Adjusted percent for male E1–E4 soldiers in theater for 9 months (Reprinted with permission from the Mental Health Advisory Team V )
Sleep and Performance
The MHAT-V  also assessed the impact of stress and emotional problems on work performance (accidents and making mistakes) as a function of sleep deprivation. Six percent of soldiers deployed to OEF reported they had an accident or made mistakes during the deployment due to sleepiness. Almost 25% of OEF soldiers reported falling asleep during convoys. Interestingly, the results were different for officers and enlisted personnel. Junior enlisted personnel who reported sleep deprivation also reported increases in sleep-related mistakes and accidents. However, sleep-deprived officers reported a slight decrease in reported accidents and mistakes. The MHAT-V authors interpreted this finding to suggest that officers may underestimate the degree to which sleep deprivation is associated with performance declines.
Medications for Sleep Disturbance
Approximately 16% of soldiers deployed to Iraq during the time of the MHAT-V survey and 17% of those deployed to Afghanistan reported taking mental health medications , and about half of these medications were for sleep . Primary care providers surveyed as part of MHAT-V (N = 135) reported significant increases in the number of medications prescribed for sleep, depression, and anxiety relative to the MHAT-IV. About half (52%) of MHAT-V primary care providers indicated that they prescribed medications for sleep problems on a weekly basis, as compared to 30% surveyed as part of MHAT-IV (P < 0.001). The MHAT-V authors hypothesize that this increase may be related to two factors. First, multiple deployments and an increased length of deployments may have contributed to more soldiers seeking care for sleep problems. Second, the Army Medical Department developed and disseminated the “Respect.Mil” program in an attempt to improve primary care providers’ ability to identify and treat behavioral health problems with medications. The dissemination of programs like Respect . Mil in the US Army may have allowed deployed primary care providers to be more comfortable with treating sleep and behavioral health problems. It should be noted that the integration of behavioral health providers into military primary care settings for the treatment of insomnia and other behavioral health problems has been used for the past decade as a means to help overcome the stigma of specialty mental health treatment [14–16].
A Model for Soldier Combat and Well-Being
The MHAT-V report  provided a Soldier Combat and Well-Being Model that includes sleep disturbance as one of the major risk factors for negatively impacting behavioral health and performance (see Fig. 6.2). This model was adapted from a model previously published by Bliese and Castro . The model assumes that the behavioral health and performance of soldiers is influenced by both environmental factors (e.g., trauma exposure) and individual-level risk factors (e.g., sleep quality). The model includes (1) risk factors (e.g., combat exposure, deployment experiences, etc.), (2) protective factors (e.g., training, willingness to seek care, etc.), and (3) behavioral health status and performance indices.
MHAT-V Recommendations for Sleep Management
The MHAT-V report highlights that sleep problems and sleep deprivation are manageable risk factors . As such, the report includes specific recommendations for sleep management, and Appendix F of the MHAT-V report outlines the Combined Arms Doctrine Directorate on Sleep Management written by the Walter Reed Army Institute of Research. Topics covered in the Sleep Management Doctrine include sleep deprivation, sleeping in the operational environment, maintaining performance during sustained or continuous operations, caffeine countermeasures, work schedules, night shift work, time zone travel, specific sleep loss effects, determining sleep loss in the operational environment, and common misconceptions about sleep and sleep loss. The MHAT-V report provides six specific recommendations for sleep management  (pp. 101–102):
Sleep recommendation: Ensure leaders at all levels develop and monitor work cycle programs that provide adequate sleep time based on the Combined Arms Doctrine Directorate (CADD) on sleep management.
Sleep recommendation: Ensure leaders at all levels encourage soldiers to seek treatment for sleep problems.
Sleep recommendation: Ensure officers know that sleep deprivation is cumulative and that their cognitive performance is highly susceptible to the effects of sleep deprivation. Finally, while much is known about sleep, there are also large gaps in research. Three areas that continue to be important from a research perspective are:
Sleep recommendation: Conduct research on the role of sleep and sleep problems in behavioral health problems such as acute stress and PTSD.
Sleep recommendation: Conduct research on ways to unobtrusively monitor sleep and provide performance estimates for individuals and groups.
Sleep recommendation: Investigate the efficacy of sleep aids as well as agents that might be used to safely maintain performance under short-term periods of sleep deprivation.
The MHAT-VI reports of OIF  and OEF  followed a format similar to MHAT-V, with the goals of assessing soldier behavioral health, examining behavioral health care delivery in OIF and OEF, and providing further recommendations for sustainment and improvement to command leadership. The MHAT-VI reports included a few notable changes from previous reports. First, platoons were randomly selected for data collection. Second, the assessments were conducted with two distinct samples: maneuver units and support and sustainment units. These distinct units might also be described as combatants versus noncombatants . Third, the MHAT-VI reports examined trends across the previous MHAT reports. However, as noted previously, the early MHAT reports included little data specifically about sleep. However, the degree to which the sleep management recommendations were implemented from MHAT-V to MHAT-VI was included. In addition, the MHAT-VI reports were the first to assess sleep medication use separate from medication use for a mental health or combat stress problem.
A total of 1260 soldiers from maneuver platoons and 1182 soldiers from support or sustainment platoons completed surveys in OIF (December 2008–March 2009) . In OEF (April 2009–June 2009), 638 soldiers from maneuver platoons and 744 soldiers from support or sustainment platoons completed surveys . Behavioral health providers also completed surveys, and focus groups were also conducted.
