UNDER SECRETARY OF DEFENSE

4000 DEFENSE PENTAGON

WASHINGTON, D.C. 20301-4000

PERSONNEL AND
READINESS
FEB 2 6 2021
The Honorable Adam Smith
Chairman
Committee on Armed Services
U.S. House of Representatives
Washington, DC 20515

Dear Mr. Chairman:

The enclosed report is in response to section 749 of the National Defense Authorization
Act for Fiscal Year 2020 (Public Law 116-92), which requires a study on the effects of sleep
deprivation on the readiness of members of the Armed Forces and a report on the study's results.

This report summarizes the Department's findings following a comprehensive review of

the impact of sleep deprivation on members of the Armed Forces, and an assessment of potential
relationships between sleep deprivation and various medical and mental health conditions.

Thank you for your continued strong support for the health and well-being of our
Service members, veterans, and their families. I am sending a similar letter to the Committee
on Armed Services of the Senate.

Sincerely,

//SIGNED//

Virginia S. Penrod
Acting

Enclosure:
As stated

cc:
The Honorable Mike D. Rogers
Ranking Member
 UNDER SECRETARY OF DEFENSE
4000 DEFENSE PENTAGON
WASHINGTON, O.C. 20301-4000

PERSONNEL AND
READINESS FEB 2 6 2021
The Honorable Jack Reed
Chairman
Committee on Armed Services
United States Senate
Washington, DC 20510

Dear Mr. Chairman:

The enclosed report is in response to section 749 of the National Defense Authorization
Act for Fiscal Year 2020 (Public Law 116-92), which requires a study on the effects of sleep
deprivation on the readiness of members of the Armed Forces and a report on the study's results.

This report summarizes the Department's findings following a comprehensive review of

the impact of sleep deprivation on members of the Armed Forces , and an assessment of potential
relationships between sleep deprivation and various medical and mental health conditions.

Thank you for your continued strong support for the health and well-being of our
Service members, veterans, and their families. I am sending a similar letter to the Committee
on Armed Services of the House of Representatives.

Sincerely,

//SIGNED//

Virginia S. Penrod
Acting

Enclosure:
As stated

cc:
The Honorable James M. Inhofe
Ranking Member
 Report to Congressional Armed Services Committees

Study on Effects of Sleep Deprivation on Readiness of

Members of the Armed Forces

March 2021

In Response To: Section 749 of the National Defense Authorization Act for
Fiscal Year 2020 (Public Law 116–92)

The estimated cost of this report or study

for the Department of Defense (DoD) is
approximately $109,000.00. This includes
$100.00 in expenses and $109,000.00 in
DoD labor.

