Policies, programs, obstacles to implementation and recommendations for the future
Sleep problems are a major complaint of military personnel returning from deployment. Sleep disorders, such as insufficient sleep time, poor sleep quality, nightmares, and daytime sleepiness, may be caused by physical (e.g., pain, brain injury), behavioral (use of stimulants or electronic devices before bedtime), or work-related (shift work, job demands) reasons. Sleep disturbances may also be related to stress or other mental health problems, such as post-traumatic stress disorder (PTSD) or depressive symptoms.
The RAND study, the first comprehensive review of sleep policies and programs in the U.S. military, examined codified policies and programs from the Department of Defense (DoD), Department of Veterans Affairs (VA), and sleep-related services to make recommendations for improving sleep in the military.
Sources include more than 100 guidelines, publications, and regulations on (1) prevention of sleep disorders, (2) medical screening and treatment, (3) sleep during training, and (4) sleep in the work environment. In addition, RAND researchers conducted key informant interviews and convened a working group of supervisors, physicians, sleep medicine experts, and policymakers to identify barriers to implementing sleep-related policies and programs in the military.
Prevention policies and programs
Sleep disorders have a major impact on current and future psychological, physical, and operational readiness. Therefore, promoting healthy sleep and preventing sleep disorders can improve the readiness and resilience of troops. Although there is no codified prevention policy, all military establishments have at least one resilience promotion program or campaign that considers healthy sleep as a key component of resilience, and recommendations to promote healthy sleep habits (so-called sleep hygiene).
However, these prevention programs are not evidence-based. Moreover, studies among military personnel suggest that the advice given in these programs may fall on deaf ears, especially during deployments, when units may have difficulty providing rest periods or dark, quiet places for personnel to rest, and when operational demands take precedence over the sleep needs of military personnel.
Other Armed Forces policies offer guidance on sleep and stress management in the post-deployment period, including seven to eight hours of rest a day to avoid combat stress, and advice to make service members aware that too little sleep can be a warning sign of suicide. However, experts say these tools are scattered and there is no control over the accuracy of the recommendations.
One of the most coordinated and systematic efforts to promote healthy sleep as a critical component of endurance and readiness is the military performance triad (nutrition, exercise and sleep). The Army continues to fund research on how poor sleep quality and quantity can affect Soldier performance. However, the efficacy of these programs in improving sleep health has yet to be proven.
Medical policies and programs
The Armed Forces' general sleep policy exists primarily to establish medical standards and qualifications for initial and continued military service or referral to a medical review board. Although sleep is mentioned as a symptom in clinical practice guidelines for common mental disorders, the U.S. Department of Veterans Affairs does not have specific clinical practice guidelines for sleep.
This can lead to underdiagnosis and undertreatment of sleep disorders. Research supports specific interventions for sleep disorders, demonstrating that treatment of sleep disorders (e.g., insomnia) can also improve comorbidities (e.g., depression or post-traumatic stress disorder).
In addition to setting medical standards, medical policy also addresses screening for sleep disorders. Self-assessments are the most commonly used tool to identify sleep problems, but military personnel may underestimate their symptoms after deployment to avoid medical tests and delays in returning home.
Gaps and recommendations to promote healthy sleep
- There is no codified policy, but all military installations have at least one resilience program or campaign in which healthy sleep is an important component. They may not have evidence-based strategies to promote healthy sleep.
- Increase training of military personnel and supervisors on healthy sleep. Fund or conduct research on sleep and its impact on operational readiness and resilience to develop policies and programs to better identify risk factors and prevent sleep problems.
- Policies refer to sleep primarily as a symptom of other medical conditions. No policy specifically addresses continuity of care. Medical screening tools are often short.
- Develop clinical guidelines on sleep disorders and increase the use of mobile technology in the clinical assessment and treatment of sleep disorders.
Education & Training
- The length of rest periods has been clarified, but only for early adopters. The service's policy of seven to eight hours of uninterrupted sleep per night allows exceptions for certain activities. It is unclear to what extent managers and employees comply with these policies.
- Introduce a training policy in the armed forces to improve sleep duration and quality. Ideally, these policies and related programs should reflect medical and scientific research recommendations.
- Operational policy provides for sleep schedules, but there is no guidance for managers on how these schedules should be developed. Although most of the principles defining the length of rest periods are relatively new, they do not necessarily reflect current research or clinical practice.
- Educate managers and disseminate positive sleep messages as operational advice to raise awareness and reduce cultural barriers. Review accident and incident data to look for links to fatigue and educate drivers to develop sleep schedules that better match circadian rhythms.