During deployments, substantially more soldiers report taking medications for sleep than for behavioral health conditions such as depression, anxiety, and acute stress . Specifically, in the OEF population, 9.2% of maneuver platoons and 13.5% of support and sustainment platoons reported sleep medication use compared to rates of 2.9% and 6.4% for behavioral health medication use . Rates in the OIF population were similar, with 8.1% of maneuver platoons and 13.5% of support and sustainment platoons reporting sleep medication use compared to rates of 4.8% and 5.1% for behavioral health medication use . In contrast to behavioral health medication use, rates of sleep medication use did not tend to increase with the number of deployments (see Fig. 6.3). Rates essentially started high and remained high, whereas rates for behavioral health dramatically increased at the third deployment and beyond.
Rates of medication use also appear to differ by platoon type, with support and sustainment platoons reporting significantly higher rates of sleep medication use than the maneuver platoon (13.5% vs. 8.1%) . This difference was found after controlling for rank, time in theater, and gender. Both the support and sustainment platoons reported lower rates than civilian samples of young adults. For example, Johnson and colleagues  found that 24.7% of male individuals in the 1996 Detroit Area Survey reported taking prescription sleep aids in the previous year.
It is unclear if the differential rates between sleep medication use and other behavioral health medication use reported here are associated with limited medication availability. In Afghanistan, 73% of providers with prescriptive privileges reported inadequate psychiatric medication availability, and 90% reported that procedures for ordering prescriptions were unclear . The report does not specify if medications specifically for sleep are more readily available than medications used for other conditions such as depression or anxiety.
Sleep and Deployment Concerns
Soldiers were asked about noncombat-related concerns regarding deployment, including not getting enough sleep. Across the MHAT reports conducted from 2005 to 2009, the percentage of service members reporting a concern about sleep deprivation ranged from 23.4 to 35.9% . Sleep deprivation was less of a concern relative to other items such as deployment length, lack of privacy or personal space, lack of time off for personal time, and boring or repetitive work. Although the percentage of service members reporting concern about sleep deprivation did not necessarily increase over time, the rank order of the sleep item tended to rise from the 9th top concern to the 6th top concern. The reason for this is unclear but could possibly be related to increased awareness about the importance of sleep or wear over time as a large number of soldiers experience multiple deployments. Furthermore, when OEF soldiers included in the MHAT-VI were asked to rate the intensity of their concerns (from 1, “very low trouble or concern,” to 5, “very high trouble or concern”) for the same items, not getting enough sleep was the highest-rated concern for maneuver units but not for support units. This data suggested that for those soldiers who endorsed sleep deprivation as a concern, they rated this concern very highly.
Sleep Management Recommendations
As previously noted, the MHAT-V recognized the important role of sleep in military operations in the deployed setting and included six recommendations to address sleep management for both OEF and OIF soldiers  (pp. 101–102). MHAT-VI found that the recommendations were largely in the process of being implemented . Specifically, the Combined Arms Doctrine Directorate on Sleep Management was incorporated into leadership courses to ensure that leaders allow adequate sleep time in work cycles. Sleep management information was also incorporated into the senior leader Battlemind training to inform leaders of the cumulative effects of sleep deprivation on cognitive performance and to encourage soldiers to seek treatment for sleep problems. Evidence suggested that Battlemind training administered post-deployment effectively reduced sleep problems . However, the extent to which leaders implemented sleep-related information during deployment was unclear. The MHAT-VI report  also highlighted that funding through the US Army Medical Research and Material Command (MRMC) was provided for research in the following areas recommended by MHAT-V: (1) the role of sleep in behavioral health problems, (2) methods for unobtrusively monitoring sleep and performance estimates, and (3) the efficacy of sleep aids and agents used to maintain performance under sleep deprivation.
The previous MHAT reports (MHAT-I through MHAT-VI) were supported by the Office of the Surgeon General of the Army. The Joint MHAT-7 report  was also supported by the Office of the Surgeon General of the Army, with additional support from the offices of the Surgeons’ General of the Navy and Air Force and the Office of the Medical Officer of the Marine Corp. As a result, J-MHAT-7 includes samples of Air Force and Navy personnel and a larger sample of marines than the previous reports. In all, 911 soldiers in the Army maneuver unit platoons completed the survey, as did 335 marines. The J-MHAT-7 report did not indicate the number of Air Force and Navy personnel surveyed. Similar to MHAT-VI, survey data was collected from a cluster sample of randomly selected platoons. J-MHAT-7 further expanded data available regarding sleep during deployment by including items about caffeine use and factors related to sleep disruption.
Medication Use and Energy Drinks
Rates of medication use in the J-MHAT-7 report  largely replicated rates found in previous MHAT reports. Forty-five percent of providers identified sleep aids as the most commonly prescribed medications. It was also found that 60% of the sample who took sleep medications also drank at least one energy drink per day, compared to just 43% of the sample who were not taking sleep medications. This difference was statistically significant. Data collected from J-MHAT-7 was further analyzed by the Centers for Disease Control and Prevention , which found that 44.7% of service members consumed at least one energy drink per day. Service members who drank three or more energy drinks per day were also more likely to report sleeping less than 4 h per day, sleep disruption due to stress and illness, and falling asleep during briefings or on guard duty. Although a direction of causality could not be determined (i.e., do sleep problems result in caffeine use or vice versa), it is likely that for some service members, regular caffeine use to promote alertness serves as a perpetuating factor that can contribute to continued sleep difficulties after deployment. The finding that service members who take sleep medications also rely on energy drinks during the day also suggests that sleep medications may not be providing an adequate amount of sleep, resulting in increased daytime sleepiness.