Generated on 2020SEP03

RefID: F-8D0CEE4
 CONTENTS
EXECUTIVE SUMMARY ........................................................................................................... i
Background ................................................................................................................................ i
Findings...................................................................................................................................... i
INTRODUCTION......................................................................................................................... 1
BACKGROUND ........................................................................................................................... 1
METHOD ...................................................................................................................................... 2
FINDINGS ..................................................................................................................................... 2
Standardized Definition of Sleep Deprivation.......................................................................... 3
Prevalence of Sleep Deprivation............................................................................................... 4
Circadian Rhythm Disturbances from Crossing Multiple Time Zones .................................... 4
Mission-Related Maladaptive Sleep Practices.......................................................................... 4
Deployed Settings................................................................................................................ 5
Training Settings................................................................................................................. 5
Occupational Duty Requirements and Maladaptive Sleep Practices ........................................ 6
Uncomfortable or Otherwise Inhospitable Sleeping Environments ......................................... 6
Prevalence of Use of Stimulants and Hypnotics to Support Operational Tempo..................... 7
Caffeine ............................................................................................................................... 7
Energy Drinks ..................................................................................................................... 7
Modafinil and Dextroamphetamine .................................................................................... 8
Sedative-Hypnotics ............................................................................................................. 8
RELATIONSHIP BETWEEN SLEEP DEPRIVATION AND MEDICAL CONDITIONS
SUCH AS TRAUMATIC BRAIN INJURY, POSTTRAUMATIC STRESS DISORDER,
AND DEPRESSION ..................................................................................................................... 9
Traumatic Brain Injury ............................................................................................................. 9
Mental Health Conditions ....................................................................................................... 10
Posttraumatic Stress Disorder.......................................................................................... 10
Depression ........................................................................................................................ 11
Sleep Deprivation and Suicide Risk.................................................................................. 11
Prevalence of Healthcare Encounters to Address Sleep Deprivation ..................................... 12
SUMMARY FINDINGS: SLEEP DEPRIVATION RISK MITIGATION STRATEGIES13
Commitment to a Duty Schedule that Allows Eight Hours of Sleep...................................... 14
Environmental Considerations................................................................................................ 15
Tactical Naps and Sleep Banking ........................................................................................... 15
Mitigating the Effect of Sleep Deprivation on Physical Performance.................................... 15
 Addressing Caffeine Use ........................................................................................................ 16
Mitigating Travel-Related Circadian Rhythm Disturbances .................................................. 16
Interventions to Improve Sleep............................................................................................... 17
Mobile Applications for Sleep Management .......................................................................... 17
Current Lines of Effort in Military Sleep Research................................................................ 18
CONCLUSION ........................................................................................................................... 19
ACRONYMS ............................................................................................................................... 20
DEFINITIONS ............................................................................................................................ 21
ATTACHMENT 1: SUBTYPES OF SLEEP DEPRIVATION............................................. 22
Total Sleep Deprivation .......................................................................................................... 22
Partial Sleep Deprivation ........................................................................................................ 23
ATTACHMENT 2: IMPACT OF SLEEP DEPRIVATION IN SPECIFIC MILITARY
CONTEXTS................................................................................................................................. 25
Travel Crossing Multiple Time Zones.................................................................................... 25
Mission-Related Maladaptive Sleep Practices........................................................................ 25
Uncomfortable and Inhospitable Sleep Environments ........................................................... 27
ATTACHMENT 3: PHARMACOLOGICAL INTERVENTION TO SUPPORT
OPERATIONS TEMPO ............................................................................................................ 29
Caffeine................................................................................................................................... 29
Energy Drinks ......................................................................................................................... 30
Modafinil and Dextroamphetamine ........................................................................................ 31
Sedative-Hypnotics ................................................................................................................. 32
REFERENCES............................................................................................................................ 34
 EXECUTIVE SUMMARY

Background
This report is in response to Section 749 of the National Defense Authorization Act (NDAA) for
Fiscal Year (FY) 2020 (Public Law 116–92), which requires the Secretary of Defense (SecDef) to
conduct a study of the effects of sleep deprivation on the readiness of members of the Armed
Forces and submit a report on the study results. Study requirements include: 1) a standardized
definition of sleep deprivation; 2) an assessment of the prevalence of sleep deprivation on members
of the Armed Forces related to circadian rhythm disturbances from crossing multiple time zones,
mission related maladaptive sleep practices, uncomfortable or otherwise inhospitable sleeping
environments, and the use of stimulants and hypnotics to support operational tempo; 3) an
assessment of whether there may be a relationship between sleep deprivation and medical
conditions such as traumatic brain injury (TBI), post-traumatic stress disorder (PTSD), and
depression; and 4) recommendations on efforts to mitigate sleep deprivation, pursuant to study
findings.

