As the number of women Veterans continues to increase as a result of changes in the composition of the active duty military, there is an increasing need to understand the healthcare needs of this growing segment of the patients we serve. From 1990 to 2000, the number of women Veterans increased from 1.2 to 1.6 million. Projections based on the number of women currently serving in the military suggest this trend will continue, and by 2020, there will be approximately 1.9 million women Veterans in the U.S. This will represent approximately 10% of the total Veteran population, an increase from 4% in 1990 and 6% in 2000. Insomnia complaints are common among women, with a mean prevalence among U.S. women of 23%. However, a 2006 systematic review of VA women's health research did not identify any prior studies of sleep disorders in women Veterans. To our knowledge, this pilot study was the first exploration of insomnia among women Veterans receiving care within VA.
This study had three key objectives, which were achieved by conducting a two-phase study (described below):
AIM 1. Estimate the prevalence of insomnia complaints among women Veterans
AIM 2. Describe the medical, psychiatric and lifestyle factors associated with self-reported and objectively measured sleep among women Veterans with insomnia
AIM 3. Identify treatment preferences among women Veterans with insomnia
PHASE I: POSTAL SURVEY (AIM 1): A 37-item postal survey was sent to the 1632 women Veterans who had received healthcare at the VA Greater Los Angeles Healthcare System (VAGLAHS) over the prior 24 months, and resided within 25 miles of the facility. Individuals who did not return the survey were sent a second survey 3-4 weeks after the first. The survey included 22 items addressing the International Classification of Sleep Disorders (ICSD) diagnostic criteria for an insomnia disorder, plus 5 demographic/descriptive questions and 10 additional items about sleep disruptive factors, sleep medication use, whether they had spoken with a doctor about sleep, and duration of sleep complaints. Respondents who met ICSD diagnostic criteria for insomnia (i.e., had a sleep disturbance lasting >3 months that impacted functioning, despite having a comfortable place to sleep) and did not "opt out" of being contacted were then invited to participate in Phase II. T-tests were used to compare responders and non-responders, and the percentage of respondents with insomnia was calculated.
PHASE II: IN-PERSON ASSESSMENT OF WOMEN WITH INSOMNIA (AIMS 2&3): 164 survey respondents were contacted, screened and invited to participate in Phase II (in the order surveys were received) until study enrollment concluded. The target enrollment for Phase II was 85 women; however, our enrollment rate was higher than expected. 107 women came to one face-to-face interview to assess sleep quality, comorbid conditions, and treatment preferences. They then wore a wrist actigraph and kept a sleep diary for one week (while sleeping at home) to objectively quantify sleep. Rates of comorbidities were calculated, and t-tests were used to compare treatment preference scores.
PHASE I: POSTAL SURVEY (AIM 1): The response rate to the survey was 41%. Of the 666 individuals who returned surveys, 363 (54%) met basic ICSD diagnostic criteria for insomnia lasting at least 3 months. Respondents were older than non-respondents (51 vs. 48 years, respectively; t=-3.45, p=.001) and had a more recent VA visit (4.1 vs. 4.3 months since last visit, respectively; t=2.11; p=.035).
PHASE II: IN-PERSON ASSESSMENT OF WOMEN WITH INSOMNIA (AIMS 2&3): A total of 107 women were enrolled (76% of those screened eligible and invited to participate). The mean age of the 107 women who completed Phase II was 49 (SD=16) years. 44% were non-Hispanic Caucasian, and the mean years of education was 15 (SD=3) years. Based on objectively measured sleep (by one week of wrist actigraphy), women Veterans spent an average of 8.5 (SD=1.3) hours in bed, of which 7.0 (SD=1.2) hours were spent asleep. The average bedtime was 23:02h (SD=1:23h), and the average morning rise time was 07:31h (SD=1:31h). They also slept for an average of 2.5 (SD=1.7) hours outside of their major sleep period (e.g., napping/dozing during the day).
All respondents scored above the clinical cutoff for sleep disturbance on the Pittsburgh Sleep Quality index (PSQI; mean score=12.7 (SD=3.6)). On the Insomnia Severity Index 68% scored in the "moderate" or "severe" range (mean score = 16.9 (SD=5.7)).
On average, women reported 4 physical and 2 mental health conditions on the Comorbidity Inventory. The most commonly-reported medical comorbidities were back pain (59%), high blood pressure (37%) and anemia (33%). The most commonly-reported psychiatric comorbidities were depression (62%), PTSD (45%), and anxiety (44%). 57% of women scored "high risk" for sleep apnea on the Berlin Sleep Apnea scale, and 28% had restless legs syndrome (RLS) based on the RLS Questionnaire.
52% (n=55) women scored above the clinical cutoff for PTSD on the PTSD Checklist-Civilian (PCL-C). They also reported significant psychological distress overall (Brief Symptom Inventory-18 score = 16 (SD=14)).
On the Treatment Acceptability Scale, women reported a preference for non-pharmacological over pharmacological treatment approaches (p<.01). They also indicated the greatest likelihood to participate in nonpharmacological treatments if they were provided in the form of women-only group treatment, or individual treatment (relative to group treatment that included both men and women).
This pilot study represents the first step in understanding insomnia problems among women Veterans. Findings suggests insomnia may be one of the most common conditions faced by women Veterans, and the results should be replicated in geographically diverse samples. The results also suggest that strategies to improve access to specialty care for sleep disorders and to evidence-based mental health treatments for insomnia are crucial. The results of this study also highlight that nonpharmacological treatments targeting women Veterans with comorbid psychiatric disorders should be developed and systematically tested across VA.
- Martin JL, Schweizer CA, Hughes JM, Fung CH, Dzierzewski JM, Washington DL, Kramer BJ, Jouldjian S, Mitchell MN, Josephson KR, Alessi CA. Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2017 May 1; 27(3):366-373.
- Song Y, Washington DL, Yano EM, McCurry SM, Fung CH, Dzierzewski JM, Rodriguez JC, Jouldjian S, Mitchell MN, Alessi CA, Martin JL. Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans. Behavioral sleep medicine. 2018 Jul 1; 16(4):371-379.
- Hughes J, Jouldjian S, Washington DL, Alessi CA, Martin JL. Insomnia and symptoms of post-traumatic stress disorder among women veterans. Behavioral sleep medicine. 2012 Dec 3; 11(4):258-74.
- Martin J, Alessi CA, Mitchell MN, Jouldjian S, Fung CH, Yano EM, Washington DL. Sleep Disorders among Women Veterans: Results of a National Survey. Presented at: VA HSR&D Enhancing Partnerships for Research and Care of Women Veterans Conference; 2014 Jul 31; Arlington, VA.
- Kole A, Fogelfeld K, Cacho V, Santiago V, Santiago S, Martin J, Zeidler MR. Epidemiology of insomnia and its effect on OSA treatment in a veteran cohort referred for sleep evaluation. Paper presented at: Associated Professional Sleep Societies, LLC Annual Meeting; 2013 Jun 1; Baltimore, MD.