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MILITARY MEDICINE, 173, 3:230, 2008
Sleep Disturbance during Military Deployment
Alan L. Peterson, PhD*†; Maj Jeffrey L. Goodie, USAF BSC‡; William A. Satterfield, PhD§;
William L. Brim, PsyD¶
ABSTRACT This preliminary investigation evaluated symptoms of sleep disturbance and insomnia in a group of 156
deployed military personnel. A 21-item Military Deployment Survey of Sleep was administered to provide self-reported
estimates of a variety of sleep parameters. The results indicated that 74% of participants rated their quality of sleep as
significantly worse in the deployed environment, 40% had a sleep efficiency of ⬍85%, and 42% had a sleep onset
latency of ⬎30 minutes. Night-shift workers had significantly worse sleep efficiency and more problems getting to sleep
and staying asleep as compared to day-shift workers. The results of the study indicate the need for programs to help
deployed military members get more and better sleep.
IMPACT OF MILITARY DEPLOYMENT ON SLEEP
Sleep disturbances are one of the most common clinical
symptoms reported by patients seen in medical settings.
1
It
has been estimated that 30– 40% of adults report some level
of insomnia within any given year, and as many as 10% have
chronic to severe problems with sleep.
2– 4
Individuals with
insomnia tend to report more health concerns, less physical
activity, less vitality, and more emotional problems.
5
Chronic
insomnia can lead to increased health care utilization
6,7
and
decreased health-related quality of life.
5,8 –10
The high prevalence of insomnia and its impact on health
care utilization have a significant economic consequence. The
direct cost of insomnia in 1995 in the United States was
estimated to be $13.93 billion.
11
These costs included $1.97
billion to treat insomnia, less than half of which was for
prescription medication. Other costs included $11.96 billion
for health care services for insomnia.
The etiology of insomnia is multifactorial.
12
The factors
related to the initial onset of insomnia are often different from
the factors that perpetuate or maintain the sleep problems.
13,14
Some of the precipitating and perpetuating factors of insom-
nia include stress,
15,16
shift work,
17
anxiety,
18
environmental
stimuli,
19
increasing age,
20
caffeine consumption,
21–23
smok-
ing,
24
and a number of medical conditions.
25
In the simplest terms, insomnia is a disorder of initiating
and maintaining sleep. Insomnia can include difficulties fall-
ing asleep, frequent awakenings during the night, or early
morning awakenings. Several formal diagnostic systems have
been developed for the diagnosis of insomnia including the
International Classification of Sleep Disorders,
26
the Diagnos-
tic and Statistical Manual of Mental Disorders,
27
and the
ICD-10 Classification of Mental and Behavioral Disorders.
28
Objective measures of sleep parameters that are often used
for the classification of insomnia in research studies include
the following: (1) sleep onset latency of ⬎30 minutes, (2)
wakenings after sleep onset (WASO) of ⬎30 minutes, and (3)
sleep efficiency of ⬍85%, which is calculated by dividing the
total sleep time (TST) by the total time in bed (e.g., 8 hours
TST/10 hours time in bed ⫽ sleep efficiency of 80%). In
terms of TST, some research indicates that ⬍4.5 hours of
sleep may lead to daytime performance decrements and an
increase in the possibility of accidents.
29,30
The active duty U.S. military population is a group that
is specifically at risk for sleep problems.
31–35
Stress, shift
work, frequent moves, and military deployments are all
factors that may contribute to insomnia and sleep distur-
bance in military personnel. This is the first study to
evaluate factors related to sleep and insomnia in A group of
deployed military personnel.
This study is a preliminary investigation of self-reported
symptoms of sleep disturbance and insomnia in a group of
military personnel deployed to an undisclosed location in
Southwest Asia in support of Operation Enduring Freedom.
The location was a “tent city” or a series of tent, extendable
modular personnel tents and other temporary facilities con-
structed as a self-sustaining camp, including tents for sleep-
ing and working. The location started as a bare-base location,
meaning there were very few permanent facilities available
when the first deployed personnel arrived in the area of
responsibility. Therefore, a considerable amount of construc-
tion occurred on an almost continuous basis that included a
*Department of Psychiatry, Mail Code 7792, University of Texas Health
Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX
78229-3900.
