National Defence Committee on Nov. 26th, 2013

[Dr. Anne Germain]

Yes, with the chronic...and starting from this basis of resilience and building on this, under any kind of chronic challenge, it doesn't matter how tough you are, at some point you will break, and sleep is often one of the factors that we put aside, that we don't think about. Actually, the more sleep deprived we are, the worse we are at evaluating how well we're functioning, so eventually we think that we're not affected by it anymore, but objective measurements show that we're actually continuing to decline in any kind of performance that we measure.

I think in making policies we need to be mindful that it's the chronicity of the sleep challenges, sleep disruptions, or sleep restrictions that happen that has to be taken into consideration. In the same way that the Canadian Armed Forces have third location decompression to allow people a buffer between the time they leave the theatre and the time they come home, we may want to think about having a decompression period for sleep too, where you can sleep.

It's hard to convince people that they can use their time sleeping. They prefer to play video games, call home, go out with their friends, or go to the gym. I do think that in terms of policy, we'd have to make it a priority that, just like being able to pass certain PT tests to maintain performance and achieving a certain level of marksmanship for people to be able to keep their jobs, there should be a certain level of sleep performance, however we would define that, that should be maintained to ensure that people are best prepared to face the kinds of challenges they have to face.

[Jack Harris, NDP, St. John's East, NL]

Well, I think you're clear that this doesn't have to affect the operational requirements.

[Dr. Anne Germain]

No, it does not, and it should not either.

[The Chair, Conservative, Peter Kent]

Thank you.

Go ahead, Ms. Gallant.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

I'd like to start where we left off on the CAREN system. We were talking about the use of it in regional pain syndrome. You were explaining the exercises that the patient would go through. How do you transfer what that patient is doing while in the CAREN system to everyday life? How do they remember that yes, they can reach for something?

[Helen Zipes]

One of the great things about the system is it gives them confidence. What we would do in a case like that is show them the results. We could say, “Look, you actually raised your arm 120 degrees”, or whatever. Then we'd give them a series of exercises, a series of tasks to do at home, and the expectation is that they would follow through at home. It really does give them the confidence, and make them think, “Gee, you know, I did that and it's not killing me. I can really do it.”

It has been a very valuable tool that way.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

Thank you.

Dr. Germain, I missed the first part of your presentation, but you have a slide showing cross-sections of the brain and indicate that sleep disturbance is not an invisible OSI. Would you relate to me what the difference is between the yellow and the red and the green activity?

[Dr. Anne Germain]

I didn't talk about that during my presentation to make sure I would be within the 10 minutes.

What you see there, the yellow and the red spots are hot spots in the brain, areas of the brain that are more active in one condition, for example, during sleep as compared to wakefulness. Those are areas of the brain that are hyperactive when people are sleeping or when they are awake, and whether they are in dream sleep or whether they are in what is supposed to be deep restorative sleep.

The slides that you see here, and these are active duty service members and veterans who were combat exposed during operations either in Iraq or Afghanistan, show that, consistently during wakefulness, as we know, pretty much all of the brain is red hot or yellow hot. It's actually localized to regions and circuits that are involved in threat response, goal-oriented behaviours, and motor preparedness. They're on the lookout, basically. They're ready to react.

What we see during sleep, during dream sleep, is that the brain doesn't change that much. They're still hyper-vigilant, ready to react to any kind of threat while they're sleeping, while they're dreaming. We do know from subsequent studies that a lot of these patterns are actually very tightly related to having nightmares.

The other slides are also looking at the same things. Red or yellow means more active brain regions. When we looked at people in deep sleep, with and without post-traumatic stress disorder, we asked the question, which regions of the brain are more active in deep sleep, which is supposed to be the restorative sleep, than in wakefulness. In those with post- traumatic stress disorder, again, you see consistently those brain networks that are involved in threat response, goal-oriented behaviours, motor preparedness, and hyper-vigilance being hyperactive.

What was surprising in the study was we found that even those who do not meet the diagnostic criteria for, or have very little symptoms of post-traumatic stress disorder, show the same kind of activation pattern during sleep as those who have PTSD. In other words, those who don't have PTSD but were deployed many times, on average three or four times for people in these studies, have this hyperactive brain; they're ready to react, ready to detect threats very quickly in the stage of sleep that is supposed to be restorative. We think this means there is an impact of chronic stress exposure on the brain that has not completely gone away even two or three years after people are back.

[Cheryl Gallant, Conservative, Renfrew—Nipissing—Pembroke, ON]

You mentioned the word “restorative”. This appears to dovetail nicely with the study that was published last month, I believe, wherein you need the amount of sleep to wash away the toxins within the brain.

Can you relate what is shown in these cross-sections to that particular study?

[Dr. Anne Germain]

I wish I could, but I can't. I can only speculate.

