, 438 were returned, 0.86 pooled specificity in a recent meta-analysis. Prior stud- yielding a response rate of 21%. ies have demonstrated acceptable levels of internal consis- tency and validity through concurrence with other measures 32,33 of depression. Internal consistency (Cronbach’s alpha) Data Analysis within the present sample was 0.80. Rates of sleep problems and potential psychiatric distress were established with simple frequencies. Gender (male vs. female) Sleep hygiene behaviors and race (Caucasian vs. non) groups were compared on the ISI Common sleep hygiene behaviors were assessed with 11 items and its potential predictors using independent samples t-tests. asking about the weekly frequency of behaviors associated with Predictors of sleep problems were evaluated with ordinary least healthy sleep including routine and consistent sleep and wake squares multiple linear regression analyses, regressing ISI total times, avoidance of alcohol, caffeine, spicy food within 4 h of scores on demographic variables, PTSD, depression, alcohol bedtime, and exercise routines. Each behavior was rated as use, sleep hygiene (routine and restricting activity), and technol- occurring between 0 and 7 times per week. The 11 items were ogy use (multiple device use and use before bed). e398 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 TABLE I. Means, Standard Deviations, and Correlations Correlations Mean SD ISI PTSD Depression Alcohol SH-Routine SH-Cons. Multi-Device Any Device ISI 8.52 5.48 1.00 0.41*** 0.49*** 0.02 −0.34*** −0.09 0.15* 0.05 PTSD 0.93 1.35 1.00 0.46*** 0.00 −0.15** −0.12* 0.07 0.04 Depression 0.88 1.24 1.00 0.02 −0.21*** −0.10* 0.12* 0.10* Alcohol 2.76 2.48 1.00 −0.03 −0.26*** 0.00 0.04 SH–routine 5.53 1.43 1.00 0.21*** −0.16** −0.13** SH–cons. 5.76 1.92 1.00 −0.17 0.05 Multi-device 2.15 1.33 1.00 0.26*** Any device 3.04 1.19 1.00 Note:SH–Routine, Sleep Hygiene Routine; SH–Cons., Sleep Hygiene Consumption; Multi-Device, Using Multiple Devices <4 h prior to sleep; Any Device, using any electronic device <4 h prior to sleep.*p < 0.05,**p < 0.01,***p < 0.001. TABLE II. Regressing Sleep Problems on Predictors RESULTS According to the ISI, 365 participants (83.7%) screened for B Beta tp either no sleep impairment (n = 203) or subthreshold insomnia (Constant) 9.56 6.58 0.000 (n = 162). The remaining 71 (16.3%) screened positive for Gender 0.99 0.09 2.10 0.036 moderate (n = 61)orsevere(n = 10) clinical insomnia. Alcohol 0.05 0.02 0.54 0.588 Regarding other psychiatric screens, 42 (9.6%) screened posi- PTSD 0.89 0.22 4.86 <0.001 tive for depression, 79 (18.1%) for PTSD, and 221 (50.7%) for Depression 1.53 0.35 7.56 <0.001 SH-Routine −0.88 −0.23 −5.47 <0.001 potentially problematic alcohol use. Male and female soldiers SH-Consumption 0.11 0.04 0.90 0.371 did not differ in terms of depression, Sleep Hygiene Routine, or Multi-Device 0.24 0.06 1.39 0.164 frequency of multi-device use before bed. Means, standard Any Device −0.32 −0.07 −1.63 0.104 deviations, and correlations are displayed in Table I. Sleep pro- Note:SH–Routine, Sleep Hygiene Routine; SH–Cons., Sleep Hygiene blems, as assessed by the ISI, were correlated with PTSD Consumption; Multi-Device, Using Multiple Devices <4 h prior to sleep; symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < Any Device, Using any electronic device <4 h prior to sleep. 0.001), Sleep Hygiene Routine (r = −0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, p = Hygiene Routine (B = −0.88, β = −0.23, t = −5.473, p < 0.001). 0.002). Considering potential demographic covariates, male Alcohol use, Sleep Hygiene Consumption, and technology use and female participants differed in terms of alcohol use (2.91; did not emerge as independent predictors (see Table II). SD = 2.63 and 2.41, SD = 2.02, respectively; t = 2.14, df = 326.63, p = 0.033), PTSD symptoms (0.81, SD = 1.27 and 1.17, SD = 1.47, respectively; t = −2.56, df = 425, p = 0.011), CONCLUSION Sleep Hygiene Restricted Activity (4.02, SD = 1.61 and 3.53, Discussion SD = 1.40, respectively; t = −2.53, df = 418, p = 0.012), use of electronics before bed (2.94, SD = 1.27 and 3.35, SD = National Guard personnel represent a vital component of the 0.91, respectively; t = −3.79, df = 343.98, p < 0.001), and nation’s armed forces with distinct roles, duties, and life cir- sleep impairment (8.13, SD = 5.26 and 9.44, SD = 5.70, cumstances. This study evaluated levels and predictors of sleep respectively; t = 2.31, df = 425, p = 0.022). Non-Caucasian impairment in a sample of National Guard soldiers as an exami- and Caucasian participants differed in terms of alcohol use nation of