†Department of Psychology, Wilford Hall Medical Center, 59 MHS/
SGOJC, 2200 Bergquist Drive, Suite 1, Lackland AFB, TX 78236-5300.
‡Department of Family Medicine, Uniformed Services University of
Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814-4779.
§David Grant Medical Center, 101 Bodin Circle, Travis AFB, CA 94535.
¶Malcolm Grow USAF Medical Center, 79 MDOS/SGOH, 1050 West
Perimeter Road, Andrews AFB, MD 20762-6601.
The views expressed in this article are those of the authors and are not the
official policy of the Department of Defense or the U.S. Air Force.
A copy of the Military Deployment Survey of Sleep can be obtained from
Alan L. Peterson, PhD, Department of Psychiatry-MSC 7792, University of
Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San
Antonio, TX 78229-3900; E-mail: petersona3@uthscsa.edu.
This manuscript was received for review in June 2007. The revised
manuscript was accepted for publication in November 2007.
230 MILITARY MEDICINE, Vol. 173, March 2008
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significant amount of noise from large construction vehicles
as well as civil engineers involved in a variety of construction
projects (hammering, using electric saws, digging trenches,
etc.). Additionally, because daytime temperatures were often
over 120°F, much of the construction projects as well as other
outside work occurred during nighttime hours.
The tent, extendable modular personnel tents used for
sleeping quarters included ⬃12 occupants per tent. The tents
included several electrical outlets and an environmental con-
trol unit to provide air conditioning inside the tents. There
was no indoor plumbing in the tents and most individuals had
to walk at least 5 minutes to reach the nearest toilet or shower
facilities. Although an attempt was made to segregate day-
and night-shift workers into separate sleeping tents, many
tents included individuals working both day and night shifts.
Each individual had about a 10 foot ⫻ 6 foot living space
inside the tent, including an aluminum and canvas cot for
sleeping. Activities that occurred in the tent, such as reading,
writing letters, and socializing, often occurred while the par-
ticipants sat on their cot. Complaints of sleep disturbance and
insomnia were widespread, and a request to assess the sleep
status of military personnel was requested by an Air Force
commander after a major aircraft accident almost occurred
because of a sleep-deprived pilot.
METHODS
Participants
Participants included 156 active duty U.S. Air Force mem-
bers who were deployed to a remote Southwest Asia location
in support of Operation Enduring Freedom. The participants
were volunteers of a population of ⬃1,200 deployed military
personnel living in a tent city. The demographic information
for the participants is included in Table I. The participants
included 130 (83%) males and 26 (17%) females, with a
mean age of 29.2 years. Approximately 60% of the partici-
pants were married. The participants included both officers
(16%) and enlisted (84%) personnel in a full range of military
grades, with the majority of participants (62%) in the middle-
enlisted (E4–E6) grades. Of the 39 individuals assigned to
work the night shift, the majority (97.4%) of individuals were
in the E1–E6 enlisted grades.
Measures
The Military Deployment Survey of Sleep is a 21-item self-
report instrument specifically developed for use in this study.
Most items were empirically derived from questions used in
previous sleep studies.
36–42
Previously published measures
were not practical or appropriate for administration in a
deployed military setting and were not sufficient to meet the
goals of the present study because they did not include items
to assess factors unique to the deployed military setting. The
Military Deployment Survey of Sleep provided self-reported
estimates of standard sleep variables ordinarily used in sleep
research including TST, sleep efficiency, sleep onset latency,
frequency of WASO, duration of WASO, early morning
awakenings, and the frequency and duration of naps.
Self-reported quality of sleep before the deployment was
measured by the use of a Likert scale in which participants
were asked, “On a scale from 1 (very poor sleep) to 10
(excellent sleep), how well did you sleep on the average night
at home before your deployment?” Similarly, self-reported
sleep quality during the deployment was measured by asking
the participants, “On a scale from 1 (very poor sleep) to 10
(excellent sleep), how well have you been sleeping over the
past week?”
