The number of Soldiers experiencing insomnia, obstructive sleep apnea and other sleep disorders has increased significantly in recent years. Department of Defense statistics show a 10-fold increase in Soldiers experiencing insomnia over the past decade. Poor sleep during deployment caused by combat stress and less-than-ideal sleeping conditions can carry over even when a Soldier returns stateside. Since chronic sleep problems have been shown to impact driving abilities and cognitive processes, exacerbate existing conditions like post traumatic stress disorder (PTSD), and increase the risk of other health problems, Sleep Medicine has become an important and growing research focus for the U.S. Army.
Lt. Col. Vincent Mysliwiec (my-slee-vich), M.D., is at the forefront of Army sleep research. As chief of Pulmonary, Critical Care Medicine and Sleep Medicine Service at Madigan Healthcare System in Tacoma, Wash., he has dedicated his medical career to learning more about risk factors and treatments for sleep disorders in Soldiers.
An Early Interest in Service through Medicine
Mysliwiec first envisioned himself as an Army officer when he was a young boy, inspired by patriotism during the pageantry of a Fourth of July parade. Years later, as a cadet at West Point, he decided that he wanted to practice medicine so he could help people while fulfilling his patriotic duty. He was accepted to medical school at the Uniformed Services University of the Health Sciences in Bethesda, Md., and went on to do his residency in internal medicine at Tripler Army Medical Center in Honolulu.
"During residency I really gravitated toward pulmonary medicine because of the variety," said Mysliwiec. "Pulmonologists get to dabble in everything from the heart and lungs to critical care, and, more recently, sleep medicine and behavioral health."
During his Pulmonary, Critical Care and Sleep Medicine Fellowship at Brooke Army Medical Center in San Antonio from 1999 to 2002, Mysliwiec discovered opportunities to dive into this relatively new and under-recognized field of medicine. As Operation Iraqi Freedom began, he and his colleagues discovered Soldiers were being affected by sleeping disorders such as insomnia, coupled with symptoms of associated conditions like PTSD. They began to examine how the war affected Soldiers' sleep habits and behaviors.
"Lack of sleep is a societal problem, but for Soldiers it's even more urgent," explained Mysliwiec. "When Soldiers don't get enough sleep and are performing hazardous duties, there is a greater chance for life-threatening error. Sleep deprivation over time is also associated with major health problems such as chronic pain, cardiovascular disease, obesity and depression. Sleepiness is also the second leading cause of traffic accidents -- akin to being legally intoxicated."
And it seems today the need for sleep research and treatments has never been greater. According to a recent research study by Mysliwiec and his colleagues, more than seven of every 10 Soldiers suffer from short sleep duration (SSD), a chronic condition -- defined in the study as less than seven hours of sleep per night -- that increases Soldiers' risks for a variety of health problems.
The study, published in the September 2011 issue of SLEEP, the monthly, peer-reviewed journal of the Associated Professional Sleep Societies, is one of few published articles that examine sleep disturbances associated with war or traumatic events in service members. Mysliwiec and his co-authors assessed the sleep habits of 3,152 redeployed Soldiers to compare the prevalence of co-existing medical conditions with sleep duration. Seventy-seven percent of Soldiers in the study experienced combat exposure and slept less than six hours per night. Additionally, the study revealed that certain medical conditions and health risks were strongly associated with lack of adequate sleep, including PTSD (37 percent), depression, mild traumatic brain injury (TBI), obesity and panic syndrome.
"This research demonstrates the need for expanded screening for sleep disorders upon redeployment and additional education and clinical services for Soldiers who experience SSD after deployment," added Mysliwiec.
Army Physicians are Dedicated to Finding New Treatments
Lt. Col. Mysliwiec is one of the Army's 26 sleep medicine specialists who evaluate tens of thousands of patients each year. Madigan Healthcare System, located at Joint Base Lewis-McChord in Tacoma, Wash., conducts 1,000 sleep studies each year. The Walter Reed Army Sleep Disorder Center in Washington, D.C. is among the largest academic sleep labs in the country, and earlier this year doubled its capacity to 18 beds, conducting more than 6,500 sleep studies per year.