needs and risk/protective factors within the popula- (2.05, SD = 2.17 vs. 3.00, SD = 2.52; t = −3.57, df = 433, p < tion. Overall, the majority of the present sample did not endorse 0.001) Sleep Hygiene Activity Consumption (4.15, SD = 1.63 high levels of sleep impairment. However, a sizeable minority and 3.79, SD = 1.53, respectively; t = 2.10, df = 422, p = (16.4%) did screen positive for moderate or even severe levels 0.037) and use of multiple devices before bed (2.46, SD = 1.31 of clinical insomnia. Greater numbers of sleep-related com- and 2.07, SD = 1.33; t = 2.69, df = 435, p = 0.008). plaints were related particularly to psychological distress Given the relationship between gender and ISI scores, gen- including depressive and PTSD symptoms. This is an expected der was included as a covariate when regressing ISI scores on finding, given prior work documenting the co-occurrence of 6–8,10 alcohol use, PTSD, depression, sleep hygiene, and technology sleep impairments with both disorders. Further, both 2 2 use. The overall model was significant (R = 0.35, adj R = depression and PTSD are definedin partbythe symptomof 0.34, F[8,408] = 27.58, p < 0.001). Significant independent impaired sleep in the Diagnostic and Statistics Manual of predictors included gender (B = 0.99, β = 0.09, t = 2.10, p = Mental Disorders. We also found, as expected, that sleep 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depres- hygiene behaviors relating to regular scheduling of bedtime and sion (B = 1.53, β = 0.35, t = 7.56, p < 0.001), and Sleep awakening and adherence to a bedtime routine were negatively MILITARY MEDICINE, Vol. 183, November/December 2018 e399 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 correlated with sleep problems. It is impossible to know, in the barrier modification (e.g., leveraging already-utilized technol- present sample, if disrupted sleep resulted from poorly struc- ogy to educate or adjust sleep-related behavior). tured sleep activities (such as chaotic bedtimes) or if sleep pro- Limitations of this study include a single time-point correla- blems led to more disrupted sleep hygiene routines. The tional design, and population sampling limitations. Although evaluation of these potential pathways will require future stud- significant relationships were identified, we are unable to con- ies making use of longitudinal methodology so that temporal firm causal relationships between variables due to the passive cause and effect can be evaluated. Recent questions have observation, cross-sectional design of the model. Furthermore, emerged regarding the role of electronic device usage in poten- only abbreviated, though validated, measures were utilized for 37–40 tially interfering with sleep. The present findings, however, many constructs due to a need to minimize participant burden provide only limited support for this hypothesis. The use of at this early phase of the research project. Utilizing more robust, multiple devices before sleep did not correlate with sleep pro- full-length versions of these instruments would allow for a blems, and the relationship between sleep problems and fre- more detailed and nuanced understanding of sleep-related vari- quency of any device use before bed was small. ables in future research endeavors. Regarding sampling limita- Impaired sleep has been associated with performance decre- tions, these results may not generalize accurately across groups 14,16,17 ments in several occupational domains. In addition, due to the unique characteristics of the Minnesota National impaired or disrupted sleep has been linked to numerous physi- Guard, such as demographic makeup, proximity to active duty 1–10 cal and mental health problems. The present findings sug- forces, and deployment rates. Notwithstanding these limita- gest that screening and intervention for sleep problems may be tions, this study demonstrates the importance of attending to helpful even very early in Army National Guard service mem- sleep and sleep behaviors within a National Guard context and bers’ careers. Particular focus may be needed for those showing identifies the role of mental health symptoms within this signs of emotional distress such as PTSD or depression, align- population. ing with the current literature on psychopathological comorbid- ities related to insomnia. Findings also suggest that a focus on ACKNOWLEDGEMENTS teaching and encouraging consistent sleep scheduling habits This project was conducted with resources from the Minneapolis VA Healthcare may be beneficial in this population, further supporting broad System and funded in part through a Departments of Defense Small Business based programs such as the Comprehensive Soldier Fitness ini- Innovation Research grant to Smart Information Flow Technologies (Award tiative. In addition, a recent RAND report highlighted the Number W81XWH-16-C-0032). importance of more individually focused evidence-based prac- tices, such as Cognitive-Behavioral Therapy for Insomnia (CBT-I). REFERENCES Finally, innovative electronic interventions, such as tailored smart- 1. Hla K., Young T., Hagen E., et al: Coronary heart disease incidence in phone apps may be helpful in engaging younger National sleep disordered dreathing: The Wisconsin Sleep Cohort Study. 