Does Sleep Apnea Disqualify You Military Service
Chest. 2013 Aug; 144(two): 549–557.
Slumber Disorders in U.s.a. Military Personnel
A High Rate of Comorbid Insomnia and Obstructive Sleep Apnea
Vincent Mysliwiec, MD, FCCP, 
Jessica Gill, PhD, Hyunhwa Lee, PhD, Tristin Baxter, AAS, Roslyn Pierce, BS, Taura L. Barr, PhD, RN, Barry Krakow, MD, and Bernard J. Roth, MD, FCCP
Received 2013 January 11; Accepted 2013 April 19.
Abstract
Groundwork:
Sleep disturbances are among the most common symptoms of military personnel who return from deployment. The objective of our study was to determine the presence of sleep disorders in The states military machine personnel referred for evaluation of sleep disturbances subsequently deployment and examine associations between sleep disorders and service-related diagnoses of depression, mild traumatic encephalon injury, pain, and posttraumatic stress disorder (PTSD).
Methods:
This was a cross-sectional study of war machine personnel with sleep disturbances who returned from gainsay within xviii months of deployment. Sleep disorders were assessed by clinical evaluation and polysomnogram with validated instruments to diagnose service-related illnesses.
Results:
Of 110 military personnel included in our assay, 97.iii% were men (mean age, 33.half-dozen ± 8.0 years; hateful BMI, thirty.0 ± 4.3 kg/chiliad2), and 70.9% returned from combat within 12 months. Nearly half (47.3%) met diagnostic criteria for two or more service-related diagnoses. Sleep disorders were diagnosed in 88.ii% of subjects; 11.8% had a normal sleep evaluation and served every bit control subjects. Overall, 62.7% met diagnostic criteria for obstructive sleep apnea (OSA) and 63.6% for insomnia. The exclusive diagnoses of insomnia and OSA were present in 25.5% and 24.5% of subjects, respectively; 38.2% had comorbid insomnia and OSA. War machine personnel with comorbid insomnia and OSA were significantly more likely to meet criteria for low (P < .01) and PTSD (P < .01) compared with control subjects and those with OSA just.
Conclusions:
Comorbid insomnia and OSA is a frequent diagnosis in military personnel referred for evaluation of sleep disturbances after deployment. This diagnosis, which is difficult to treat, may explicate the refractory nature of many service-related diagnoses.
Sleep disturbances are reported in almost i-tertiary of armed forces personnel who have deployed in back up of Overseas Contingency Operations (OCO), resulting in approximately 600,000 military personnel and veterans with clinically relevant sleep conditions. 1 US Section of Defense medical data report a marked increase in the incident diagnoses of insomnia and obstructive sleep apnea (OSA) across all services. 2,3 From 2001 to 2009, the diagnostic rates for indisposition and OSA increased past 19 and five.eight times, respectively. However to appointment, the research on sleep disorders in armed services personnel is limited to subjective assessment tools or retrospective analyses. 1,4‐8 Thus, at that place is limited understanding of the etiology of sleep disorders and the contributing impact of comorbid psychologic and medical factors.
Sleep disturbances in armed services personnel are attributed to a multifactorial procedure. Deployment across multiple time zones results in circadian misalignment. ix Chronic sleep impecuniousness, a component of the armed services culture, 10 is exacerbated by the physical and emotional stressors of deployment; this results in slumber fragmentation and insomnia. iv Mission requirements foster maladaptive sleep practices such as excess caffeine intake and the use of sedative hypnotics. eleven,12 Upon returning from combat operations, sleep disturbances frequently persist. ane,iv,13,14 Information technology is currently unknown, though, if deployment exacerbates a previously undiagnosed slumber disorder or results in the onset of a new sleep disorder. The sleep disorder nigh probable to develop equally a effect of deployment is insomnia. v,8 Still, military personnel in previous studies that included polysomnography (PSG) were diagnosed primarily with OSA. vi,7,15 Conceivably, comorbid insomnia and OSA, a status originally termed "complex insomnia" in 2001, 16 may be an underdiagnosed or misdiagnosed clinical entity. 17 Moreover, sleep-disordered breathing may be aggravated past the detrimental effects of indisposition and slumber deprivation motivating war machine personnel to seek care. Failure to fully accost all aspects of disordered sleep could result in a less-than-optimal clinical response, potentially compromising the ability of service members to perform military duties or respond fully to treatments.
In addition to sleep disorders, electric current studies link gainsay or war-zone experiences to the evolution of chronic psychologic and physical health problems, including the service-related illnesses of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), low, and chronic pain. 13,14,18,19 We recently reported that 58.ane% of military machine personnel undergoing a slumber study accept one or more medical comorbidities, and that those diagnosed with insomnia are two times more than likely to have PTSD and 1.five times more probable to have hurting. xv Collen et al 8 reported on 116 soldiers with TBI, noting 97.4% had sleep complaints, with insomnia and OSA as the chief diagnoses. A more comprehensive assessment of sleep disorders and associated diagnoses may demonstrate important implications for the health and well-being of war machine personnel.
Our study assessed the presence of slumber disorders in military machine personnel presenting for the evaluation of sleep disturbances after deployment, besides as the service-related diagnoses of low, mild TBI, hurting, and PTSD. The purpose of the study was to determine relationships betwixt service-related diagnoses in military personnel with slumber disorders.
Materials and Methods
Study Design
This was a cross-sectional written report of United states of america armed services personnel presenting for an initial evaluation of sleep disturbances. The study was approved by the institutional review board at Madigan Ground forces Medical Center (Protocol #210090), and informed consent was obtained from each participant prior to whatever measurements. Participants were recruited by advertisements in the Sleep Medicine Clinic and notification by clinic personnel regarding the study. All 1,416 military machine personnel who underwent a slumber medicine evaluation between March 2011 and May 2012 were potentially eligible to participate. There were 160 who volunteered for participation in the written report protocol and underwent eligibility screening (Fig 1). Inclusion criteria included the following: active-duty war machine personnel presenting for an initial evaluation of sleep disturbances and having returned from deployment within 18 months. Exclusion criteria included the following: no ongoing treatment, or military administrative actions regarding drug or booze abuse, or unstable psychiatric diagnoses (ie, schizophrenia or bipolar disorder). I hundred and seventeen patients met eligibility criteria and consented to enrollment. 4 subjects were excluded for failure to complete the PSG and sleep medicine evaluation. One hundred thirteen subjects completed baseline assessments, clinical evaluations, and a diagnostic PSG. For these analyses, nosotros excluded three participants who were diagnosed with uncommon sleep disorders in our cohort: periodic limb motility disorder (n = ane), restless legs syndrome (n = 1), and shift-piece of work sleep disorder (northward = 1). While these represent pregnant sleep disorders, their small-scale numbers limit our ability to identify substantive relationships with the variables of interest.