Findings
Definition: Following a comprehensive literature review, for purposes of this study, the
Department identified an empirically-derived definition of sleep deprivation germane to the
examination of sleep deprivation on readiness and health promotion to inform the Department’s
prioritization of policy pertaining to sleep in the military context: Inadequate sleep that negatively
impacts a Service member’s military effectiveness, evidenced by a reduced ability to execute
complex cognitive tasks, communicate effectively, quickly make appropriate decisions, maintain
vigilance, and sustain a level of alertness required to carry out assigned duties.
Prevalence of Sleep Deprivation: Amongst active duty personnel, inadequate sleep appears to be
more the rule than the exception. In general, rates of individuals sleeping less than seven hours per
night in the military are roughly twice of those in the civilian population. The prevalence of sleep
deprivation varies across the Military Services and occupations. Several mission-related factors
contribute to inadequate sleep in Service members, including austere deployment and training
environments, cross-time-zone travel and its impact on circadian rhythm, operational and
occupational requirements such as operations tempo, and inhospitable sleep environments. Use of
stimulants and hypnotics can mitigate operational impacts of sleep deprivation and promote sleep
in inhospitable sleep environments, but such pharmaceutical interventions offer short-term
solutions and are neither intended nor suitable for sustained implementation.
Relationship with Other Conditions: Sleep deprivation is a symptom of—and a contributing factor
to—mental health disorders and physical diseases, conditions, and syndromes. The presence of
externally caused sleep deprivation may contribute to the development of PTSD, depressive
disorders, and risk for TBI, and may exacerbate symptom severity in established cases. On the
other hand, sleep deprivation can also be a sign or symptom of an underlying medical condition,
such as depression, a side effect from medication or substance such as caffeine, or an endocrine
disorder. The role of sleep deprivation as a contributing factor may be particularly important in
relation to TBI, principally caused by accidents in the military population and more likely to occur
when an individual is sleep deprived. Sleep deprivation substantially increases accident risk,
which, in turn, increases the risk of TBI.
Results of the comprehensive review of the impact of sleep deprivation on the readiness and health
promotion of members of the Armed Forces are informing the Department’s policy development.

i
INTRODUCTION

This report is in response to section 749 of the NDAA for FY 2020 (Public Law 116–92), which
requires the SecDef to conduct a study on the effects of sleep deprivation on the readiness of
members of the Armed Forces, and provide a report on the results of this study. Study
requirements include: 1) a standardized definition of sleep deprivation; 2) an assessment of the
prevalence of sleep deprivation on members of the Armed Forces related to circadian rhythm
disturbances from crossing multiple time zones, mission related maladaptive sleep practices,
uncomfortable or otherwise inhospitable sleeping environments, and the use of stimulants and
hypnotics to support operational tempo; 3) an assessment of whether there may be a relationship
between sleep deprivation and medical conditions such as TBI, PTSD, and depression; and 4)
recommendations on efforts to mitigate sleep deprivation, pursuant to study findings. Findings
from this study are informing Department of Defense (DoD) policy.

BACKGROUND

Twenty-first century combat operations demanded an institutional shift in how military leaders
manage Service member health as a critical component of readiness and performance.
Throughout the wars of the past two decades, the DoD has shown an increasing commitment to
Service member mental and physical readiness. This commitment is evident in the collaborative
partnership between commanders and medical professionals striving to maximize wellness
behaviors among Service members in training, operational, and combat environments.
Throughout the DoD, an emphasis on physical activity, nutrition, resilience, sleep, and fatigue
management has worked to mitigate the potentially deleterious effects of maintaining an always-
ready force.

Sleep may be the most important biological factor that determines Service member health and
combat readiness.1 U.S. military personnel across settings tend to self-report significantly higher
rates of sleep deprivation than the general national population.2 The majority of Service
members report they receive less sleep than needed to perform their military duties well.3 Rates
of sleep deprivation typically are higher in training and deployed settings than in garrison.4,5
Between 27 and 38 percent of Service members indicate that the length of the duty day and the
overall pace of 24-hour-per-day military operations result in sleep deprivation due to restricted
opportunity for sleep.6,7

Although it can be argued that intermittent, short-term sleep deprivation due to operational and
training demands is an unavoidable cost that must be paid to ensure an always-ready force, it is
likely that prolonged and chronic sleep deprivation has the opposite effect on the readiness of the
U.S. Armed Forces.8 Impairment from sleep deprivation can be equivalent to the effects of
alcohol intoxication9 and significantly increases the risk of physical injury.10 A growing body of
research, reviewed in this study, indicates that sleep deprivation has significant effects on the
physical, cognitive, and emotional functioning needed for readiness, occupational, and
operational mission fulfillment in the military.11 Risk of accident in training, operational, and

