Soldiers stand as a performance of the National Anthem plays. Photo by Scott Ball.
San Antonio is home to one of the nation’s largest active-duty and retired military populations. Credit: Scott Ball / San Antonio Report

Twenty percent of active duty military report symptoms of insomnia prior to deployment. Insomnia is also the single most commonly reported symptom among service members returning from deployment.

San Antonio, now officially designated as Military City, USA, is home to one of the nation’s largest active and retired military populations and the Department of Defense’s largest medical center at Joint Base San Antonio Fort Sam Houston. Sixty-four percent of Texas’ total military population resides in Bexar County.

A recent study out of UT Health San Antonio found that cognitive behavioral therapy for insomnia is highly effective for active duty military members, proving beneficial for participants who engaged in treatment either in-person or online.

The research was funded by a $1.6 million grant from the Department of Defense and conducted by institutions affiliated with the STRONG STAR Consortium, including UT Health SA and the University of North Texas.

STRONG STAR is a federally funded network of national experts seeking the best ways to treat behavioral health problems impacting post-9/11 service members and veterans.

Chronic insomnia is defined by the Diagnostic and Statistical Manual of Mental Disorders as sleeping poorly at least three nights a week for one month or longer, despite adequate opportunity for a full night’s sleep. While everyone has some level of vulnerability, military members often develop insomnia due to rapidly changing schedules and occupational demands.

Although medications can be effective in the short-term treatment of insomnia, side effects can include grogginess, slow cognitive processing, and impaired reaction that could prove dangerous for deployed military personnel.

The study, the largest of its kind to date, surveyed 100 Fort Hood soldiers with chronic insomnia. All completed one week of sleep monitoring by keeping sleep diaries and wearing activity monitors to track sleep patterns.

One third of the participants met with clinicians for cognitive behavioral therapy for insomnia once a week for six weeks, while another third received the therapy online once a week for six weeks. The foundation of cognitive behavioral therapy is talking through difficulties in order to determine steps toward behavioral change.

Both the in-person and online therapy had the same content, with the online lessons presented as audio recordings accompanied by visual graphics and animations. A third control group of participants was contacted by the researchers every other week during the six weeks, but did not receive cognitive behavioral therapy.

Participants who received in-person cognitive behavioral treatment for their insomnia reported significantly greater improvements in sleep quality than those who received the online therapy. Both groups had greater improvements in sleep quality than those who did not receive any cognitive behavioral therapy.

Alan Peterson, a professor of psychiatry at UT Health SA and a director at STRONG STAR, told the Rivard Report that “an effective, non-medication therapy for insomnia is very much needed in the military.” The finding that an online version of the treatment can be effective is important because that option could be used to make the therapy more accessible.

Treatment for chronic insomnia includes helping those affected understand how their behaviors keep good or bad sleep patterns going.

While deployed, military personnel are often encouraged to take naps and “sleep when they can.” But these negative sleep behaviors continue after deployment, and when coupled with existing or added stressors or diagnoses, take a greater toll, researchers said.

Peterson explained that insomnia is often a secondary diagnosis with symptoms exacerbated by other conditions such as depression, anxiety, substance abuse, or PTSD –conditions that are prevalent throughout all branches of the military and often diagnosed in tandem with insomnia.

“You can treat PTSD, but the most common [symptom] people remain with is insomnia,” Peterson said. “If you can improve sleep, the brain is functioning as it should because a lot of important work happens in the brain when you sleep. If you treat both, the treatment of PTSD may be improved.”

How these diagnoses impact one another already is the subject of another research study at Fort Hood by STRONG STAR-affiliated investigators through the federally funded Consortium to Alleviate PTSD.

Kristi Pruiksma, an assistant professor of psychiatry at UT Health SA and a STRONG STAR collaborating investigator who served as a clinical psychologist for the study, said she noticed “the increased mastery people felt like they had over their sleep” as a result of learning and implementing behavioral changes.

Many factors can cause difficulty falling or staying asleep. Pruiksma rattled off a list of examples of things people do in bed that hamper sleep, such as checking emails, playing games on their phone, worrying, eating, reading, and drinking.

“What kind of relationship would you have if you were dating 10 different people?” Pruiksma asked. “The main thing we need to do is associate the bed with sleep and sex only” and take the necessary steps to do that, such as plugging your phone in away from your bed and not having a TV in the bedroom.

Kelly Perez is an Air Force retiree who deployed to Saudi Arabia and Kuwait during her time enlisted. She told the Rivard Report she has PTSD and insomnia brought on by her experience working in a military mortuary, where she handled the bodies of more 5,000 fallen soldiers.

Perez has participated in talk therapy, believes in its benefits, and feels that the military is working to make treatment for mental health less stigmatized.

“[In] some [positions], where you could lose security clearance, there is a stigma,” Perez said.

People who lose security clearance could lose their jobs or receive restrictions. “For the rest of the military, the stigma is declining and it’s more okay to seek help,” Perez said.

Perez practices a sleep routine that includes listening to a guided meditation on headphones, which she says is “the only way [she is] able to fall asleep.”

Pruiksma said that having a better understanding of sleep and the steps to improve it alleviated a lot of stress for participants, even if the duration of their sleep didn’t change over the course of the study.

“One of the big benefits [for people] was simply feeling more in control of their sleep.”

Roseanna Garza

Roseanna Garza reports on health and bioscience for the San Antonio Report.