The study showed that during sleep in animals—I believe they were rats, not mice—brain cells shrink, which increased the amount of liquid that can be cleared through the cerebral spinal fluid. One of the implications for that animal study was that it may be a way for the brain to get rid of the toxins that accumulate while we're awake and that it happens while we're asleep. Whether or not the same is true in humans, we do not know. I would suspect that with the brain that remains as active in sleep as it is when it is awake, as we see in these people, if there is a similar mechanism at play in humans, it would be prevented by this level of activity. If your brain is not really sleeping, then you wouldn't have the opportunity to clear your brain of those toxins, however this happens, but we do not have human data to support this.

[The Chair, Conservative, Peter Kent]

Thank you.

Ms. Murray, you have the final questions.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thanks.

More on sleep, when you talked about the word “restorative”, but also the idea of sleep [inaudible—Editor], I've also heard from others that it doesn't work that way, that when you've lost the sleep you've lost the sleep.

Can you talk to us a bit about how that works?

[Dr. Anne Germain]

On sleep debt, I can give you a very concrete example.

Let's say as a person you need eight hours of sleep, which is on the long side, as most of us need seven hours of sleep, but let's say that you need eight. Because of work, during the weekdays or school days, you can only get six and a half, so you have five days a week where you accumulate an hour and a half of sleep debt. Even if you catch up on weekends are you going to catch up all the hours that you lost during the week? Usually the answer is no, because there are other demands on the weekend, and even if you can sleep in a little bit later, it may be for an hour or two, but certainly it would not be seven or eight hours more sleep that you would get over the weekend.

We're chronically sleep deficient. We don't accumulate sleep. You can't prepare to sleep longer because you know that you won't be sleeping the next 24 hours as much. That, too, doesn't accumulate. There is a limit on how much sleep the brain can produce over a 24-hour period, or in a consolidated sleep episode. It doesn't matter how much we try to cut it or extend it, we can't do that as a preventative measure.

The best we can do is have a regular amount of sleep that is occurring at regular times, that is expected, and of the quality that is hopefully satisfactory to the point that you wake up rested.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you.

Has any of your research actually tied a healthy sleep cycle to the lower likelihood of mental health effects from deployment? One thing I've heard is that it's not always predictable who's going to suffer from severe PTSD because, in a given situation, some of the armed forces members will suffer and others won't.

Has there been any research that connects healthy sleep as a preventative in terms of mental health challenges after deployment, such that it could be seen in the same way you learn to clean your equipment and to do certain things, that healthy sleep is part of that preventative set because the research shows or predicts for lower problems?

[Dr. Anne Germain]

We have to have a longitudinal perspective study to really address this very important question conclusively. We don't have that. What we do have is prospective studies that kind of implicitly looked at the relationship between sleep and mental health outcomes and found that those with more sleep problems, with more mental health issues and difficulties post-deployment.... Implicitly and embedded in this data is where we see that those who don't have sleep problems during deployment, or those who have problems during deployment but can actually go back to a relatively healthy sleep pattern once they come back, are the ones at the lowest risk.

It's kind of by exclusion or by default embedded in the longitudinal studies that are available where we see that those without sleep problems or with fewer sleep problems are those who do better. In terms of intervention, it's mostly coming from clinical trials, relatively small studies, but prospectively to see if prior to deployment or during deployment or immediately after deployment, if we have everybody get sleep intervention and we follow people over time to see who uses it, if their sleep gets better, and if their sleep gets better, did we lower the risk of mental health issues.

I don't know that any studies have actually been done specifically to answer those questions.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Is sleep health part of a standard kind of assessment of a person pre-deployment, and is there a way to tie that into a larger—

[Dr. Anne Germain]

The only place where sleep shows up in pre-deployment or post-deployment assessments that are mandatory in the U.S., and I'm sure in Canada as well, is one of the screening questions asked about nightmares and another one asked about insomnia.

The nightmare question is embedded in the PTSD screening, and the insomnia question is embedded in the depression screening, as if those sleep disorders are secondary to having the other disorders. We know that they're not secondary. They are co-morbid or oftentimes precede the occurrence of depression or post-traumatic stress disorder. To ask how is your sleep, I know for a fact in the U.S. military is not a screening question.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Would that be helpful?

[Dr. Anne Germain]

Yes.

[The Chair, Conservative, Peter Kent]

Thank you very much. Our time has run out.

I have a couple of very brief questions, finally, for Dr. Germain.

Is the war fighter sleep kit available to Canadian Forces?

[Dr. Anne Germain]

Yes, it's available to everyone.

[The Chair, Conservative, Peter Kent]

Has it been acquired and distributed, to your knowledge?

[Dr. Anne Germain]

Not to my knowledge.

[The Chair, Conservative, Peter Kent]

To your knowledge, have the Canadian Armed Forces taken steps with regard to sleep analysis, sleep therapy, for operational stress injuries, including PTSD?

[Dr. Anne Germain]

As I said, I talked to Dr. Jetly recently, and I do believe that sleep is one of the main components they're looking at integrating. I don't know exactly what shape it has taken.