Training & educational programs and policies
In field training policies, the length of mandatory rest periods for new recruits was relatively consistent across units; however, these policies apply to initial recruits, not necessarily to operational forces. In general, these policies provide for seven to eight hours of uninterrupted sleep per night, with exceptions for certain activities, such as end-of-course exercises or guard duty.
The Air Force policy also recommends proper sleep habits; the military policy provides guidance to students on sleep management and recognition of sleep disturbances as a symptom of stress. The Navy and Marine Corps grant recruits “rights” to sleep, as they are normally entitled to eight hours of uninterrupted sleep per night, unless they are assigned specific duty duty, if the training program includes night training, or during final training.
Maintaining sleep hygiene is a training task in these units; to demonstrate competency, trainees must understand the impact of sleep deprivation on performance and the means to combat fatigue, and be able to assess their own sleep hygiene. However, research shows that individuals are generally unable to assess the extent to which sleepiness or fatigue affects their performance.
Despite this recommendation, training principles that call for rest are not necessarily conducive to eight hours of uninterrupted sleep, especially when military personnel face competing demands and environmental factors that affect sleep, such as exposure to light and noise. For example, “down time” may be sacrificed to study or to prepare equipment or uniforms for the next day's activities.
Implementation plans and policies
An operational policy is the most commonly identified type of policy. Sometimes there are different policies within the same department, with differences in the importance of sleep. In addition, although most stress and stress tolerance policies are relatively new, they do not necessarily reflect current research or clinical practice.
This can lead to misunderstandings about the minimum amount of sleep acceptable for military personnel or supervisors, and is in direct contradiction to the strong scientific evidence demonstrating the negative impact of sleep deprivation on performance.
RAND conducted the first comprehensive review of military sleep policies and programs to provide recommendations for improving soldiers' sleep health. The results of the policy analysis showed that there were few preventive policies or programs and that treatment guidelines mentioned sleep primarily as a symptom of mental health or general readiness.
In contrast, operational policies, while abundant, focused on the minimum amount of sleep needed during operations, sometimes contradicting established recommendations for optimal sleep. For example, there is no guidance for managers on how to develop and implement sleep schedules that determine the team's work and rest periods during ongoing operations.
While most publications state that the appropriate amount of sleep for military personnel is seven to eight hours, they provide little guidance on how to achieve quality sleep. As with many training policies, those that focused on providing rest periods did not include conditions to ensure that sufficient time was allocated to provide quality sleep, nor did they provide guidance to leaders on how sleep plans should be developed and implemented.
Strengthening policies and programs that promote healthy sleep is an important step in preventing the consequences of sleep problems, both for individual members and the unit as a whole.
Implement policies and programs that promote healthy sleep and improve force readiness
Even evidence-based best practices, programs, and policies to prevent and treat sleep problems among military personnel face barriers to implementation. Military health professionals, commanders, and other sleep medicine experts cited several factors that can hinder sleep for soldiers in particular.
The ability to cope with sleep deprivation can be considered a “badge of honor.” There is still a stigma associated with seeking help, but this may be less for sleep disorders than for mental health disorders; perhaps self-recognition or systematic screening for sleep disorders could avoid the stigma associated with other problems. Commanders under great pressure to be available to their units and to advise them on mission planning may be especially sleep deprived. Unit personnel may receive behavioral cues from their superiors.
“Mission first” is every soldier's credo. Mission needs and training requirements may take precedence over sleep, and units may not have adequate mechanisms in place to ensure adequate rest. In addition, characteristics of the operating environment (e.g., noise or an uncomfortable or unsafe sleep environment) may directly affect the quality and duration of sleep.
Military personnel may not be aware of healthy sleep patterns, including the risks associated with chronic use of stimulants or sleeping pills. They may also be unaware of how sleep deprivation can affect cognitive performance and functional ability. There is no centralized resource for information on sleep policy and training at the military level.
Barriers to medical and treatment systems
Military personnel may experience negative attitudes or career-related consequences when seeking help for their sleep problems from the military healthcare system. Experts also cited a lack of sleep clinics, lack of adequate screening, and deficiencies in post-deployment care.
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David W. Newton is a board certified pharmacist and also has been a board member for boards of examiners for the National Association of Boards of Pharmacy since 1983. His areas of expertise are primarily pharmaceuticals as well as cannabinoids. You can read an article about his expertise in CBD on the National Library of Medicine.