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J Clin Sleep Med 2017; 13: 1001–8. doi:10.5664/ Res 2003; 49: S184–96. doi:10.1002/art.11409. jcsm.6704. MILITARY MEDICINE, Vol. 183, November/December 2018 e401 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Military Medicine Oxford University Press

Sleep Patterns and Problems Among Army National Guard Soldiers

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Copyright © 2022 The Society of Federal Health Professionals
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Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 MILITARY MEDICINE, 183, 11/12:e396, 2018 Sleep Patterns and Problems Among Army National Guard Soldiers Lucas P. Hansen, MA*; Caroline Kinskey, BA†; Erin Koffel, PhD*‡§; Melissa Polusny, PhD*‡§; John Ferguson, PhD*║; Sonja Schmer-Galunder, MS¶; Christopher R. Erbes, PhD*‡§ ABSTRACT Introduction: Adequate sleep plays an integral role in the physical and mental health of individuals, while simultaneously influencing their cognitive and work performance. Having recognized this, the U.S. Army has focused efforts on improving soldiers’ healthy sleep behaviors. This study examines the extent to which mental health, alcohol use, and cer- tain sleep hygiene behaviors predict sleep problems within an Army National Guard sample (N = 438). Materials and Methods: This manuscript is part of a larger study approved through the Minneapolis Veterans Affairs Medical Center Institutional Review Board. Mailed surveys were sent to Minnesota Army National Guard soldiers collecting data on sleep hygiene behaviors, mental health symptoms (post-traumatic stress disorder and depression), and alcohol use. Predictors of sleep problems were evaluated with ordinary least squares multiple linear regression analyses, regressing Insomnia Severity Index total scores on demographic variables, post-traumatic stress disorder (PTSD), depression, alcohol use, sleep hygiene factors (routine and consumption activity; both derived from exploratory factor analysis), and technology use (multiple device use and use before bed). Results: Overall, the majority of participants did not endorse high levels of sleep impairment, while 16.4% screened positive for moderate or even severe levels of clinical insomnia. Bivariate correlations demon- strated that sleep problems were correlated with PTSD symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < 0.001), Sleep Hygiene Routine (r = −0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, 2 2 p = 0.002). The overall regression model predicting sleep problems was significant (R = 0.35, adj R = 0.34, F[8,408] = 27.58, p < 0.001). Independent predictors of sleep problems included gender (B = 0.99, β = 0.09, t = 2.10, p = 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depression (B = 1.53, β = 0.20, t = 7.56, p < 0.001), and Sleep Hygiene Routine (B = −0.88, β = −0.23, t = −5.473, p < 0.001). Alcohol use, Sleep Hygiene Consumption, and technology use did not emerge as independent predictors. Conclusion: Although most soldiers denied sleep problems, a sizeable minority met screening criteria for clinical insomnia. Greater numbers of sleep-related complaints were related to psychological dis- tress including depressive and PTSD symptoms, while adherence to a bedtime routine (Sleep Hygiene Routine) showed an inverse relationship. Alcohol use and sleep hygiene consumption activities were not predictive of sleep problems, suggesting that different sleep hygiene behaviors have differential relationships with sleep problems. Screening and intervention for specific sleep problems may be helpful even very early in Army National Guard service members’ careers. Particular focus may be needed for those showing signs of emotional distress, such as PTSD or depression. Future research examining the impact of individual sleep hygiene components is warranted. INTRODUCTION well-being of military personnel. Sleep is a necessary activity A large body of empirical work has demonstrated that sleep for the body and brain to function optimally. To date, sleep has has significant importance to the physical and psychological been linked to several different physical health outcomes such 1,2 3 as cardiovascular disease, inflammatory responses, and 4,5 excess weight gain, to name a few. Regarding mental health, *Minneapolis VA Health Care System, 1 Veterans Drive, Minneapolis, 6–8 MN 55417. poor sleep has been further associated with depression, sui- 7 9 †Minnesota State University, Mankato, 103 Armstrong Hall, Mankato, cidal ideation, anxiety/stress, post-traumatic stress disorder MN 56001. 