Probable trauma associated sleep disorder in post-9/11 US Veterans

Abstract

Study objectives: The purpose of this study was to (1) estimate trauma associated sleep disorder (TASD) prevalence among post-9/11 era veterans and to describe differences in service and comorbid mental health clinical characteristics among individuals with and without probable TASD, and (2) estimate TASD prevalence and characteristics of reported traumatic experiences stratified by sex.

Methods: We used cross-sectional data from the post-deployment mental health study of post-9/11 veterans, which enrolled and collected baseline data from 2005 to 2018. We classified veterans as having probable TASD using self-reported measures: traumatic experiences from the traumatic life events questionnaire (TLEQ) and items from the Pittsburgh sleep quality index with Addendum for posttraumatic stress disorder (PTSD) mapped to TASD diagnostic criteria and ascertained mental health diagnoses (PTSD, major depressive disorder [MDD]) via Structured Clinical Interview for DSM-IV. We calculated effect sizes as prevalence ratios (PR) for categorical variables and Hedges' g for continuous variables.

Results: Our final sample included 3618 veterans (22.7% female). TASD prevalence was 12.1% (95% CI: 11.1% to 13.2%) and sex-stratified prevalence was similar for female and male veterans. Veterans with TASD had a much higher comorbid prevalence of PTSD (PR: 3.72, 95% CI: 3.41 to 4.06) and MDD (PR: 3.93, 95% CI: 3.48 to 4.43). Combat was the highest reported most distressing traumatic experience among veterans with TASD (62.6%). When stratifying by sex, female veterans with TASD had a wider variety of traumatic experiences.

Conclusions: Our results support the need for improved screening and evaluation for TASD in veterans, which is currently not performed in routine clinical practice.

Keywords: combat; military; nightmares; parasomnias; sleep–wake disorders; trauma; trauma associated sleep disorder; veterans.

Figure 1.

Study sample flow diagram.

Figure 2.

Combat exposure scale score distribution stratified by probable trauma associated sleep disorder status. Scores of 0-8 = light exposure; 9-16 = light to moderate exposure; 17-24 = moderate exposure; 25-32 = moderate to heavy exposure; 33-41 = heavy exposure. N missing = 7 (2 with probable trauma associated sleep disorder; 5 without).

Figure 3.

Cumulative count of traumatic experiences stratified by probable trauma associated sleep disorder status. Panel A: All veterans in the sample; Panel B: Female veterans; Panel C: Male veterans. Frequency for each traumatic experience type is counted on a scale of 0 (never) to 6 (more than 5 times). N missing = 61 (0 with TASD; 61 without).

Figure 4.

Number of unique traumatic experiences relative to military service period by probable trauma associated sleep disorder status. Panel Column A: All veterans in the sample; Panel Column B: Female veterans; Panel Column C: Male veterans. Panel row 1: Before military service; Panel row 2: During military service; Panel row 3: After military service. Instances, where the same repeated traumatic event type occurred more than once during the specified period, are not reflected. N missing = 61 (0 with TASD; 61 without).

Figure 5.

Years since traumatic experience distribution stratified by probable trauma associated sleep disorder status. Panel Column A: All veterans in the sample; Panel Column B: Female veterans; Panel Column C: Male veterans. Panel row 1: Years since last traumatic experience; Panel row 2: Years since most distressing traumatic experience. N missing = A-1. 63 (1 with trauma associated sleep disorder; 62 without); A-2. 87 (3 with trauma associated sleep disorder; 84 without).

Figure 6.

Frequency of current posttraumatic stress disorder diagnosis by probable trauma associated sleep disorder status. N missing = 7 (1 with probable trauma associated associated sleep disorder; 6 without). Panel A: All veterans regardless of which diagnostic criteria were used; Panel B: Limited to those diagnosed with DSM-IV criteria; Panel C: Limited to those diagnosed with DSM-5 criteria.

Figure 7.

Frequency of current major depressive disorder diagnosis by probable trauma associated sleep disorder status. N missing = 10 (2 with probable trauma associated sleep disorder; 8 without).

Figure 8.

Beck Depression Inventory-II score distribution stratified by probable trauma associated sleep disorder status.

Figure 9.

Beck Scale for Suicide Ideation score distribution stratified by probable trauma associated sleep disorder status. N missing = 5 (2 with probable trauma associated sleep disorder; 3 without).