1
combat environments significantly increases if Service members are sleep deprived.12 To
counteract the effects of sleep deprivation, Service members consume large amounts of caffeine.
There is some evidence that moderate doses of caffeine can maintain alertness, attention, and
vigilance during short-term sleep deprivation.13 However, caffeine countermeasures cannot
replace the need for sleep, and overuse of this stimulant drug in military settings can disrupt
sleep patterns and increase levels of sleep deprivation.14,15 If sleep problems are not addressed,
medical and psychological health conditions can be exacerbated, resulting in persistent
symptoms. As sleep disruption is a core symptom of depression, PTSD, and TBI, individuals
with these conditions show a greater risk for sleep-related problems following combat
deployment.16

Military commanders can help prevent and mitigate the effects of sleep deprivation among their
Service members.17 Risk mitigation begins with a leader’s commitment to duty schedules that
allow for eight hours of sleep with adequate recovery time when mission requirements result in
reduced or disrupted sleep.18 Leaders can take specific steps to monitor caffeine intake and
decrease environmental disruption in sleep areas.19 Several well-established techniques exist for
managing anticipated travel-related sleep disruptions, such as tactical naps and sleep
banking.20,21 Leaders can also encourage the use of behavioral interventions to improve sleep
quantity and quality, such as the use of mobile applications to help track sleep.22,23 If viewed as
a key component of readiness, military cultural attitudes regarding sleep deprivation can be
shifted to ensure that Service member performance is optimized, and even enhanced, rather than
compromised.

METHOD

A comprehensive review was conducted of relevant scientific literature published in the past two
decades to inform the identification of an empirically sound, standardized, ‘consensus’ definition
of sleep deprivation; assess the prevalence of sleep deprivation among Service members; identify
factors resulting in sleep deprivation in the military context; examine the use of stimulants and
hypnotics in response to sleep disturbances caused by operational tempo; and support an
examination of the relationship between sleep deprivation and medical conditions, such as TBI.
Complete summaries of selected literature reviews are included as attachments and cited by topic
within the body of this report.

FINDINGS

It is important to note at the outset that sleep deprivation is not a specific disease, and that most
sleep-related disorders typically result in sleep deprivation. Two of the most common of these
disorders often affect Service members. The first is insomnia. Insomnia diagnoses result from
inadequate sleep quantity or quality due to problems initiating or maintaining sleep, which
interferes with occupational functioning and occurs despite an adequate opportunity for sleep.24
Whereas all individuals with insomnia typically experience partial sleep deprivation, not all
individuals with partial sleep deprivation will meet diagnostic criteria for insomnia.25 The
second condition that typically results in sleep deprivation and is common among Service
members is behaviorally-induced insufficient sleep syndrome (BIISS). Like insomnia, BIISS is

2
characterized by inadequate sleep quantity or quality that interferes with occupational
functioning. Unlike insomnia, BIISS is characterized by an inadequate amount of time spent in
bed or a restricted opportunity to obtain adequate sleep. This could result from factors beyond
the control of the individual (e.g., occupational demands such as long hours or shift work) or
leisure activities (such as television or video games).26,27 Studies of both insomnia and BIISS
have been used in the research literature to capture the occurrence of sleep deprivation as defined
herein.

Standardized Definition of Sleep Deprivation

A consensus of reports in the scientific literature defines sleep deprivation as “obtaining
inadequate sleep to support adequate daytime alertness.”28 There are two general types of sleep
deprivation: total sleep deprivation and partial sleep deprivation (See Attachment 1, Sub Types
of Sleep Deprivation, for the complete literature review):

 Total sleep deprivation is defined as a period of continuous wakefulness that exceeds 24

hours, or getting zero sleep time during the typical sleep-wake cycle.29,30 Total sleep
deprivation is relatively rare for more than short periods of time and can be lethal after
extended periods, but may occur in military settings due to operational demands such as
sustained operations, overnight duty, extended missions, or direct combat.31

 Partial sleep deprivation (or sleep restriction) is defined broadly as at least one night of
partial or interrupted sleep.32 Although the amount of sleep needed each night varies by
individual, partial sleep deprivation is operationalized typically as less than seven hours of
sleep per night for adults.33

 Chronic partial sleep deprivation is partial sleep deprivation with at least one week in which
an individual gets less than seven hours of sleep on most nights and is unable to get sufficient
recovery sleep to make up for lost sleep time.

