Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study

Abstract

Study objectives: Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans.

Methods: A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning.

Results: A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively).

Conclusions: Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

Keywords: anxiety; insomnia; posttraumatic stress disorder; trauma; veterans.

Figure 1. Percentage of veterans with disorder by insomnia severity.

(A) Percentage of veterans with disorder over lifetime by insomnia severity (with 95% upper and lower CIs). Prevalence increased as a function of insomnia severity, such that clinical insomnia > subthreshold insomnia > no insomnia for all disorders (χ2 range = 96.8–591.0, all P < .001) except for DUD and ND, where clinical insomnia = subthreshold insomnia > no insomnia (χ2 = 47.4–151.4, P < .001). (B) Percentage of veterans with current disorder by insomnia severity. Prevalence increased as a function of insomnia severity, such that clinical insomnia > subthreshold insomnia > no insomnia for all disorders (χ2 range = 110.3–524.0, all P < .001) except for AUD, where clinical insomnia = subthreshold insomnia > no insomnia (χ2 = 112.2, P < .001). AUD = alcohol use disorder, DUD = drug use disorder, GAD = generalized anxiety disorder, MDD = major depressive disorder, ND = nicotine dependence, PTSD = posttraumatic stress disorder.