The Military Deployment Survey of Sleep also included
descriptive items specifically developed to measure factors
related to sleep disruption in military personnel sleeping in a
tent city at a deployed location. A Likert scale from 1 (no
interference) to 5 (extreme interference) was used and par-
TABLE II. Summary of Sleep Variables (N ⫽ 156)
Variable (time in minutes) Mean SD
TST (minutes) 399.95 116.38
Sleep efficiency 83.28% 15.24%
Sleep onset latency (minutes) 32.15 35.20
Frequency of WASO 1.94 1.67
Duration of WASO 19.54 27.25
Early morning awakenings (minutes) 25.87 52.68
Frequency of naps 0.24 0.56
Duration of naps (minutes) 14.95 39.40
TABLE III. Percentage of Participants with Sleep Disturbance
(N ⫽ 156)
Variable Percent
TST ⬍4.5 hours 13.5
Sleep efficiency ⬍85% 40.0
Sleep onset latency ⬎30 minutes 41.7
WASO ⬎30 minutes 26.3
Early morning awakening ⬎30 minutes 24.4
TABLE I. Participant Demographics
Characteristic
Total
(N ⫽ 156)
Work Shift
Day
(n ⫽ 117)
Night
(n ⫽ 39)
Age (years (mean (SD)) 29.2 (7.7) 30.7 (7.9) 25.0 (4.7)
Gender (%)
Male 83.3 73.9 80.1
Female 16.7 26.1 19.9
Marital status (%)
Married 57.0 60.7 46.2
Single, never married 34.0 29.9 46.2
Divorced 9.0 9.4 7.6
Military rank (%)
E1–E3 14.1 10.3 25.6
E4–E6 62.2 59.0 71.8
E7–E9 7.7 10.3 0.0
O1–O3 10.3 12.8 2.6
O4–O6 5.8 7.6 0.0
231MILITARY MEDICINE, Vol. 173, March 2008
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ticipants were asked, “How much have the following factors
interfered with your sleep over the past week?” Items mea-
sured included: (1) sleep disruption related to jet lag, (2)
rotating shifts, (3) loud noises inside the tent, (4) loud noises
outside the tent, (5) having an uncomfortable bed, (6) aches,
pains, or physical problems, (7) the temperature being too hot
or too cold, (8) worry over current safety, and (9) worry over
family back home.
Procedures
The surveys were completed in a large warehouse-type build-
ing that was temporarily being used as a recreation center. It
was the primary location where the deployed military per-
sonnel gathered during off-duty time. The building included
several televisions, basic exercise equipment, reading mate-
rials, and an odd assortment of chairs, tables, and couches. It
was also the only location to access the Internet for personal
e-mail. Because of the limited number of computers that were
available, individuals had to queue-up and wait for ⬃30 to 90
minutes for access to the Internet. The surveys were placed
on a table near the area where individuals sat in the queue
waiting to use a computer. A sign advertising the study and
providing basic instructions for the completion of the survey
was placed next to the surveys. The sign indicated that the
study was voluntary and did not include any personnel-
identifying information. Clipboards and pens were provided
to the volunteer participants who chose to complete the
surveys. A sealed drop box was located next to the surveys
for participants to drop their surveys after completion. The
Military Deployment Survey of Sleep took an average of ⬃5
minutes to complete.
All participants were volunteers and the Military Deploy-
ment Survey of Sleep was completed anonymously without
any personal identifying information. There were no items on
the survey that were believed to cause any harm or distress to
participants during the completion of the survey. The study
was approved as an exempt research protocol by the director
of the Institutional Review Board at Eglin Air Force Base. All
research procedures in this study were consistent with the
principles of research ethics published by the American Psy-
chological Association.
43
Surveys were completed an average
of 32.9 days after arrival at the deployed location.
RESULTS
A summary of the overall sleep variables for the entire group
of participants is included in Table II. The results indicated
that the average TST was ⬃6.5 hours. The mean sleep effi-
ciency was 83%, which is slightly lower than the 85% thresh-
old that is ordinarily used for the classification of insomnia.