8,10 11–13 (PTSD), and memory. In addition, inadequate sleep has ‡Center for Chronic Disease Outcomes Research, 1 Veterans Drive, an impact on one’s ability to work effectively. In some cases, Minneapolis, MN 55417. these impacts are merely expressed through decreased cognitive §Department of Psychiatry, University of Minnesota Medical School, 11–13 14 2450 Riverside Ave South, Minneapolis, MN 55454. function, which results in a loss of productivity. However, ║Division of Rehabilitation Science, Department of Rehabilitation on military deployments service members are often subject to Medicine, University of Minnesota, 420 Delaware St. SE, MMC 297, operational demands that require prolonged periods of incon- Minneapolis, MN 55455. 7,15 sistent or insufficient sleep. Such sleep deficiencies can ¶Smart Information Flow Technologies, 319 1st Ave North, Suite 400, account for a substantial proportion of accidents and poten- Minneapolis, MN 55401. 16,17 The views expressed here are those of the authors and not of the tially dangerous behaviors (e.g., sleeping while on guard Department of Defense, Department of Veteran Affairs, or the U.S. duty). In these cases, what may be simply an inconvenience in Government. the civilian sector may have severe consequences in a combat- doi: 10.1093/milmed/usy107 related environment. Published by Oxford University Press on behalf of the Association of The military has acknowledged the importance of sleep and Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. the role it plays in maintaining soldier readiness to execute e396 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 18–20 military operations. There are currently active programs sleep problems. Given the increasing availability of handheld such as the Comprehensive Soldier Fitness initiative, designed electronic devices, and the accompanying potential for increased to enhance sleep education in an effort to improve unit readiness engagement across multiple electronic devices prior to sleep and resilience. The military population is incredibly diverse, (e.g., texting while watching TV or playing games), we also however, and the effectiveness of intervention strategies is likely examined multiple device usage prior to sleep-onset as a poten- to be constrained by the characteristics of service members and tial predictor of sleep problems. the environment and context in which they operate. Since the events leading to the Global War on Terror, MATERIALS AND METHODS approximately 850,000 National Guard soldiers have been mobilized and deployed throughout the world in support of mil- Participants itary operations. Currently, the National Guard provides the This sample is composed of 438 Minnesota Army National Army with 39% of its operational forces and is responsible for Guard soldiers who filled out and returned a mailed survey as managing 42% of its manned and unmanned aircraft. part of a larger study. The soldiers were identified by expres- Furthermore, the director of the Army National Guard, sing interest in future research while completing their enlist- Lieutenant General Timothy Kadavy, recently stated that mobi- ment contract. All soldiers have an enlistment date within the lizations will increase and combat center rotations will double last three years. Of those soldiers, 295 (67.4%) identified as in 2018. The prominence and activity of National Guard and male, 134 (30.6%) female, 2 (0.5%) as “other,” and data on Reserve (NGR) Component troops brings with it questions gender were missing for 7 (1.6%) participants. Ages ranged about the specific environmental context and demands faced by from 17 to 54 (M = 22.8, SD = 5.274). The majority of partici- these “citizen soldiers.” Unlike regular component service pants (325, or 74.2%) identified as White, 37 (8.4%) identified members, NGR personnel are required to make regular trans- as African-American or Black, 27 (6.2%) identified as Asian or ition from civilian roles and functioning to military contexts. Pacific