Sleep Disorders in Military Women: Identifying Causal Factors and the Impact of Treatment on Psychological Health and Resilience

Feb 22, 2019

Military personnel are at heightened risk for sleep disorders. In fact, they suffer from insomnia at twice the rate of civilians. This is of concern for the military, because sleep problems can impair performance and resiliency, adversely affect individuals’ physical and psychological health, and decrease military operational readiness.

Also of concern is that military women may be uniquely affected by sleep disorders. For example, limited data from clinical reports shows that they have higher insomnia rates than military men. And although they have lower rates of sleep apnea, this diagnosis appears to occur in military women at younger ages and lower body weights than military men or civilian women.

Unfortunately, the unique factors contributing to sleep disorders in military women and impacting their response to treatment are inadequately understood because (1) previous military sleep studies have focused almost exclusively on men and (2) in civilian studies, females have generally been older than military women. Sleep studies including military women are sorely needed in order to improve sleep disorder prevention efforts and treatment outcomes.

Biological, gender and military factors

The first of its kind, this STRONG STAR-affiliated study with military men and women will collect data and analyze factors related to biology, gender roles, and military roles and experiences to help understand how they lead to and perpetuate specific sleep disorders and influence treatment response.

Led by Principal Investigator Major Matthew Brock, MD, of Wilford Hall Ambulatory Surgical Center at Joint Base San Antonio-Lackland, the prospective observational study will involve 480 active duty military personnel – 240 men and 240 women – who are evaluated and treated for insomnia, obstructive sleep apnea, or both at the San Antonio Military Health System Sleep Disorders Center.

Initially, patients will undergo diagnostic evaluations, complete a variety of study assessments, and provide blood samples for analyses. They then will receive standard-of-care, sleep-focused therapy for their sleep disorder(s). Patients will be reassessed after treatment completion and at six weeks and 12 weeks following treatment, and they will provide new blood samples at the 12-week follow-up. Blood samples will be analyzed for sex hormones and for quantities of certain biomarkers – specific, measurable substances that are related to inflammation and neuronal health.

Advancing care for military women

By examining patient diagnostics, assessments and bloodwork before and after standard-of-care treatment, investigators seek to do three things: (1) determine how biology, gender roles, and military service-related factors cause and perpetuate sleep disorders and impact health; (2) assess how sleep therapy changes mental and physical health, resilience, and biological indicators, including inflammation markers and neurological proteins that may differ between the sexes; and (3) explore whether physical characteristics and psychological disorders differ for military men and women with obstructive sleep apnea.

Study findings are expected to yield unprecedented insight specific to military women, including the identification of particular stressors that lead or contribute to their sleep disorders, how sleep disorders affect their psychological health and resilience, and factors that influence their treatment outcomes.

This, in turn, could lead to many positive changes for military women with sleep disorders. For example, findings are expected to guide improved methods, strategies, and policies regarding screening for sleep disorders in military women, helping more military women receive an appropriate sleep diagnosis and treatment. In addition, the identification of unique barriers for military women who seek care could lead to treatment modifications that make it easier for them to complete treatment and lead to better treatment outcomes. Likewise, if military women with sleep disorders are shown to have unique or disproportionate risk for other physical or psychological health problems, clinicians may do more risk assessments and provide referrals for complementary care to otherwise improve their physical and mental health.

Ultimately, study findings will lead to interventions, programs and policies that better address sleep disturbances among military women and improve their quality and quantity of sleep. This, in turn, will improve military women’s physical and psychological health and the resilience and readiness of our armed forces.

A Behavioral Economic Analysis of PTSD Using Ecological Momentary Assessment (Project BRAVE)

Dec 07, 2016

Posttraumatic stress disorder (PTSD) can cause distress that puts individuals at risk for behavior that inhibits recovery from their trauma. That behavior too often includes social withdrawal, avoidance of certain situations, and substance misuse.

Traditional PTSD diagnosis typically looks at internal distress, based on self-reported ratings by patients.

This study for the Consortium to Alleviate PTSD seeks to enhance diagnosis and treatment by assessing individuals’ behavior rather than their thoughts and emotions. It will use what is known as “behavioral economics,” which involves examining the context in which a given behavior occurs, considering all possible available alternatives. Decisions about behavior are seen as the result of a complex cost/benefit analysis. For example, a person with PTSD may choose a behavior such as social withdrawal, which could bring immediate relief to someone who wishes to avoid social interaction. Or that person may choose a behavior that involves engaging with others, which could bring a more delayed pattern of benefits over time, such as strengthened relationships, or stable employment.

“Project BRAVE”

In a novel approach, Principal Investigator Meghan McDevitt-Murphy, PhD, of the University of Memphis, and her research team will focus on the daily choices that patients make. Using hand-held electronic devices, 70 combat veterans with PTSD will record their activity, its context, and their emotional responses several times a day for three weeks. This type of data collection is known as “ecological momentary assessment” because participants are giving a self report about their behavior while in their natural environment.

This study operates under the name “Project BRAVE,” an acronym for Behavioral Recording of Activities in Veterans’ Environments.

The data will be consolidated and analyzed to determine the proportion of behavior allocated to avoidance, constructive activity, social activity, and substance use. Investigators will look at the reinforcement gained from each of those types of behavior to predict PTSD severity and functional impairment. From the data obtained from this daily reporting of behavior, they will develop a questionnaire for clinicians to use with patients and for researchers to use in future studies. The questionnaire will allow for collection of information from patients on various aspects of activity engagement without having to repeat the daily recording of information by individuals.


Findings from this study may help guide improvements to psychotherapy for PTSD by demonstrating how the activity patterns of individuals with PTSD may contribute to persistent PTSD and functional impairment. In the future, study investigators hope to develop intervention modules that will promote greater activity engagement among individuals with PTSD. This potentially could help the hundreds of thousands of active duty military personnel and veterans suffering from PTSD and related psychological trauma.