 The requirement for a minimum of seven hours of sleep per night aligns with
recommendations from numerous scientific organizations, including the American Academy
of Sleep Medicine, the Sleep Research Society, and the National Sleep Foundation.34,35
Large-scale studies further support this cut point by showing that optimal performance in
communication and reasoning require between seven to eight hours of sleep.36,37 Chronic
partial sleep deprivation (or chronic sleep restriction) occurs following at least one week of
consecutive days with partial sleep deprivation (i.e., less than seven hours of sleep per day).38

Both total sleep deprivation and partial sleep deprivation can have significant effects on
cognitive, emotional, and physical capabilities that directly affect military performance. These
include deficits in marksmanship, physical training, decision making, and risk-taking
behavior.39,40,41,42 As applied to the military context, sleep deprivation is operationalized as
meaning inadequate sleep that negatively impacts a Service member’s military effectiveness,
evidenced by a reduced ability to execute complex cognitive tasks, communicate effectively,
quickly make appropriate decisions, maintain vigilance, and/or sustain a level of alertness
required to carry out assigned duties.43,44,45

3
Prevalence of Sleep Deprivation
In the general U.S. population, approximately 28 to 37 percent of adults receive less than seven
hours of sleep per night.46,47,48 In comparison, U.S. military personnel across settings tend to
self-report significantly higher rates of partial sleep deprivation than the general U.S. population.
Results from the DoD Health Related Behavior Surveys conducted between 2005–2018 indicate
that between 55 and 76 percent of Service members endorsed sleeping less than seven hours per
night.49,50,51,52 The most recent estimates indicate that 64 percent of Service members report less
than seven hours of sleep per night.53 Members of the Air Force consistently reported a higher
rate of sufficient sleep (seven hours or more) per night when compared with the other Military
Services.54,55,56

Circadian Rhythm Disturbances from Crossing Multiple Time Zones

Travel-related circadian rhythm disturbances (see Attachment 2, Impact of Sleep Deprivation in
Specific Military Contexts, for a detailed literature review) in the military context primarily affect
aviation Service members and units that must deploy on short notice across several time zones.57
The majority of military studies on circadian rhythm disturbances related to travel focus on the
use of medication to reduce the effects of crossing multiple time zones rapidly,58 as reviewed
under the subsequent section of this report, Prevalence of Use of Stimulants and Hypnotics to
Support Operations Tempo.

For military operations that last longer than two weeks (such as a deployment of Service
members involving several months), jet lag is worse upon arrival to the new time zone and
dissipates over time. In general, an individual is able to adapt to a time zone change of one hour
per day. For example, if an individual travels three time zones, it will take three days for that
individual to adapt to the new time zone. Service members who engage in operational
requirements (such as nighttime operations or rotating shifts) that prevent them from
experiencing normal light-dark cycles may have exacerbated performance impairment due to
circadian rhythm disturbance, which will prevent or delay adjustment to a new time zone.59

Mission-Related Maladaptive Sleep Practices

A number of specific military contextual factors affect the occurrence of sleep deprivation in
operational environments. Examples of such factors include austere deployment and training
settings with inhospitable sleeping environments, and circadian rhythm disturbances caused by
rapidly crossing multiple time zones. Despite reporting high rates of sleep deprivation, only a
minority of Service members indicate that sleep deprivation affects their overall job
performance.60 Army surveys from 2009 to 2013 showed that 27 to 34 percent of Soldiers
reported concern about not getting enough sleep.61 A DoD survey conducted in 2015 found that
56 percent of Service members reported getting less sleep than needed to perform their military
duties well.62

Culturally and operationally, a Service member’s ability to maintain maximum performance

while being sleep deprived has been lauded as a key skill for military personnel and has been
perceived to demonstrate toughness.63,64 Among military commands, attitudes toward sleep may
range from viewing sleep as a controlled ration to asserting that a need for sleep is a sign of
weakness.65 Leadership plays a significant role in whether Service members in a given unit