Inclusion criteria for study participants. BIISS = behaviorally induced insufficient sleep syndrome; OSA = obstructive sleep apnea.
Slumber Medicine Evaluation
All participants underwent a sleep medicine evaluation and diagnostic, attended PSG using standardized techniques. PSG was performed with 16 channels, including electrooculogram, EEG, ECG, electromyogram (submental, bilateral tibial), airflow measurements using both oronasal-thermal sensors and nasal air pressure transducers, tracheal sounds via microphone, rib cage and abdominal movement by inductance plethysmography using thoracoabdominal belts, and continuous pulse oximetry. The patient's sleep period was approximately 8 h long with recording fourth dimension starting at approximately nine:thirty pm and ending at 5:30 am. This sleep catamenia is conducive for the evaluation of war machine personnel and their duty requirements. Nosotros used the American Academy of Sleep Medicine alternate scoring method for hypopneas requiring a ≥ fifty% decrease in the nasal force per unit area signal excursion from baseline lasting ≥ x s with either a ≥ 3% desaturation or an arousal. 20 PSGs were scored and interpreted in accordance with American Academy of Sleep Medicine criteria. 20 Vi of the participants with OSA underwent a split-night PSG in accordance with our laboratory's standard procedures. The PSG variables we analyzed included sleep onset latency, rapid eye-movement onset latency, total sleep time, wakefulness after sleep onset, sleep efficiency, arousal index, sleep stages (stages N1-iii, stage R), apnea-hypopnea alphabetize (AHI), and maximal desaturation.
Slumber diagnoses were classified in accordance with the International Nomenclature of Slumber Disorders, 2nd Edition, 21 integrating the clinical assessment, PSG, and questionnaires. For the diagnosis of insomnia, participants were required to have one or more sleep-related complaints consisting of difficulty initiating sleep, maintaining slumber, waking too early on, or sleep that is chronically nonrestorative or of poor quality with at least ane of the associated symptoms of daytime impairment. The diagnosis of OSA was rendered in cases where the participant's PSG demonstrated apneas or hypopneas with an AHI > v/h. For the purposes of this study, the diagnoses of indisposition and OSA were not mutually exclusive; specifically, the diagnosis of comorbid insomnia and OSA was rendered if the participant met criteria for indisposition and if the AHI was > 5/h, unless their insomnia symptoms were solely from a service-related diagnosis or some other medical disorder, in accordance with Research Diagnostic Criteria for indisposition related to sleep apnea. 22 For assay purposes, we used the following diagnostic categories: insomnia, comorbid indisposition and OSA, OSA, and control subjects, equally these were the most frequent diagnoses rendered. Control subjects were participants diagnosed with behaviorally induced insufficient slumber syndrome or snoring with an otherwise normal PSG. While these military personnel are not without sleep disturbances, our prior research validated these diagnoses as an acceptable control population for military personnel. 15 All diagnoses were adjudicated past a physician board-certified in sleep medicine (Five. Thou.).
Demographic characteristics included sex, historic period, BMI, education, branch of service, rank, deployment history (number and times each military participant left their abode base of operations in support of OCO), and fourth dimension since most recent deployment. Medications that the participants were taking at the time of their PSG were recorded in the following categories: antidepressants, atypical antipsychotics, benzodiazepines, nonbenzodiazepine receptor agonists (NBDRAs), prazosin, and narcotics.
Questionnaires
Clinical data regarding combat experiences, including TBI, psychologic health, pain, and sleep were obtained using validated scales that have demonstrated reliability and validity. The Gainsay Experiences Scale was used to assess combat intensity, with scores ranging from 0 to fifteen, with a higher score indicating more, dissimilar combat-related exposures on one or more occasions. 23 The cess of TBI was determined using the Warrior Administered Retrospective Casualty Assessment Tool. This tool obtains data on possible TBI-related war injuries besides every bit postdeployment injuries, assessing amending of consciousness and presence of postconcussive symptoms at the time of injury. 24 The diagnosis of mild TBI was fabricated in accordance with the American Congress of Rehabilitation Medicine mild TBI criteria, which required an injury event followed past a loss of consciousness or amending of mental land. 25
PTSD was assessed by the PTSD Checklist Armed forces Version, with a score of ≥ 50 resulting in a positive diagnostic screen, which is a score that provides the maximum specificity (0.98) and is consistent with the Structured Clinical Interview for Diagnostic and Statistical Transmission of Mental Disorders, Third Edition, Revised. 26 The Quick Inventory of Depressive Symptoms was used to screen for low, using a cutoff score of 11 for a positive screen for low. 27 Chronic pain was evaluated using the RAND 36-Item Curt-Form Health Survey component for the bodily pain score. Nosotros used this score in conjunction with the subject'southward medical record to determine a diagnosis of hurting, by either score < lxx for armed forces personnel with a hurting diagnosis in their electronic medical record, 28 or by low bodily pain subscale score (< 30) on the RAND 36-Particular Brusk Form Health Survey. 29
Subjective sleep assessments included the following: self-reported habitual sleep duration; measures of sleep quality including difficulties falling asleep, staying asleep, frequent awakenings, and reporting slumber was non sound or refreshing; and the Epworth Sleepiness Scale (ESS), which assesses an individual's "likelihood of dozing or falling asleep" in eight situations of daily living. Scores > 10 on the ESS are consistent with significant sleepiness. 30
Statistical Assay
Data are presented as the mean ± SD or No. (%). To decide differences amid the slumber diagnoses groups, χ2 tests with mail service hoc standardized residuals exam for categorical variables were used; one-way assay of variance with post hoc analyses was performed using the Bonferroni correction for multiple comparisons. The significance level for group comparisons was set at 0.05 and was corrected for multiple comparisons. The mean and proportional differences amid participant groups for the demographic characteristics and the health-related variables are reported in Tables i to 3. Information were analyzed using Predictive Analytics SoftWare version 18.0 (IBM).