Islander, 2 (0.5%) identified as American Indian or Simply to maintain unit readiness, National Guard soldiers Alaskan Native, and 39 (8.9%) as Other or Multiracial. Data on interrupt their established, civilian routines for military duty on race were missing for 8 (1.8%) participants. Thirty-two partici- a monthly basis, at minimum. When mobilized for an extended pants identified as of Hispanic origin (7.3%). Regarding rela- period, soldiers must acclimate to specific sleep patterns dic- tionship status, 180 (41.1%) identified as single, 63 (14.4%) tated by the requirements of the mission and the environmental married, 72 (16.4%) were in a relationship and living their part- hazards in which those soldiers operate. Often, when returning ner, and 116 (26.5%) were in a relationship, but not living home from an extended mobilization, soldiers are not subject to together. the same demands and are forced to again acclimate to previous sleep patterns. The unique needs and environmental demands Measures faced by NGR personnel are demonstrated in part by elevated All participants completed questionnaires assessing sleep and rates of mental health disorders, including PTSD, within the sleep difficulties, mental health difficulties, sleep-related beha- context of military deployments. It is, therefore, essential that viors, and the use of technology before going to sleep. levels of sleep impairment and predictors of that impairment within NGR populations be investigated so that intervention Insomnia Severity Index efforts can be evaluated and, if needed, tailored, for this critical component of today’smilitary. TheInsomniaSeverity Index(ISI) is abrief self-report instru- ment of people’s perception of their sleep. The measure includes both objective and subjective symptoms of insomnia, Study Rationale and Hypotheses as well as their perceptions of negative consequences that may The purpose of this study is to examine sleep patterns among occur due to poor sleep. The ISI is made up of seven items that Army National Guard (NG) soldiers and predictors of sleep assess problems with sleep onset, sleep maintenance difficulties, problems within this population. This specificworkispartofa level of satisfaction with sleep, level of noticeable impairment larger study of sleep-related behaviors and interventions. due to sleep problems, and level of distress due to the sleep Following prior findings in military and civilian samples, we problem. Items are rated on a 0–4 scale; total scores range from hypothesized that sleep problems would be predicted by psy- 0 to 28. A higher score is indicative of more sleep problems. chiatric distress (PTSD and depressive symptoms), poor sleep Prior studies have demonstrated acceptable levels of internal 6–10 hygiene behaviors, and heightened alcohol use. Given that consistency and validity through concurrence with other mea- 24,25 there are many distinct types of behaviors discussed as influenc- sures of sleep impairment. Established cutoffs for the ISI ing sleep quality, this study also investigated the dimensionality demonstrate that a score from 0 to 7 indicates no sleep pro- of a sleep hygiene questionnaire containing commonly men- blems, 8 to 14 indicates subthreshold insomnia, 15 to 21 indi- tioned sleep-related behaviors to facilitate analyses. In addition, cates moderate clinical insomnia, and 22 to 28 suggests severe we examined the relationship between electronic usage (i.e., clinical insomnia. Internal consistency (Cronbach’s alpha) within screen time) immediately before bed and amount of sleep and the present sample was 0.86. MILITARY MEDICINE, Vol. 183, November/December 2018 e397 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 subject to a principal components factor analysis with promax Alcohol Use Disorders Identification factor rotation. Three factors produced eigenvalues greater than Test-Consumption one, accounting for a total of 49.41% total item variance, and Alcohol Use Disorders Identification Test-Consumption the scree plot confirmed a three-factor solution. The first factor (AUDIT-C) is a three-item measure that is used to measure (eigenvalue = 2.64, 24.03% total variance accounted for) potential heavy and/or hazardous drinking. Items in the involved items related to sleep routine including “go to bed the AUDIT-C address frequency of drinking in the last year, how same time each night,”“get up at the same time each day,” much alcohol on average is consumed on a day where the “create a sleep environment that is dark, quiet, comfortable, and individual does drink alcohol, and frequency of binge drinking cool,”“reserve your bed for