Thank you for inviting me. It's really an honour to be here today.
As you said, I am Anne Germain. I'm an associate professor in psychiatry and psychology at the University of Pittsburgh School of Medicine. I graduated in 2001 from the University of Montreal with a Ph.D. in clinical psychology and moved to Pittsburgh for a post-doctoral fellowship, where I joined the faculty in 2005.
Since then my research program there has focused on understanding how sleep disruption can compromise mental health and mental readiness in military populations, active duty service members and veterans, as well as on developing and testing sleep-focused treatments as a pathway to enhance psychological resilience and accelerate recovery from chronic maladaptive stress reactions in service members.
My research program has been continuously funded by the U.S. Department of Defense and the National Institutes of Health.
I want to take the opportunity today to demonstrate that sleep is a core component of mental health and mental readiness, especially for the armed forces.
Sleep is a fundamental brain function and biological process that is involved in sustaining mental and physical performance.
We all sleep, and we've all occasionally experienced the adverse effects of sleep disruption, but unless we have chronic sleep disturbances, we spend very little time thinking about sleep and its function, especially in a military context.
In 1981, Major-General Aubrey Newman wrote the following in his book:
In peace and war, the lack of sleep works like termites in a house: Below the surface, gnawing quietly and unseen to produce gradual weakening, which can lead to sudden and unexpected collapse.
This citation is a great illustration of how sleep disruption is really a threat to mental readiness and operational performance in military settings.
Sleep is essential for survival, and it's involved in different biological and mental functions, including emotion regulation, decision-making, learning and memory, as well as cardiovascular and immune functions.
Sleep can and will temporarily adapt to unusual and extreme demands and circumstances. However, we need to think about it as malnutrition. Chronic sleep deficiency will lead to organ damage and failure.
In the case of sleep, the primary organ is the brain. Failure and chronic damage means compromised mental health and readiness in our armed forces.
Sleep disturbances are the most common problems reported during and after military deployment. We have many studies now that show the likelihood of poor sleep quality and short sleep duration dramatically increases during deployment in service members. We also have quite a bit of evidence that post-deployment the sleep problems that occur during deployments do not return to pre-deployment levels. In other words, sleep does not just return to normal after people come home from different deployments.
That's true even when operational demands and stressors are terminated. In fact, in the U.S. among active duty service members and veterans we know that anywhere between 40% and 90% of those who have served in different theatres since 2001 report clinically significant sleep problems, including insomnia. It's true even in those who don't meet full-blown criteria for post-traumatic stress: depression, anxiety disorders, or mild traumatic brain injury, for example.
It's also important to remember that sleep problems are also prevalent in those who have not deployed. Luxton and colleagues recently showed that over 70% of non-deployed service members have a very short sleep duration, less than six hours a night, chronically. That number is about 30% in the general civilian population.
When we put that together, what we can realize is that our service members continuously operate and fulfill missions under conditions of marked sleep restriction, if not full-blown sleep disorders. This may very well be unavoidable during different military operations; however, it should and needs to be addressed when people come home so that the service members can return to their optimal levels of readiness and veterans can be best prepared to return to a healthy civilian life.
There's a very tight and robust relationship between sleep disturbances and poor psychiatric outcomes following exposure to stress or trauma exposure.
We know that sleep disturbances that precede or occur shortly after exposure to stress or traumatic events are a very strong predictor of poor psychiatric outcomes, and those include post-traumatic stress disorder, depression, heightened suicidality and other anxiety disorders, alcohol abuse and other addictive disorders, as well as the cognitive problems that are oftentimes associated with mild traumatic brain injury. The same observations, however, suggest that the preservation of sleep during stressful conditions or the rapid restoration of consolidated sleep after stress exposure is a pathway not only to enhance psychological resilience but also to accelerate recovery from expected stress reactions.
Although sleep disturbances are prevalent in service members and they are associated with an increased risk with poor psychiatric outcomes, they are a treatable condition. In other words, they are a modifiable threat to mental readiness and psychological resilience in military service members. We, as well as others, have shown that evidence-based treatment not only improves sleep quality in service members and veterans but also that sleep improvements are consistently associated with improvements in daytime symptoms of post-traumatic stress, depression, anxiety, and even cognitive functioning in those with mild traumatic brain injury.
There are two types of stress strategies for the treatment of sleep disturbances. The more behavioural treatments involve initiating and maintaining different sleep-promoting habits and behaviours. Those have shown to be highly effective in improving sleep and daytime consequences of sleep disturbances or of co-morbid psychiatric disorders. Pharmacological treatments can also be helpful, and when sleep is improved, we consistently see improvements in daytime functioning.
Even though we have effective sleep treatments that are evidence based, there is still a lot of work to be done to test their true effectiveness in military health care settings and in military populations. For example, the behavioural treatment of insomnia typically requires six to eight weeks of individual therapy delivered by a specialist in behavioural sleep medicine. This is typically not widely available, and it's not practical for most military health care settings, or in most military populations, for that matter.
By the way, engaging service members for two months of therapy is not a small challenge either.
Effective treatments that we have must be re-evaluated and adapted for the reality of military health care settings and the kinds of challenges that are faced by our service members. For example, we have shown that we can effectively treat insomnia within four weeks of using evidence-based educational material and personalized treatments that are delivered over a single 45-minute session and a two-week follow-up by phone. In this pilot trial we have seen full insomnia remission within four weeks in over 50% of people who received the intervention.
We've also worked to develop intervention packages that can be deployed and used in theatre. You may have seen an example of the war fighter sleep kit. It's a little box that contains information about sleep, an eye mask, and earplugs. It's not perfect. It's a prototype. There's still a lot of work that can be done to improve the impact, but this just shows that this kind of effort is feasible. We have deployed over 5,000 of these to service members deploying previously to Iraq and now to Afghanistan.
The last argument I want to offer in support of the notion that sleep is a core component of mental health and mental readiness is that sleep is a non-stigmatizing entry into mental health care. Everybody's sleep is disrupted during military training and military operations. Sleep disturbances are the norm rather than the exception during military service. Everybody easily acknowledges having sleep problems which do not bear the stigma of mental illness, so if we promote sleep health, we can actually provide an acceptable entry into mental health care where other psychiatric problems can be identified and adequately treated.
In summary, what I wanted to convey to you today is, first, that sleep is a core component of mental health and mental readiness in military samples; second, sleep disturbances are a threat to mental health but they are a modifiable threat. We can treat sleep disturbances with evidence-based treatments and therefore modify the risk that is associated with poor sleep in terms of psychiatric outcomes.
It's true there is still a lot of work to be done before we can effectively package and disseminate the evidence-based sleep treatments that we have, but I strongly believe that targeting sleep health can have a significant and rapid impact on the life of our service members and veterans.
In conclusion, I would like to recommend that the committee recognize that sleep is a core component of mental and physical readiness and mental health, and that efforts aimed at understanding, evaluating, detecting, and treating sleep disturbances should be encouraged and supported.
Thank you very much.