Table ane
—Characteristics of Report Participants
| Characteristics | Overall (Due north = 110) | Indisposition (n = 28) | Comorbid (north = 42) | OSA (north = 27) | Control Subjects (n = xiii) | χii or F | P Value |
| Demographics | |||||||
| Male sexual activity | 107 (97.3) | 26 (92.9) | 42 (100.0) | 27 (100.0) | 12 (92.3) | five.xx | .158 |
| Historic period, y | 33.half dozen ± 8.0 | 31.4 ± 7.5 a | 33.8 ± 7.9 | 38.6 ± 7.2 a,b | 27.8 ± 5.viib | seven.67 | < .001 |
| BMI, kg/one thousand2 | 30.0 ± 4.3 | 27.eight ± 3.nine a,b | 31.6 ± 3.7 a,c | 31.3 ± iv.1 b,d | 27.0 ± 4.0 c,d | 8.77 | < .001 |
| Education, y | 13.ix ± 2.0 | thirteen.8 ± i.9 | 13.7 ± 1.7 | 13.ix ± 2.1 | xiv.6 ± 3.v | 0.43 | .735 |
| Co-operative of service | 0.99 | .804 | |||||
| Army | 102 (92.vii) | 26 (92.9) | twoscore (95.two) | 24 (88.9) | 12 (92.3) | ||
| Air Force | 8 (vii.iii) | 2 (7.1) | 2 (four.viii) | 3 (eleven.1) | 1 (7.vii) | ||
| Rank | 12.38 | .054 | |||||
| Inferior enlisted (E1-E4) | 69 (62.7) | 19 (67.9) | 29 (69.0) | 13 (48.ane) | eight (61.5) | ||
| Senior enlisted (E5-E9) | 34 (30.9) | 7 (25.0) | 12 (28.half dozen) | 13 (48.i) | 2 (xv.iv) | ||
| Officers | 7 (half dozen.4) | 2 (seven.1) | 1 (2.iv) | 1 (3.7) | 3 (23.i) | ||
| Deployments, No. | seven.31 | .605 | |||||
| ane | 39 (35.5) | 11 (39.3) | 16 (38.1) | 5 (18.five) | 7 (53.8) | ||
| 2 | 28 (25.5) | 7 (25.0) | 11 (26.2) | 8 (29.vi) | ii (xv.4) | ||
| iii | 25 (22.7) | half dozen (21.4) | 7 (16.7) | nine (33.iii) | iii (23.1) | ||
| ≥ four | 18 (sixteen.4) | 4 (14.three) | viii (19.0) | five (18.v) | 1 (7.7) | ||
| Time since last deployment, mo | nine.90 | .359 | |||||
| < iii | 15 (xiii.half-dozen) | 1 (iii.half-dozen) | 10 (23.viii) | 3 (11.one) | 1 (seven.seven) | ||
| 3-6 | 18 (16.4) | vi (21.4) | v (11.ix) | 4 (fourteen.viii) | 3 (23.1) | ||
| vi-12 | 45 (40.9) | 14 (50.0) | sixteen (38.1) | 9 (33.3) | 6 (46.2) | ||
| 12-eighteen | 32 (29.1) | 7 (25.0) | eleven (26.two) | xi (forty.7) | 3 (23.1) |
Table 3
—Medications past Class
| Medication | Overall (North = 110) | Insomnia (n = 28) | Comorbid (n = 42) | OSA (north = 27) | Control Subjects (due north= 13) | χ2 | P Value |
| Currently on medications | 41 (37.3) | 12 (42.9) | 21 (50.0) a,b | 6 (22.2)a | 2 (15.four)b | 8.56 | < .05 |
| NBDRA | 6 (5.5) | ii (7.1) | three (7.one) | ane (3.seven) | 0 (0.0) | 1.thirty | .730 |
| Antidepressants | xxx (27.iii) | 8 (28.6)a | 18 (42.9)b | 2 (7.4) a,b | ii (15.iv) | 11.47 | < .01 |
| Atypical antipsychotics | 2 (1.8) | 1 (3.6) | i (2.4) | 0 (0.0) | 0 (0.0) | 1.xxx | .730 |
| Benzodiazepines | iv (3.6) | 3 (10.7) | 0 (0.0) | 1 (three.vii) | 0 (0.0) | 6.08 | .108 |
| Narcotics | eighteen (16.4) | 6 (21.4) | 9 (21.4) | three (11.1) | 0 (0.0) | 4.40 | .221 |
| Prazosin | 6 (five.5) | 2 (7.ane) | 4 (9.v) | 0 (0.0) | 0 (0.0) | 3.81 | .283 |
Results
This study included 110 active duty military personnel. Almost participants were men (97.3%), and 92.7% were agile duty in the The states Ground forces; 7.3% were active duty in the The states Air Force (Table ane). The mean age of participants was 33.6 ± 8.0 years. Virtually participants recently returned from deployment, with 70.ix% in the past twelvemonth; 64.5% had deployed multiple times. Ninety-seven participants (88.2%) were diagnosed with a sleep disorder and 13 (11.8%) served as control subjects (Table 1). Sixty-nine (62.7%) met PSG criteria for OSA with an AHI > 5 and seventy (63.half dozen%) for indisposition using International Classification of Sleep Disorders, Second Edition, criteria for insomnia. Participants are grouped into the diagnostic categories of indisposition, comorbid indisposition and OSA, OSA, and control subjects.
The category comorbid insomnia and OSA applied to 38.2% of the cohort. Indisposition and OSA were exclusively diagnosed in 25.5% and 24.5% of subjects, respectively. The mean BMIs of participants in the comorbid insomnia and OSA group (31.6 ± 3.7 kg/thoutwo) and OSA group (31.3 ± 4.1 kg/m2) were elevated compared with the control grouping (27.0 ± iv.0 kg/chiliad2) (P = .001, P < .01, respectively) and insomnia group (27.8 ± 3.nine kg/yard2) (P = .001, P < .01, respectively) (Tabular array 1). Reported habitual sleep duration was less in participants with insomnia (five.v ± 1.iii h) (P < .05) and subjects with comorbid insomnia and OSA (5.ane ± ane.3 h) (P < .001) compared with control subjects (6.8 ± 1.0 h) (Table 2). The mean ESS for all participants was 13, consistent with aberrant daytime sleepiness, which did not differ among the groups (Table 2).