sleep or sex,” and “haveabedtime episodes (6 or more drinks on one occasion). Total scores range routine.” The second factor (eigenvalue = 1.69, 15.36% vari- from 0 to 12. A higher score suggests that alcohol abuse is ance accounted for) contained items relating to consumption likely a problem for that individual. A score of 3 or more is con- behaviors involving food, drink, or chemicals prior to bed sidered a positive screening for hazardous drinking in women, including “avoid caffeine within 4 h of bedtime,”“avoid spicy and a score of 4 or more is a positive screening for men. There foods within 4 h of bedtime,”“avoid alcohol within 4 h of bed- is strong evidence for the use and interpretation of this instru- time,” and “avoid nicotine within 4 h of bedtime.” Two items ment, specifically in younger, OIF/OEF veterans. Internal with low commonalities loaded on a final factor (eigenvalue = consistency (Cronbach’s alpha) within this sample was 0.84. 1.10, 10.01% variance accounted for): “exercise” and “get out of bed if you have been awake for more than 20 minutes”.As Primary Care-Post-traumatic Stress Disorder the resulting factor had only two items and a reliability of 0.19, Screen these items were excluded from further analysis. Mean scores The Primary Care-Post-Traumatic Stress Disorder Screen is a were calculated for the two remaining factors: Sleep Hygiene four-item screening tool for PTSD that is commonly used in Routine and Sleep Hygiene Consumption. primary care settings and considered an acceptable screening method within the VA system. The screen addresses symp- Screen Use Before Bed toms of re-experiencing a traumatic event, numbing, avoidance, This section consisted of two questions regarding electronic and hyperarousal. The items are answered with either “Yes” or device usage within 1 h of going to sleep. Multiple device usage “No.” Total scores range from 0 to 4. A cutoff score of 3 was measured on a five-point Likert scale ranging from “never” demonstrated a strong sensitivity (0.78) and specificity to “all the time,” asking how often in a given week multiple (0.87) in VA general medical settings. Prior studies have devices (e.g., computers, cell phones, tablets, game consoles, demonstrated acceptable levels of internal consistency and 29,30 television, or electronic reading devices) were used. Any device validity through concurrence with other measures of PTSD. usage was measured by asking (with the same response format) Internal consistency (Cronbach’s alpha) within the present sample how often any devices were used in the bedroom in the hour was 0.80. before going to bed. Patient Health Questionnaire-2 Procedures The Patient Health Questionnaire-2 is a two-item depression A standard survey protocol was followed in which potential screening tool. The items address depressed mood and anhe- participants were first sent a pre-notification postcard explaining donia over the past 2 wk. Both items are scored from 0 the study. Two weeks later they were sent the survey along (“not at all”)to3(“nearly every day”). The total score (the with a cover-letter detailing the study and a modest ($2) pay- sum of both items) ranges from 0 to 6. A score of ≥3or ment. Non-responders were sent, at 2-wk intervals, a reminder higher is considered a positive initial screening for depres- postcard, a second survey, and then a third survey (this time via sion. These items demonstrated a 0.76 pooled sensitivity and priority mail). Of 2,063 surveys mailed out, 438 were returned, 0.86 pooled specificity in a recent meta-analysis. Prior stud- yielding a response rate of 21%. ies have demonstrated acceptable levels of internal consis- tency and validity through concurrence with other measures 32,33 of depression. Internal consistency (Cronbach’s alpha) Data Analysis within the present sample was 0.80. Rates of sleep problems and potential psychiatric distress were established with simple frequencies. Gender (male vs. female) Sleep hygiene behaviors and race (Caucasian vs. non) groups were compared on the ISI Common sleep hygiene behaviors were assessed with 11 items and its potential predictors using independent samples t-tests. asking about the weekly frequency of behaviors associated with Predictors of sleep problems were evaluated with ordinary least healthy sleep including routine and consistent sleep and wake squares multiple linear regression analyses, regressing ISI total times, avoidance of alcohol, caffeine, spicy food within 4 h of scores on demographic variables, PTSD, depression, alcohol bedtime, and exercise routines. Each behavior was rated as use, sleep hygiene (routine and