Similarly, the mean sleep onset latency for the group was 32
minutes, which is slightly greater than the 30-minute thresh-
old for insomnia.
Descriptive statistics of the percentage of participants with
sleep disturbances are included in Table III. Approximately
40% of all participants had a sleep efficiency of ⬍85% or a
sleep onset latency of ⬎30 minutes. Approximately 25% of
participants had a WASO or early morning awakening of
⬎30 minutes. Almost 15% of participants had a TST of ⬍4.5
hours.
The results were analyzed (see Table IV) to compare the
sleep variables for those participants who were working
the day shift (n ⫽ 117) as compared to those working on the
night shift (n ⫽ 39). Individuals working on the night shift
were significantly more likely to have a lower sleep efficiency
(F
(1,154)
⫽ 7.213, p ⫽ 0.008) and greater sleep onset latency
(F
(1,154)
⫽ 6.644, p ⫽ 0.011). Similarly, night shift workers
had a greater frequency of WASO (F
(1,154)
⫽ 8.872, p ⫽
0.003) and the episodes of WASO were of a greater duration
(F
(1,154)
⫽ 5.304, p ⫽ 0.023).
TABLE IV. Comparison of Sleep Variables between Workers on Day versus Night Shift
Variable (time in minutes)
Day Shift Night Shift
F
(1,154)
p
a
Mean SD Mean SD
TST 405.02 108.59 384.74 137.61 0.887 0.348
Sleep efficiency 85.14 14.16 77.72 17.11 7.213 0.008**
Sleep onset latency 28.03 27.93 44.51 49.63 6.644 0.011*
Frequency of WASO 1.72 1.29 2.62 2.39 8.872 0.003**
Duration of WASO 16.68 22.47 28.13 37.21 5.304 0.023*
Early morning awakenings 23.00 44.49 34.49 71.95 1.394 0.239
Frequency of naps 0.25 0.56 0.21 0.57 0.171 0.680
Duration of naps 16.38 41.51 10.64 32.33 0.620 0.432
a
Values of p: ⴱⴱ, p ⬍ 0.01; ⴱ, p ⬍ 0.05.
TABLE V. Factors Interfering with Sleep (N ⫽ 156)
Variable Mean SD
Jet lag 1.31 0.83
Rotating shift 1.79 1.28
Loud noise inside tent 2.03 1.22
Loud noise outside tent 2.99 1.45
Uncomfortable bed 2.38 1.24
Aches, pains, and physical problems 1.77 1.05
Too hot or too cold 2.03 1.10
Worry over current safety 1.31 0.70
Worry over family back home 2.18 1.33
232 MILITARY MEDICINE, Vol. 173, March 2008
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The results were also analyzed to compare the self-re-
ported ratings of quality of sleep before the deployment as
compared to in the deployed setting. A binomial test com-
paring the frequency of those reporting lower sleep quality to
the frequency of those reporting the same or higher sleep
quality revealed that a significant proportion of participants
(74.4%; p ⬍ 0.001) rated their subjective sleep quality as
significantly worse in the deployed setting. Similarly, a
paired-sample t test revealed that the mean sleep quality was
significantly lower (t ⫽ 10.89; p ⬍ 0.001) in the deployed
setting (M ⫽ 5.5; SD ⫽ 2) compared to the week before
deployment (M ⫽ 7.9; SD ⫽ 1.9).
The participants’ ratings of factors interfering with their
sleep are included in Table V. The top three factors rated to
have had the greatest interference in sleep included: (1) loud
noises outside the tent, (2) having an uncomfortable bed, and
(3) worry about family back at home. The factors interfering
with sleep were compared for day- versus night-shift workers
(see Table VI). Individuals working the night shift reported
having greater sleep interference from loud noises outside of
their tent (F
(1,154)
⫽ 14.341, p ⬍ 0.001) as well as loud noises
inside their tent (F
(1,154)
⫽ 5.874, p ⫽ 0.017). Additionally,
night-shift workers reported more sleep interference from
rotating shifts as compared to the day-shift workers (F
(1,154)
⫽
7.227, p ⫽ 0.008).