4
experience partial sleep deprivation. Army surveys indicate that only 26 percent of leaders
encourage Service members to get adequate sleep, while 24 percent work to ensure an adequate
sleep environment, and 35 percent consider sleep as an important factor in operational planning,
such as establishing an adequate shift rotation that supports sufficient sleep.66

Deployed Settings
Rates of partial sleep deprivation have been assessed in deployed settings. Among Army
personnel in Afghanistan, 86 percent report sleeping less than seven hours per night.67 Air Force
personnel in Afghanistan report an average total sleep time of 6.7 hours per night, with 15
percent of personnel reporting less than 4.5 hours per night, and 74 percent rating sleep quality as
significantly worse in the deployed environment.68 A study of Navy personnel in Afghanistan
similarly showed an average total sleep time of 5.9 hours per night, with 67 percent reporting
less than seven hours per night.69 These results are consistent with other studies of Army and
Marine Corps personnel, which demonstrate that 50 percent of deployed Service members report
sleeping five hours or less per night.70 Leaders also experience partial sleep deprivation when
deployed. Army infantry officers report that sleep in the deployed environment depends on
operations tempo (OPTEMPO), with officers typically sleeping only four hours per night during
high OPTEMPO.71 Despite these high rates, a much smaller percentage (3.6 percent) of
deployed Service members seeks behavioral health care for sleep-related concerns.72 Partial
sleep deprivation can also continue following deployment. The majority of Service members in
the Millennium Cohort Study reported sleeping less than seven hours per night, regardless of
deployment status.73 Between 90 and 180 days after return from deployment, 72 percent of
Service members reported sleeping less than seven hours per night.74

Training Settings
Military training settings show significant rates of partial sleep deprivation, despite evidence that
trainees perform better when they receive more sleep.75 Cadets at the United States Military
Academy consistently sleep less than five hours per night during the week, and remain below
seven hours per night on weekends, suggesting that they are unable to effectively recuperate
from “sleep debt” (the cumulative effect of not having enough sleep).76 Soldiers in basic training
report receiving an average of five–six hours of sleep per night, and are typically awoken by
interruptions between two–four times per night.77 Similarly, Marines in training settings
frequently report less than six hours of sleep per night on average, even when periods of sleep
deprivation are not required for operational tasks.78 National Guard members show a significant
decrease in hours of sleep per night when comparing typical sleep patterns to sleep during
training, with an average of six hours of sleep per night during training exercises.79 Soldiers in
Ranger School typically receive an average of only three hours of sleep per night, and engage in
operational training that requires several days of total sleep deprivation.80 Even when training
schedules in basic training environments specify eight hours of sleep a night for trainees, the
actual number of hours of sleep received by trainees—as measured by actigraphy (a non-invasive
method of monitoring human rest and activity cycles)—is significantly less.81 Although the
belief exists that short-term sleep deprivation during training is necessary to prepare Service
members for combat environments that might require conducting operations with little sleep,
sustained chronic partial sleep deprivation may become counterproductive to overall training
objectives.82

5
Occupational Duty Requirements and Maladaptive Sleep Practices
The majority of Service members experiencing circadian rhythm disruptions are likely to work in
occupations that require regular or recurring shift work. Shift work causes circadian rhythm
disturbance that contributes to sleep deprivation, if not properly managed. Extensively detailed
in the literature (Attachment 2), occupational duty requirements may be the most prominent
factor driving chronic partial or total sleep deprivation among Service members. Shift work
(scheduled, unplanned, and ad-hoc), unpredictable schedules, 24-hour duty assignments, and
manning shortages all can result in sleep deprivation among Service members.83 In both
deployed and garrison settings, military personnel face extended duty hours to accomplish all
maintenance, training, and administrative duty requirements.84 When deployed, between 15 and
21 percent of Soldiers report that high OPTEMPO results in sleep deprivation.85 Thirty-six to 38
percent of Soldiers and 27 to 33 percent of Marines indicate that the length of the duty day
provides insufficient time to complete personal business, in turn resulting in restricted
opportunity to sleep.86 Although sleep deprivation in the military has been compared to
equivalent civilian occupational categories, military Service members (55–76 percent) report
significantly greater rates of partial sleep deprivation than firefighters (46 percent), law
enforcement officers (40 percent), and healthcare professionals (40 percent).87