restricting activity), and technol- occurring between 0 and 7 times per week. The 11 items were ogy use (multiple device use and use before bed). e398 MILITARY MEDICINE, Vol. 183, November/December 2018 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 TABLE I. Means, Standard Deviations, and Correlations Correlations Mean SD ISI PTSD Depression Alcohol SH-Routine SH-Cons. Multi-Device Any Device ISI 8.52 5.48 1.00 0.41*** 0.49*** 0.02 −0.34*** −0.09 0.15* 0.05 PTSD 0.93 1.35 1.00 0.46*** 0.00 −0.15** −0.12* 0.07 0.04 Depression 0.88 1.24 1.00 0.02 −0.21*** −0.10* 0.12* 0.10* Alcohol 2.76 2.48 1.00 −0.03 −0.26*** 0.00 0.04 SH–routine 5.53 1.43 1.00 0.21*** −0.16** −0.13** SH–cons. 5.76 1.92 1.00 −0.17 0.05 Multi-device 2.15 1.33 1.00 0.26*** Any device 3.04 1.19 1.00 Note:SH–Routine, Sleep Hygiene Routine; SH–Cons., Sleep Hygiene Consumption; Multi-Device, Using Multiple Devices <4 h prior to sleep; Any Device, using any electronic device <4 h prior to sleep.*p < 0.05,**p < 0.01,***p < 0.001. TABLE II. Regressing Sleep Problems on Predictors RESULTS According to the ISI, 365 participants (83.7%) screened for B Beta tp either no sleep impairment (n = 203) or subthreshold insomnia (Constant) 9.56 6.58 0.000 (n = 162). The remaining 71 (16.3%) screened positive for Gender 0.99 0.09 2.10 0.036 moderate (n = 61)orsevere(n = 10) clinical insomnia. Alcohol 0.05 0.02 0.54 0.588 Regarding other psychiatric screens, 42 (9.6%) screened posi- PTSD 0.89 0.22 4.86 <0.001 tive for depression, 79 (18.1%) for PTSD, and 221 (50.7%) for Depression 1.53 0.35 7.56 <0.001 SH-Routine −0.88 −0.23 −5.47 <0.001 potentially problematic alcohol use. Male and female soldiers SH-Consumption 0.11 0.04 0.90 0.371 did not differ in terms of depression, Sleep Hygiene Routine, or Multi-Device 0.24 0.06 1.39 0.164 frequency of multi-device use before bed. Means, standard Any Device −0.32 −0.07 −1.63 0.104 deviations, and correlations are displayed in Table I. Sleep pro- Note:SH–Routine, Sleep Hygiene Routine; SH–Cons., Sleep Hygiene blems, as assessed by the ISI, were correlated with PTSD Consumption; Multi-Device, Using Multiple Devices <4 h prior to sleep; symptoms (r = 0.41, p < 0.001), depression (r = 0.49, p < Any Device, Using any electronic device <4 h prior to sleep. 0.001), Sleep Hygiene Routine (r = −0.34, p < 0.001), and more frequent use of multiple devices before bed (r = 0.15, p = Hygiene Routine (B = −0.88, β = −0.23, t = −5.473, p < 0.001). 0.002). Considering potential demographic covariates, male Alcohol use, Sleep Hygiene Consumption, and technology use and female participants differed in terms of alcohol use (2.91; did not emerge as independent predictors (see Table II). SD = 2.63 and 2.41, SD = 2.02, respectively; t = 2.14, df = 326.63, p = 0.033), PTSD symptoms (0.81, SD = 1.27 and 1.17, SD = 1.47, respectively; t = −2.56, df = 425, p = 0.011), CONCLUSION Sleep Hygiene Restricted Activity (4.02, SD = 1.61 and 3.53, Discussion SD = 1.40, respectively; t = −2.53, df = 418, p = 0.012), use of electronics before bed (2.94, SD = 1.27 and 3.35, SD = National Guard personnel represent a vital component of the 0.91, respectively; t = −3.79, df = 343.98, p < 0.001), and nation’s armed forces with distinct roles, duties, and life cir- sleep impairment (8.13, SD = 5.26 and 9.44, SD = 5.70, cumstances. This study evaluated levels and predictors of sleep respectively; t = 2.31, df = 425, p = 0.022). Non-Caucasian impairment in a sample of National Guard soldiers as an exami- and Caucasian participants differed in terms of alcohol use nation of needs and risk/protective factors within the popula- (2.05, SD = 2.17 vs. 3.00, SD = 2.52; t = −3.57, df = 433, p < tion. Overall, the majority of the present sample did not endorse 0.001) Sleep Hygiene Activity Consumption (4.15, SD = 1.63 high levels of sleep impairment. However, a sizeable minority and 3.79, SD = 1.53, respectively; t = 2.10, df = 422, p = (16.4%) did screen positive for moderate or even severe levels 0.037) and use of multiple devices before bed (2.46, SD = 1.31 of clinical insomnia. Greater numbers of sleep-related com- and 2.07, SD = 1.33; t = 2.69, df = 435, p = 0.008). plaints were related particularly to psychological distress Given the relationship between gender and ISI scores, gen- including depressive and PTSD symptoms. This is an expected der was included as a covariate when regressing ISI scores on finding, given prior work documenting the co-occurrence of 6–8,10 alcohol use, PTSD, depression, sleep hygiene, and technology sleep impairments with both disorders. Further, both 2 2 use. The overall model was significant (R = 