Table 2
—Validated Questionnaires and Service-Related Diagnoses
| Variable | Overall (N = 110) | Indisposition (n = 28) | Comorbid (n = 42) | OSA (northward = 27) | Command Subjects (n = 13) | χ2 or F | P Value |
| Questionnaires | |||||||
| PCL-Thousand | 40.3 ± sixteen.ii | 42.2 ± 16.6 a | 48.vi ± fifteen.4 b,c | 29.4 ± 10.7 a,b | 31.9 ± 11.twoc | 11.63 | < .001 |
| QIDS | 10.iii ± 5.0 | 10.9 ± 5.anea | 13.0 ± 4.i b,c | 6.5 ± 3.ane a,b | 8.0 ± v.0c | 14.41 | < .001 |
| SF-36 Bodily Hurting | 58.half dozen ± 25.2 | 53.0 ± 25.1 | 50.9 ± 23.8 a,b | 69.4 ± 24.0 a | 73.3 ± twenty.vb | 5.46 | < .01 |
| CES | vi.five ± iv.3 | 7.5 ± 4.5 | vii.1 ± 4.ii | four.9 ± three.9 | 5.v ± 4.iv | 2.34 | .077 |
| ESS | 13.0 ± 5.two | 12.3 ± 4.five | 12.viii ± 5.7 | 14.5 ± 4.9 | 12.2 ± v.0 | 1.05 | .375 |
| SR-Habitual Sleep Duration | 5.6 ± one.3 | v.5 ± 1.threea | five.1 ± 1.threeb | 6.0 ± i.1 | 6.8 ± 1.0 a,b | 6.73 | < .001 |
| Diagnosis | |||||||
| > 2 | 52 (47.3) | 14 (fifty.0) a | 28 (66.seven) b,c | vi (22.two) a,b | 4 (thirty.8)c | 14.64 | < .01 |
| None | 33 (xxx.0) | 7 (25.0) | 6 (14.3) a,b | xiii (48.ane) a | seven (53.viii)b | 13.03 | < .01 |
| PTSD | 39 (35.v) | x (35.7)a | 25 (59.v) b,c | 2 (7.4) a,b | two (15.4)c | 22.twenty | < .001 |
| Depression | 49 (44.5) | 12 (42.9) a,b | thirty (71.4) a,c,d | 3 (11.ane) b,c | 4 (xxx.8)d | 25.54 | < .001 |
| Pain | 43 (39.1) | 14 (50.0) | 17 (twoscore.v) | 10 (37.0) | 2 (xv.4) | 4.55 | .208 |
| Mild TBI | 48 (43.6) | 14 (50.0) | 23 (54.8) | seven (25.9) | iv (30.8) | 6.89 | .075 |
Seventy percent of our cohort exhibited service-related diagnoses with a mean of 1.six (± 1.four) diagnoses, which included depression, mild TBI, pain, and PTSD (Table 2). The comorbid insomnia and OSA group reported the highest scores on the Quick Inventory of Depressive Symptoms and PTSD Checklist Military Version, with 71.4% meeting criteria for depression and 59.5% for PTSD, rates that were far college than the command group (P = .001) and the OSA grouping (P < .001). Non surprisingly, subjects in the comorbid insomnia and OSA group were also more likely than those in the OSA group to be taking one of the medication classes assessed (P < .05) likewise as antidepressants (P < .01) (Table 3).
Mail hoc analysis amid the four diagnostic groups revealed a significant increment in rapid middle-move latency in the insomnia vs the OSA group (+65.vi; P = .01) (Tabular array 4). Comparison the severity of sleep-disordered breathing in war machine personnel with OSA vs the comorbid indisposition and OSA group, those with OSA had a college AHI (+14.0; P = .001), with a similar desaturation percentage (Tabular array iv). Otherwise, there were no significant differences in the PSG variables between the OSA and comorbid insomnia and OSA groups.
Tabular array 4
—Polysomnographic Variables by Slumber Diagnoses
| Variable | Overall (N = 110) | Indisposition (northward = 28) | Comorbid (n = 42) | OSA (n = 27) | Control Subjects (n = 13) | F | P Value |
| SOL, min | 10.three ± 15.iii | 12.nine ± 22.six | 12.6 ± 15.2 | 5.3 ± iv.nine | seven.5 ± 6.0 | ane.72 | .168 |
| REM latency, min | 114.6 ± 78.3 | 145.i ± 93.2a | 114.seven ± 77.2 | 79.six ± 54.iva | 121.0 ± 66.iii | 3.47 | < .05 |
| TST, min | 422.9 ± 57.1 | 422.7 ± l.7 | 421.9 ± 59.vii | 420.1 ± 64.i | 432.4 ± 51.8 | 0.xiv | .935 |
| Slumber efficiency, % | 91.3 ± half-dozen.7 | xc.6 ± 9.0 | 90.3 ± 7.0 | 92.4 ± 3.five | 93.7 ± 4.0 | 1.25 | .296 |
| Stage N1, % | 11.three ± 7.0 | 9.4 ± 4.7 | 11.8 ± 5.5 | 13.8 ± eleven.0 | 8.7 ± iii.3 | ii.51 | .063 |
| Stage N2, % | 43.v ± 9.1 | 44.ane ± 8.8 | 43.iii ± 9.six | 43.four ± ten.3 | 43.1 ± 5.8 | 0.06 | .981 |
| Stage N3, % | nineteen.7 ± 9.two | xx.7 ± 9.1 | eighteen.8 ± 8.6 | eighteen.ix ± 10.7 | 21.7 ± 8.3 | 0.53 | .660 |
| Stage R, % | eighteen.six ± 8.3 | 16.7 ± vi.4 | 17.7 ± 6.2 | 21.4 ± 12.4 | 20.i ± 5.9 | 1.88 | .137 |
| WASO, min | 38.0 ± 29.0 | 41.3 ± xl.one | 41.9 ± 28.0 | 33.6 ± nineteen.6 | 27.7 ± 16.6 | 1.14 | .338 |
| Arousal index | 21.viii ± 16.7 | 15.v ± ten.iiia | 22.3 ± thirteen.5 | 31.ii ± 25.0 a,b | fourteen.8 ± 5.1b | 5.42 | < .01 |
| Apnea-hypopnea index | 13.four ± 17.iii | 2.0 ± 1.4 a,b | 14.7 ± 11.1 a,c,d | 28.7 ± 24.v b,c,due east | one.ix ± 1.5 d,east | 20.06 | < .001 |
| Desaturation, % | 86.0 ± 6.2 | ninety.4 ± iii.viii a,b | 84.0 ± 5.ii a,c | 83.3 ± 7.3 b,d | 88.8 ± 4.seven c,d | 11.27 | < .001 |
| Self-reported sleep duration, h | 5.3 ± 1.7 | 5.5 ± 2.0 | five.0 ± 1.three | v.four ± 1.7 | five.8 ± 2.0 | 0.88 | .457 |
Discussion
To our knowledge, this is the start study to diagnose sleep disorders with a clinical evaluation and PSG, also as associated psychologic and medical comorbidities, using validated clinical instruments in a sample of armed services personnel recently returned from deployment. In military personnel with slumber disturbances afterward deployment that warranted a sleep medicine evaluation, 88.2% were diagnosed with a clinically significant sleep disorder. Considering insomnia and OSA equally separate disorders, 62.vii% subjects met PSG criteria for OSA and 63.half-dozen% clinical criteria for insomnia. However, if comorbid indisposition and OSA is classified equally a distinct disorder, information technology was the nearly common diagnosis in 38.ii% of subjects. The reported incidence of slumber disturbances in military personnel and veterans who served in OCO ranges from 30% to 93.5% 1,iv,13,xiv ; nonetheless, most research efforts have focused on the diagnoses of mild TBI and PTSD. Slumber disorders are increasingly recognized by medical providers; nonetheless, information technology is common to accredit sleep disturbances solely to insomnia or an associated diagnosis, viii,31 and delay or forgo a definitive sleep evaluation and PSG. This filibuster farther aggravates the difficulties in treating service-related diagnoses of low, balmy TBI, and PTSD. 32,33
Our finding that comorbid insomnia and OSA ("complex insomnia") was a frequent diagnosis in war machine personnel with combat exposures is consistent with previously reported civilian studies of patients who had traumatic experiences. 16,34,35 Equally our study, to our noesis, is the first substantial assessment of the circuitous indisposition diagnosis in war machine personnel, it raises concerns about whether comorbid insomnia and OSA is underreported in military personnel as has been noted in civilian studies. 17,36 In the literature, there are ii distinct groups of patients with comorbid insomnia and OSA: patients without an associated behavioral-medicine diagnosis 37,38 and those who have anxiety, low, or PTSD with comorbid insomnia and OSA. 16,34,35,39,40 Most of the patients with comorbid indisposition and OSA (66.7%) met criteria for a service-related diagnosis, which is consistent with the "circuitous sleep disorders or circuitous insomnia" model postulated by Cracow et al 31 that integrates their sleep and behavioral-medicine diagnoses and treatment. A contempo written report showed compliance with CPAP in soldiers with OSA and PTSD, many of whom had comorbid insomnia and OSA, was suboptimal, suggesting that treating this syndrome is hard. 33 Another study reported that achieving CPAP compliance in these patients requires much more effort, which is consistent with our clinical feel. 41 There are no definitive treatment recommendations for comorbid insomnia and OSA, although combined therapy addressing insomnia with cognitive behavioral therapy and either surgical treatment or CPAP for OSA has shown promise. 38,42‐44