DISCUSSION
The results of this study indicated that military members
reported significant disruptions in sleep as a result of working
in a deployed environment. Overall, ⬃75% of participants
rated their quality of sleep in the deployed environment as
significantly worse than their sleep at home before the de-
ployment. Sleep efficiency and sleep onset latency were the
two sleep variables most consistently in the range generally
indicative of insomnia. Night-shift workers had worse sleep
efficiency and more problems with getting to sleep and staying
asleep as compared to day-shift workers. Similarly, night-shift
workers reported more difficulties with noises both inside and
outside of their tents that interfered with their sleep. Most
individuals (86.5%) reported that they were getting at least 4
1/2 hours of sleep per night, which is considered the mini-
mum amount required for sustained performance in a de-
ployed military environment.
There are several limitations with this preliminary study.
First, this study is based on the results of only 156 deployed
U.S. Air Force personnel and may not be an accurate repre-
sentation of the entire population of military personnel in the
deployed location. It would also have been preferable to
obtain a 1-week sleep diary from all participants to obtain
more objective sleep data that is considered the established
standard for sleep research. Although obtaining this data was
not practical for this preliminary investigation, future re-
search should attempt to collect data using a sleep diary, if
possible. Another limitation is that the study was completed
at just one deployed location. As operational environments
and demands can vary widely over time and are unique to the
mission being performed, it would be valuable to collect
similar data from a variety of other deployed locations and
include military personnel from the Army, Navy, and Ma-
rines. Finally, it would have been helpful to readminister the
Military Deployment Survey of Sleep later in the deployment
to determine whether sleep disturbance continued or if there
was a natural recovery process to resuming normal sleep
patterns.
The results of this preliminary study indicate the need for
additional research on sleep in deployed military personnel.
The operational impact of insomnia and sleep disturbance on
deployed military personnel is not known. The results of this
study also suggest that programs may be needed to help
deployed military members get more and better sleep.
Previous military studies have evaluated the potential use-
fulness of medications to either induce sleep
44
or to stimulate
arousal and wakefulness before military operations.
45
For
insomnia, nonpharmacological behavioral treatments have
the best empirical evidence for their support and are the
treatment of choice for chronic insomnia.
46,47
Behavioral
treatments include a combination of stimulus control, sleep
hygiene, and sleep restriction.
46,48 –53
Behavioral treatment for insomnia has also been shown to
be effective for the treatment of military personnel.
54
How
TABLE VI. Comparison of Factors Interfering with Sleep between Workers on Day versus Night Shift
Variable (time in minutes)
Day Shift Night Shift
F
(1,154)
p
a
Mean SD Mean SD
Jet lag 1.33 0.82 1.26 0.85 0.253 0.616
Rotating shift 1.63 1.19 2.26 1.43 7.227 0.008**
Loud noise inside tent 1.90 1.16 2.44 1.33 5.874 0.017*
Loud noise outside tent 2.74 1.45 3.72 1.21 14.341 0.000***
Uncomfortable bed 2.41 1.27 2.28 1.15 0.311 0.578
Aches, pains, and physical problems 1.74 1.01 1.87 1.15 0.498 0.481
Too hot or too cold 1.97 1.07 2.21 1.20 1.385 0.241
Worry over current safety 1.30 0.67 1.33 0.77 0.070 0.792
Worry over family back home 2.22 1.35 2.18 1.33 0.480 0.489
a
Values of p: ⴱⴱⴱ, p ⬍ 0.001; ⴱⴱ, p ⬍ 0.01; ⴱ, p ⬍ 0.05.
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well behavioral treatment approaches will work in the de-
ployed environment is not known. Our anecdotal evidence
suggests that behavioral treatment for insomnia in the de-
ployed setting is a very promising approach that warrants
evaluation in a controlled treatment-outcome study. Applied
research is also needed to evaluate the potential for medicinal
or behavioral approaches to prevent the onset of insomnia and
other sleep disturbances if applied before or immediately
after arrival in the deployed setting.
ACKNOWLEDGMENTS
We thank Ms. Joyce Dudley for her assistance in the completion of this
manuscript.
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