The Army's integrated health care system and large patient base allow researchers to follow groups of patients over time to assess the effectiveness of treatments and outcomes, which can benefit civilian medicine as well. For example, obstructive sleep apnea (OSA) is a very common sleep disorder that is associated with a variety of health problems in both the civilian and military population. Popular treatments for OSA, such as a continuous positive airway pressure (CPAP) machine, are not well tolerated by all patients, and may prove logistically difficult for Soldiers to use in some locations. To overcome these obstacles, Army sleep medicine physicians have found that maxilla-mandibular advancement surgery, to open the upper airway, can cure OSA in many patients. Mysliwiec presented an abstract on this subject at a sleep conference in June 2011, which showed that more than half of Soldiers had significantly reduced symptoms and 43 percent had no signs of OSA at all after undergoing the procedure.
But other sleep disorders like insomnia, often linked to conditions such as PTSD, are more complicated to assess and diagnose. Mysliwiec says sleep studies are a helpful first step. They begin with an extensive questionnaire about a Soldier's sleep and lifestyle habits. Next, the patient spends the night in a sleep lab, where he or she undergoes a polysomnogram test to assess the body's physiological changes and activity during sleep. Certain changes in movement, brainwaves, blood oxygenation, heart arrhythmias, and even muscle tone can signal a possible issue.
"Sleep studies are especially important for Soldiers because we need to know that it is safe for them to deploy," says Mysliwiec. "Additionally, by the time they come to us for a sleep study, many Soldiers are being treated for associated conditions like PTSD and TBI. By identifying and treating abnormal sleep patterns, we often find that the co-existing conditions are improved as well."
Soldiers can also be evaluated at home or in the field with Actigraphs, wrist watch devices that track sleep-wake patterns and movements to identify abnormalities.
One treatment for insomnia is sleep restriction therapy, which limits a patient to lying in bed for only the number of hours he or she will actually sleep. For example, a patient who is only sleeping an average of five hours each night should be in bed for approximately that amount of time, and not lie in bed for longer periods of time. As the patient's sleep efficiency increases, the time in bed is gradually increased allowing the patient to have longer sleep duration -- and sleep quality should improve as well.
"Whether short sleep duration precedes, or is caused by PTSD or TBI, it's imperative to treat both at the same time and diligently follow up with patients," emphasizes Mysliwiec. "These conditions aren't something you can cure with a pill, but rather the body and mind need to be conditioned over time. The Army's highly organized health care system and multi-disciplinary models allow us to keep track of patient progress and educate other providers to ensure the best outcomes possible."
Lt. Col. Mysliwiec is passionate about his work to help Soldiers overcome sleep disorders, and grateful for the opportunities he's been afforded as an Army physician. He plans to continue advancing his career in Army medicine at Madigan, where his wife is chief of Hematology/Oncology. "Not very many civilian physicians my age hold administrative leadership positions, actively conduct research and have a clinical practice all at once," he said. "Since I joined, I knew I would retire in the Army -- it was a done deal."
In the meantime, there is much work to do. While Army physicians are making tremendous strides in the area of sleep medicine, Mysliwiec emphasizes there's still more to learn. For example, Madigan is collaborating with the Center for Neuroscience and Regenerative Medicine (CNRM), looking at biomarkers for TBI, PTSD and sleep disorders. This may lead to a blood test that could more efficiently diagnose TBI and sleep disorders some day. More short-term, Madigan and Telehealth/Telemedicine researchers are also exploring the potential uses of a newly developed iPhone breathing application and how it can help Soldiers improve sleeping disorders with relaxed breathing exercises.
The Army's ongoing research in sleep medicine promises to help Soldiers overcome obstacles that prevent so many from getting enough sleep each night, and ease the burden of debilitating co-disorders that affect their daily lives. It may also hold the key for those physicians treating chronically stressed civilians who, juggling demanding work schedules and family obligations, would benefit from new tools for a healthier night's sleep.