In this report, we written report that medical and psychologic comorbidities are frequent in military personnel referred for sleep disturbances, with 70% having at least one of the following: depression, mild TBI, hurting, or PTSD, and almost one-half (47.three%) reporting two or more diagnoses. These rates are similar to studies that used either an interview or questionnaire to determine rates of diagnoses, and lower than studies that relied on retrospective reviews of medical records. 13,45‐48 Patients with comorbid indisposition and OSA had the highest rates of depression, mild TBI, PTSD, and two or more diagnoses. When compared with both the command and OSA groups, these were pregnant differences except for mild TBI, which trended toward significance. This finding is consistent with previous reports in which patients with comorbid insomnia and OSA had elevated rates of psychiatric diagnoses and illustrates the multifaceted nature of circuitous insomnia in military personnel. 49
Medication use, especially antidepressants and narcotics, was frequent in our cohort and highest in military personnel diagnosed with comorbid indisposition and OSA. Notably, while 63.7% of the participants received an insomnia diagnosis, only 5.five% were receiving an NBDRA. Possible explanations for this include that participants with insomnia were non previously diagnosed with this sleep disorder, that is, were referred solely for sleep disturbances, or that prior treatment with an NBDRA was not constructive, thus, resulting in a sleep referral. Similarly, while 35.5% of participants met diagnostic criteria for PTSD, only five.5% were receiving prazosin, a medication used in the handling of nightmares. Previous studies have shown that OSA is more prevalent in both veteran and nonveteran populations with PTSD and mental health disorders. 41,50‐52 This is consequent with our finding of a high prevalence of sleep-disordered breathing (62.7%) in our accomplice. Seal et al 53 recently reported veterans with PTSD were two.6 times more than probable to receive opioids and 5.v times more probable to receive allaying hypnotics than those without PTSD. In this study, prescription opioids were associated with adverse outcomes (eg, ED or inpatient admissions). While there are no studies, to our knowledge, that specifically addressed this, a sleep medicine evaluation early in the diagnoses of PTSD and pain could feasibly help mitigate medication-related complications. Treating insomnia and OSA with nonpharmacologic therapies such as cognitive behavioral therapy and CPAP may well subtract the demand for, and the complications of, sedatives and opioids; the latter have been known to exacerbate OSA or even provoke central sleep apnea.
The pathogenesis of sleep disorders, specifically the onset of symptoms, in participants in our study is unknown as there was no difference in number of deployments or time from deployment amidst the diagnostic groups. The nigh likely etiology in those that received a diagnosis of insomnia is that it developed, in role, due to stressors during their deployment, as their Combat Experiences Scale scores were the highest. 4,5 It is also more than likely that some proportion of participants in our written report who were diagnosed with OSA suffered from this condition prior to deployment. Hoge et al 13 suggests disturbed sleep in combat, which is the result of prolonged operations or lack of quality sleep due to insomnia, is a potential precursor non only to PTSD simply to postconcussive symptoms post-obit a TBI. There is evidence that disturbed sleep prior to a traumatic outcome poses an increased chance of PTSD. 54 The importance of this temporal relationship is farther illustrated by a study of armed forces personnel that reported high levels of sleep disturbances following deployment, which were subsequently linked to a greater take a chance for PTSD. 55 Every bit our study shows high rates of insomnia and sleep-matted animate in otherwise young, healthy military personnel, information technology is possible that prolonged sleep impecuniousness along with fragmentation and hyperarousal due to the concrete and psychologic stressors of combat contributed to the pathogenesis of not only insomnia but OSA every bit well. A potential machinery is the combined effects of sleep deprivation, which are known to exacerbate sleep-disordered breathing, 56,57 and increased arousals resulting in the evolution of OSA. Arousals are typically viewed equally protective for patients with OSA. In some patients with OSA, arousals tin can cause ventilatory instability by triggering ventilatory overshoot, resulting in an increased tendency for upper airway collapse. 58,59
At that place are several limitations to our report that should be addressed. Participation in our study was low, with only xi.three% of potentially eligible military personnel referred for screening. Information technology is possible that through this pick bias, only those with more pregnant slumber disturbances volunteered for our report. This could drag the percentage of those diagnosed with sleep disorders and service-related illnesses. Our control group was not truly normal, every bit control subjects had slumber complaints and nearly i-half had a service-related diagnosis. This may have minimized the differences between the diagnostic and control groups regarding service-related diagnoses. The cross-sectional nature of our written report did not allow united states of america to definitively plant the onset or etiology of the sleep disorders rendered. Military personnel are assessed for medical disorders prior to deployment and receive appropriate evaluations to ensure predeployment conditions are addressed. Thus, it is more than likely that their deployment experiences contributed in some part to the evolution or worsening of their sleep disorder. Half-dozen participants in our study underwent a split-nighttime PSG. This probable affected their AHI but would not have otherwise affected their sleep diagnosis. As we only evaluated military personnel, the results of our study likely practice not apply to all patients with slumber disturbances, but are potentially applicable to civilians who experience significant trauma, especially those who afterward develop PTSD or TBI. Although there are limits to our methods, this is the beginning report, to our knowledge, to comprehensively assess sleep disorders and service-related diagnoses in military personnel and can serve equally a reference for larger studies that are required given the scope of this problem.