Uncomfortable or Otherwise Inhospitable Sleeping Environments

Due to the nature of military operations in austere locations worldwide, a number of
environmental factors in combat, training, and operational settings may contribute to sleep
deprivation.88 Between 27 and 35 percent of deployed Army personnel surveyed between 2010
and 2013 reported that a poor sleep environment affected their ability to get sufficient sleep.89
Although Service members may be encouraged to “sleep whenever you can” in operational
settings, it is unlikely that sleeping in tactical vehicles, military aircraft, large transient tents,
hangars, or near machinery, is restorative.90 The most common environmental factors reported
by deployed Air Force personnel as affecting their sleep were loud noise outside sleeping tents,
uncomfortable beds, loud noise inside sleeping tents, and uncomfortable heat or cold.91 Ambient
temperature is an important environmental factor that can contribute to partial sleep deprivation,
as it influences the optimal core body temperature, which is an important factor in sleep initiation
and maintenance.92 When deployed to a warmer climate, it can take Service members several
days for their regulation of core body temperature to normalize, in turn resulting in partial sleep
deprivation.93 Summer nighttime temperatures in Iraq and Afghanistan during Operation IRAQI
FREEDOM and Operation ENDURING FREEDOM frequently exceeded ideal ranges for sleep
initiation.94,95 When daytime temperatures in the deployed environment exceed 90 degrees
Fahrenheit (°F), most base construction projects occur at night; however, this causes significant
noise that disrupts the sleep of Service members in tents.96 Furthermore, daytime temperatures
of most U.S. military basic training sites exceed 90°F for more than 50 days per year, potentially
contributing to sleep deprivation among trainees.97 Military trainees also report receiving
insufficient bedding to stay warm during the night in barracks, contributing to partial sleep
deprivation.98

Occupational factors also can interact with environmental factors to worsen sleep deprivation.
Problems caused by shift work during 24-hour operations can be exacerbated by light and noise
contamination, if crew sleeping areas are not set aside from daytime operation personnel, not
adequately blacked out to ensure darkness, or are still used for mission-related tasks (such as

6
obtaining keys or log books).99 In initial entry settings, trainees report several factors that disrupt
their sleep, such as excessive noise in communal sleeping areas, light contamination from
security lights, and rotational nighttime duties that wake both the trainees and their bunkmates.100
Furthermore, co-location of crew sleeping areas with work areas—such as flight crews sleeping
near the airfield—tends to contribute to significant sleep disruption due to noise characteristic of
24-hour operational environments.101 All these factors suggest that maintaining adequate sleep
for personnel should be a primary consideration in establishing operational rotations, work
locations, and standard operating procedures.

Prevalence of Use of Stimulants and Hypnotics to Support Operational Tempo

Throughout the past several decades, studies have examined a number of pharmacological
interventions to determine their effectiveness for mitigating the effects of sleep deprivation in
military operational settings. Attachment 3 provides a comprehensive review of the literature,
Pharmacological Intervention to Support Operational Tempo. These studies include
investigation of stimulants (such as caffeine and modafinil) and sedative-hypnotics.

Caffeine
The intent of controlled caffeine administration in military settings is to maintain operational
performance at typical levels when Service members are sleep deprived.102 The efficacy of
caffeine and other psychostimulants is transient, and can delay—but not replace—the need for
sleep.103 Evidence synthesized from across military and civilian studies provides some support
that moderate doses of caffeine ((approximately 200–300 milligrams (mg)) can maintain levels
of alertness, attention, vigilance, and reasoning during sleep deprivation.104,105 In addition,
caffeine doses over 200mg show positive effects on physical performance, including time-trial or
sprint speed, muscle strength and endurance, and time-to-exhaustion.106