0.35, adj R = depression and PTSD are definedin partbythe symptomof 0.34, F[8,408] = 27.58, p < 0.001). Significant independent impaired sleep in the Diagnostic and Statistics Manual of predictors included gender (B = 0.99, β = 0.09, t = 2.10, p = Mental Disorders. We also found, as expected, that sleep 0.036), PTSD (B = 0.89, β = 0.22, t = 4.86, p < 0.001), depres- hygiene behaviors relating to regular scheduling of bedtime and sion (B = 1.53, β = 0.35, t = 7.56, p < 0.001), and Sleep awakening and adherence to a bedtime routine were negatively MILITARY MEDICINE, Vol. 183, November/December 2018 e399 Downloaded from https://academic.oup.com/milmed/article/183/11-12/e396/4999173 by DeepDyve user on 13 July 2022 correlated with sleep problems. It is impossible to know, in the barrier modification (e.g., leveraging already-utilized technol- present sample, if disrupted sleep resulted from poorly struc- ogy to educate or adjust sleep-related behavior). tured sleep activities (such as chaotic bedtimes) or if sleep pro- Limitations of this study include a single time-point correla- blems led to more disrupted sleep hygiene routines. The tional design, and population sampling limitations. Although evaluation of these potential pathways will require future stud- significant relationships were identified, we are unable to con- ies making use of longitudinal methodology so that temporal firm causal relationships between variables due to the passive cause and effect can be evaluated. Recent questions have observation, cross-sectional design of the model. Furthermore, emerged regarding the role of electronic device usage in poten- only abbreviated, though validated, measures were utilized for 37–40 tially interfering with sleep. The present findings, however, many constructs due to a need to minimize participant burden provide only limited support for this hypothesis. The use of at this early phase of the research project. Utilizing more robust, multiple devices before sleep did not correlate with sleep pro- full-length versions of these instruments would allow for a blems, and the relationship between sleep problems and fre- more detailed and nuanced understanding of sleep-related vari- quency of any device use before bed was small. ables in future research endeavors. Regarding sampling limita- Impaired sleep has been associated with performance decre- tions, these results may not generalize accurately across groups 14,16,17 ments in several occupational domains. In addition, due to the unique characteristics of the Minnesota National impaired or disrupted sleep has been linked to numerous physi- Guard, such as demographic makeup, proximity to active duty 1–10 cal and mental health problems. The present findings sug- forces, and deployment rates. Notwithstanding these limita- gest that screening and intervention for sleep problems may be tions, this study demonstrates the importance of attending to helpful even very early in Army National Guard service mem- sleep and sleep behaviors within a National Guard context and bers’ careers. Particular focus may be needed for those showing identifies the role of mental health symptoms within this signs of emotional distress such as PTSD or depression, align- population. ing with the current literature on psychopathological comorbid- ities related to insomnia. Findings also suggest that a focus on ACKNOWLEDGEMENTS teaching and encouraging consistent sleep scheduling habits This project was conducted with resources from the Minneapolis VA Healthcare may be beneficial in this population, further supporting broad System and funded in part through a Departments of Defense Small Business based programs such as the Comprehensive Soldier Fitness ini- Innovation Research grant to Smart Information Flow Technologies (Award tiative. In addition, a recent RAND report highlighted the Number W81XWH-16-C-0032). importance of more individually focused evidence-based prac- tices, such as Cognitive-Behavioral Therapy for Insomnia (CBT-I). REFERENCES Finally, innovative electronic interventions, such as tailored smart- 1. Hla K., Young T., Hagen E., et al: Coronary heart disease incidence in phone apps may be helpful in engaging younger National sleep disordered dreathing: The Wisconsin Sleep Cohort Study. 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Journal

Military Medicine – Oxford University Press

Published: Nov 5, 2018

Keywords: sleep; insomnia; sleep hygiene; soldiers; army; sleep disorders; post-traumatic stress disorder; depressive disorders; alcohol drinking; medical devices; mental health

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