The near universal characteristic of all service-related diagnoses is the complaint of "slumber disturbances," and our findings evidence information technology is not only sleep disturbances but specific "sleep disorders" in the majority of cases. Although our written report included only military personnel, sleep disturbances are present in near all patients with TBI and PTSD. Thus, our findings of a loftier prevalence of slumber-disordered animate and comorbid indisposition and OSA are likely applicable to physicians who care for noncombatant patients with like traumatic experiences. Of considerable clinical import, seeking care for disturbed sleep does non typically acquit the stigma of mental health disorders in military personnel. 60 Therefore, we believe slumber evaluations are an underused portal to address the complex disorders of armed forces personnel and veterans. With the extremely high reported rates of slumber disturbances, the mounting evidence that these are specific slumber disorders, and that improved sleep results in enhanced outcomes, the requirement for sleep research in war machine personnel is substantial.
Acknowledgments
Author contributions: Dr Mysliwiec had total access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the information assay.
Dr Mysliwiec: contributed to the data collection, project design, and the majority of the manuscript writing.
Dr Gill: contributed to the project pattern, statistical and information analysis, and writing of the manuscript.
Dr Lee: contributed to the statistical and information assay and editing of the manuscript.
Ms Baxter: contributed to the data collection, statistical and information assay, and editing of the manuscript.
Ms Pierce: contributed to the information collection, project design, and writing of the manuscript.
Dr Barr: contributed to the project design and editing of the manuscript.
Dr Cracow: contributed to the editing of the manuscript.
Dr Roth: contributed to the editing of the manuscript.
Fiscal/nonfinancial disclosures: The authors have reported to Breast the following conflicts of involvement: Dr Cracow conducts continuing medical pedagogy/standing education units educational programs for medical and mental wellness providers to learn about sleep disorders. Sometimes these programs involve the attendee paying a fee directly to the Slumber and Human Health Establish. Other times, Dr Krakow conducts the workshops at other locations, which may be paid for past vendors such as Respironics Inc and ResMed Corp, or other institutions such as the Usa Regular army Medical Department Center and School, Veterans Affairs Medical Centers, and regional sleep center conferences. He is also president of a nonprofit sleep inquiry center, the Slumber & Human being Wellness Institute, that occasionally provides consultation services or receives grants for airplane pilot studies, the most recent of which were from the Con Alma Wellness Foundation; Respironics, Inc; GlaxoSmithKline plc; Covidien, Inc; the Simon Charitable Foundation; and the Oxnard Foundation. Drs Mysliwiec, Gill, Lee, Barr, Roth, and Mss Baxter and Pierce accept reported that no potential conflicts of involvement be with whatever companies/organizations whose products or services may be discussed in this article.
Role of sponsors: The sponsors had no office in the pattern and acquit of the report; collection, management, analysis, and interpretation of the data; or grooming, review, or approval of the manuscript. The opinions and assertions in this manuscript are those of the authors and do not necessarily represent those of the Department of the Ground forces, Section of Defence force, United states Government, the National Institutes of Wellness, or the Center for Neuroscience and Regenerative Medicine.
Other contributions: This study was performed at the Madigan Regular army Medical Center.The authors give thanks the following for their contributions: Angela Mysliwiec, Physician, Madigan Army Medical Center, for editing aid and review of the manuscript, and Raywin Huang, PhD, Madigan Ground forces Medical Center, for statistical consultation. Neither of these individuals received bounty for their contributions.
Abbreviations
| AHI | apnea-hypopnea index |
| ESS | Epworth Sleepiness Scale |
| NBDRA | nonbenzodiazepine receptor agonist |
| OCO | Overseas Contingency Operations |
| OSA | obstructive slumber apnea |
| PSG | polysomnography |
| PTSD | posttraumatic stress disorder |
| TBI | traumatic encephalon injury |
Footnotes
Funding/Support: This report was supported, in part, by the Heart for Neuroscience and Regenerative Medicine [Grant 60855]. Funding support was provided past the intramural department of the National Institutes of Health, National Institute of Nursing Research (to Drs Gill and Lee).
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References
one. Seelig Ad, Jacobson IG, Smith B, et al. ; Millennium Cohort Written report Team. Sleep patterns earlier, during, and subsequently deployment to Iraq and Afghanistan. Sleep. 2010;33(12):1615-1622. [PMC free commodity] [PubMed] [Google Scholar]
ii. Armed Forces Health Surveillance Center. Insomnia, active component, The states Armed Forces, January 2000-December 2009. Medical Surveillance Monthly Report. 2010;17(5):12-15. [Google Scholar]
3. War machine Health Surveillance Center. Obstructive slumber apnea, active component, United states Armed forces, January 2000-December 2009. Medical Surveillance Monthly Study. 2010;17(5):8-eleven. [Google Scholar]
iv. Peterson AL, Goodie JL, Satterfield WA, Brim WL. Sleep disturbance during armed forces deployment. Mil Med. 2008;173(3):230-235. [PubMed] [Google Scholar]
5. Luxton DD, Greenburg D, Ryan J, Niven A, Wheeler One thousand, Mysliwiec V. Prevalence and impact of short sleep duration in redeployed OIF soldiers. Sleep. 2011;34(9):1189-1195. [PMC free article] [PubMed] [Google Scholar]
half dozen. Capaldi VF, II, Guerrero ML, Killgore WD. Sleep disruptions among returning combat veterans from Republic of iraq and Afghanistan. Mil Med. 2011;176(8):879-888. [PubMed] [Google Scholar]
7. Lettieri CJ, Eliasson AH, Andrada T, Khramtsov A, Raphaelson Grand, Kristo DA. Obstructive sleep apnea syndrome: are we missing an at-risk population? J Clin Sleep Med. 2005;ane(4):381-385. [PubMed] [Google Scholar]
eight. Collen J, Orr N, Lettieri CJ, Carter K, Holley AB. Sleep disturbances among soldiers with combat-related traumatic encephalon injury. Chest. 2012;142(three):622-630. [PubMed] [Google Scholar]
ix. Ferrer CF, Jr, Bisson RU, French J. Circadian rhythm desynchronosis in military deployments: a review of electric current strategies. Aviat Infinite Environ Med. 1995;66(6):571-578. [PubMed] [Google Scholar]
10. Miller NL, Shattuck LG, Matsangas P. Longitudinal study of slumber patterns of United States Military Academy cadets. Sleep. 2010;33(12):1623-1631. [PMC free commodity] [PubMed] [Google Scholar]
11. Centers for Affliction Control and Prevention. Bang-up American Smokeout. MMWR. 2012;61(44):889-908. [PubMed] [Google Scholar]
12. Joint Mental Health Advisory Team 7 (J-MHAT vii). Operation Enduring Freedom 2010. Office of the Surgeon General U.s.a. Army Medical Command, Office of the Command Surgeon HQ, USCENTCOM and Office of the Command Surgeon US Forces Transitional islamic state of afghanistan USFOR-A. Joint Mental Wellness Advisory Squad 7 (J-MHAT seven) Operation Enduring Freedom 2010 Afghanistan. Army Medicine website. http://www.armymedicine.ground forces.mil/reports/mhat/mhat_vii/J_MHAT_7.pdf. Accessed November v, 2012.
13. Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, Castro CA. Mild traumatic brain injury in Us soldiers returning from Iraq. North Engl J Med. 2008;358(5):453-463. [PubMed] [Google Scholar]
14. Lew HL, Pogoda TK, Hsu PT, et al. Bear on of the "polytrauma clinical triad" on sleep disturbance in a section of veterans diplomacy outpatient rehabilitation setting. Am J Phys Med Rehabil. 2010;89(half dozen):437-445. [PubMed] [Google Scholar]
fifteen. Mysliwiec 5, McGraw L, Pierce R, Smith P, Trapp B, Roth BJ. Sleep disorders and associated medical comorbidities in agile duty military personnel. Sleep. 2013;36(2):167-174. [PMC free article] [PubMed] [Google Scholar]
16. Cracow B, Melendrez D, Pedersen B, et al. Complex insomnia: insomnia and slumber-disordered breathing in a consecutive series of offense victims with nightmares and PTSD. Biol Psychiatry. 2001;49(11):948-953. [PubMed] [Google Scholar]
17. Al-Jawder SE, Bahammam As. Comorbid insomnia in sleep-related breathing disorders: an under-recognized clan. Sleep Breath. 2012;16(two):295-304. [PubMed] [Google Scholar]
18. Seal KH, Bertenthal D, Miner CR, Sen S, Marmar C. Bringing the war back home: mental health disorders amidst 103,788 U.s. veterans returning from Iraq and Transitional islamic state of afghanistan seen at Department of Veterans Affairs facilities. Arch Intern Med. 2007;167(5):476-482. [PubMed] [Google Scholar]
19. Hoge CW, Castro CA, Messer SC, McGurk D, Cotting DI, Koffman RL. Gainsay duty in Iraq and Transitional islamic state of afghanistan, mental health bug, and barriers to intendance. N Engl J Med. 2004;351(1):13-22. [PubMed] [Google Scholar]
20. Iber C, Ancoli-Israel South, Chesson AL, Jr, Quan SF. The AASM Transmission for the Scoring of Slumber and Associated Events. Westchester, IL: American Academy of Slumber Medicine; 2007. [Google Scholar]
21. American University of Sleep Medicine. International Nomenclature of Sleep Disorders: Diagnostic and Coding Manual.Second edition Westchester, IL: American Academy of Sleep Medicine; 2005. [Google Scholar]
22. Edinger JD, Bonnet MH, Bootzin RR, et al. ; American University of Sleep Medicine Work Grouping. Derivation of research diagnostic criteria for insomnia: report of an American University of Sleep Medicine Work Grouping. Sleep. 2004;27(eight):1567-1596. [PubMed] [Google Scholar]
23. Vogt DS, Proctor SP, Rex DW, King LA, Vasterling JJ. Validation of scales from the Deployment Take a chance and Resilience Inventory in a sample of Functioning Iraqi Liberty veterans. Assessment. 2008;15(4):391-403. [PubMed] [Google Scholar]
24. Terrio H, Brenner LA, Ivins BJ, et al. Traumatic encephalon injury screening: preliminary findings in a Us Army Brigade Combat Team. J Head Trauma Rehabil. 2009;24(1):xiv-23. [PubMed] [Google Scholar]
25. American Congress of Rehabilitation Medicine. Definition of mild traumatic encephalon injury. American Congress of Rehabilitation Medicine website. http://www.acrm.org/pdf/TBIDef_English_Oct2010.pdf. Accessed September 20, 2012.
26. Wilkins KC, Lang AJ, Norman SB. Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depress Anxiety. 2011;28(7):596-606. [PMC free article] [PubMed] [Google Scholar]
27. Trivedi MH, Rush AJ, Ibrahim HM, et al. The Inventory of Depressive Symptomatology, Clinician Rating (IDS-C) and Self-Report (IDS-SR), and the Quick Inventory of Depressive Symptomatology, Clinician Rating (QIDS-C) and Self-Written report (QIDS-SR) in public sector patients with mood disorders: a psychometric evaluation. Psychol Med. 2004;34(one):73-82. [PubMed] [Google Scholar]
28. McHorney CA, Ware JE, Jr, Lu JF, Sherbourne CD. The MOS 36-detail Short-Course Wellness Survey (SF-36): Iii. Tests of data quality, scaling assumptions, and reliability beyond diverse patient groups. Med Intendance. 1994;32(1):forty-66. [PubMed] [Google Scholar]
29. Sinnott C, Rogers MA, Lehmann D, Weinstock RS. Bodily pain, poor physical operation, and poor glycemic control in adults with diabetes. Diabetes Care. 2005;28(half-dozen):1534. [PubMed] [Google Scholar]
30. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545. [PubMed] [Google Scholar]
31. Cracow B, Melendrez D, Warner TD, Dorin R, Harper R, Hollifield M. To breathe, perchance to sleep: slumber-disordered breathing and chronic insomnia amidst trauma survivors. Sleep Breath. 2002;6(4):189-202. [PubMed] [Google Scholar]
32. Peppard PE, Reichmuth KJ. Sound sleep, a crucial component of military medicine'due south armamentarium? Slumber. 2013;36(ane):7-8. [PMC gratuitous commodity] [PubMed] [Google Scholar]
33. Collen JF, Lettieri CJ, Hoffman M. The bear on of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea. J Clin Sleep Med. 2012;viii(half dozen):667-672. [PMC free article] [PubMed] [Google Scholar]
34. Krakow B, Melendrez D, Johnston L, et al. Sleep-disordered breathing, psychiatric distress, and quality of life impairment in sexual assault survivors. J Nerv Ment Dis. 2002;190(7):442-452. [PubMed] [Google Scholar]
35. Krakow BJ, Melendrez DC, Johnston LG, et al. Sleep dynamic therapy for Cerro Grande Fire evacuees with posttraumatic stress symptoms: a preliminary study. J Clin Psychiatry. 2002;63(8):673-684. [PubMed] [Google Scholar]
36. Luyster FS, Buysse DJ, Strollo PJ., Jr Comorbid insomnia and obstructive sleep apnea: challenges for clinical practice and enquiry. J Clin Sleep Med. 2010;6(2):196-204. [PMC gratis commodity] [PubMed] [Google Scholar]
37. Chung KF. Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea. Respiration. 2005;72(five):460-465. [PubMed] [Google Scholar]
38. Guilleminault C, Davis Thousand, Huynh NT. Prospective randomized study of patients with insomnia and balmy slumber disordered animate. Sleep. 2008;31(11):1527-1533. [PMC free article] [PubMed] [Google Scholar]
39. Smith S, Sullivan K, Hopkins W, Douglas J. Frequency of insomnia report in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS). Sleep Med. 2004;five(5):449-456. [PubMed] [Google Scholar]
40. Yang CM, Liao YS, Lin CM, Chou SL, Wang EN. Psychological and behavioral factors in patients with comorbid obstructive sleep apnea and indisposition. J Psychosom Res. 2011;lxx(iv):355-361. [PubMed] [Google Scholar]
41. Krakow B, Melendrez D, Ferreira E, et al. Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest. 2001;120(half dozen):1923-1929. [PubMed] [Google Scholar]
42. Wickwire EM, Collop NA. Indisposition and sleep-related breathing disorders. Chest. 2010;137(vi):1449-1463. [PubMed] [Google Scholar]
43. Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;four(5):487-504. [PMC free article] [PubMed] [Google Scholar]
44. Krakow B, Lowry C, Germain A, et al. A retrospective written report on improvements in nightmares and post-traumatic stress disorder following treatment for co-morbid sleep-disordered breathing. J Psychosom Res. 2000;49(5):291-298. [PubMed] [Google Scholar]
45. Vanderploeg RD, Belanger HG, Horner RD, et al. Health outcomes associated with war machine deployment: mild traumatic encephalon injury, boom, trauma, and combat associations in the Florida National Guard. Arch Phys Med Rehabil. 2012;93(eleven):1887-1895. [PubMed] [Google Scholar]
46. Frayne SM, Chiu VY, Iqbal Southward, et al. Medical care needs of returning veterans with PTSD: their other burden. J Gen Intern Med. 2011;26(i):33-39. [PMC free article] [PubMed] [Google Scholar]
47. Hoge CW, Auchterlonie JL, Milliken CS. Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. JAMA. 2006;295(9):1023-1032. [PubMed] [Google Scholar]
48. Brenner LA, Ivins BJ, Schwab Thou, et al. Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from Republic of iraq. J Head Trauma Rehabil. 2010;25(5):307-312. [PubMed] [Google Scholar]
49. Krell SB, Kapur VK. Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath. 2005;9(3):104-110. [PubMed] [Google Scholar]
50. Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M. Association of psychiatric disorders and sleep apnea in a large cohort. Slumber. 2005;28(xi):1405-1411. [PubMed] [Google Scholar]
51. Krakow B, Haynes PL, Warner TD, et al. Nightmares, insomnia, and sleep-disordered breathing in fire evacuees seeking treatment for posttraumatic slumber disturbance. J Trauma Stress. 2004;17(3):257-268. [PubMed] [Google Scholar]
52. Spoormaker VI, Montgomery P. Disturbed sleep in post-traumatic stress disorder: secondary symptom or core feature? Sleep Med Rev. 2008;12(3):169-184. [PubMed] [Google Scholar]
53. Seal KH, Shi Y, Cohen G, et al. Clan of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA. 2012;307(9):940-947. [PubMed] [Google Scholar]
54. Bryant RA, Creamer M, O'Donnell M, Silove D, McFarlane AC. Sleep disturbance immediately prior to trauma predicts subsequent psychiatric disorder. Sleep. 2010;33(ane):69-74. [PMC free article] [PubMed] [Google Scholar]
55. McLay RN, Klam WP, Volkert SL. Insomnia is the near commonly reported symptom and predicts other symptoms of post-traumatic stress disorder in U.S. service members returning from armed forces deployments. Mil Med. 2010;175(10):759-762. [PubMed] [Google Scholar]
56. Persson HE, Svanborg E. Sleep impecuniousness worsens obstructive sleep apnea. Comparison between diurnal and nocturnal polysomnography. Breast. 1996;109(3):645-650. [PubMed] [Google Scholar]
57. Stoohs RA, Dement WC. Snoring and slumber-related breathing abnormality during partial sleep deprivation. N Engl J Med. 1993;328(17):1279. [PubMed] [Google Scholar]
58. Ryan CM, Bradley TD. Pathogenesis of obstructive slumber apnea. J Appl Physiol. 2005;99(6):2440-2450. [PubMed] [Google Scholar]
59. Younes One thousand. Function of arousals in the pathogenesis of obstructive sleep apnea. Am J Respir Crit Intendance Med. 2004;169(5):623-633. [PubMed] [Google Scholar]
lx. Greene-Shortridge TM, Britt TW, Castro CA. The stigma of mental wellness bug in the military. Mil Med. 2007;172(2):157-161. [PubMed] [Google Scholar]
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