Energy Drinks
Although coffee is the most prevalent source of daily caffeine among Service members overall,
energy drinks are the most common source among younger Service members.107 Energy drinks
are considered dietary supplements, with caffeine content typically ranging from 80–300mg per
serving.108 Studies show significantly higher rates of energy drink consumption in the U.S.
military compared to the general population. For example, a survey of military personnel in
operational, training, and medical settings found that 53 percent of Service members consumed
at least one energy drink in the past 30 days, while 38 percent consumed at least one energy
drink per week.109 Among Service members, U.S. Army personnel use energy drinks most
frequently (54 percent), while U.S. Air Force personnel consume energy drinks least frequently
(26 percent).110 Although generally considered relatively benign, caffeine consumption can have
unfavorable effects. Service members who regularly consume energy drinks frequently report
problems sleeping; the alerting effects of caffeine possibly contribute to these problems,
especially if caffeine consumption occurs within six hours prior to bedtime.111 Energy drink
consumption can bring significant health risks, including cardiac arrest, myocardial infarction,
spontaneous coronary dissection, and coronary vasospasm.112,113 In contrast to studies on
carefully dosed caffeine during military tasks, energy drinks likely provide an irregular dose of
caffeine at various intervals, possibly canceling out potential benefits and increasing operational
risk. Furthermore, many energy drinks contain several substances (e.g., taurine, guarana,

7
excessive amounts of B vitamins) in addition to caffeine, the effects of which, both individually
and in combination, have yet to be fully determined.114

Modafinil and Dextroamphetamine

The prescription stimulant drug dextroamphetamine is approved for use under the direction of a
flight surgeon in Army, Navy, Air Force, and Marine Corps aviation.115,116,117,118 The
prescription drug modafinil is also approved for wakefulness promotion under the direction of a
flight surgeon in the Air Force, depending on specific Major Command guidance.119 A recent
study on the prevalence of these drugs in combat aviation operations showed that pilots used
either dextroamphetamine or modafinil in 35 percent of combat sorties.120 Research on these
stimulants generally demonstrates that they are safe and effective in counteracting fatigue during
combat or other emergency conditions, and can be used to their optimal effect upon following
strict dosing and recovery sleep guidelines.121 Studies on modafinil use have generally
demonstrated effective restoration of normal performance levels for several hours during total
sleep deprivation.122,123,124,125 Outside of use for counteracting fatigue during combat or other
emergency situations, these pharmaceutical measures should be used only after other options for
ensuring adequate aircrew rest (especially protected sleep time) have been exhausted.126

Sedative-Hypnotics
Prescription sedative-hypnotic drug use has occurred in military contexts for many years. These
drugs are most effective for short-term use to promote sleep in inhospitable military
environments, to counteract circadian adjustment associated with jet lag, or to facilitate work
shift transitions.127 Approximately 11 percent of Service members report using prescribed
sedative-hypnotics to facilitate sleep in deployed settings.128 Studies on workplace and
operational applications of short-term sedative-hypnotic drug use have shown some benefits,
including alleviating sleep debt by restoring sleep levels to baseline prior to periods of known
sleep deprivation, and possibly counteracting environmental noise effects.129,130,131 Sedative-
hypnotic drugs have been used frequently to treat partial sleep deprivation related to clinical
sleep conditions. Between 2009 and 2015, approximately 2.4 million prescriptions for sedative-
hypnotic medications were given to active duty Service members.132 Table 1 details the number
of prescriptions filled by active duty Service members for three different sleep-related, non-
benzodiazepine sedative-hypnotics—zolpidem, zaleplon, and eszopiclone—in Military Health
System (MHS) encounters from FY 2016–FY 2019. These data show that prescriptions for
sleep-related non-benzodiazepine sedative-hypnotics have decreased overall between FY 2016
and FY 2019. Although there is continued use of sedative-hypnotics in the military, studies
show that behavioral treatments are preferable to sedative-hypnotic drugs for ongoing treatment
of insomnia, which is supported by the downward trend in the percent of Service members with a
filled prescription during this period.133 Clinical guidelines recommend only brief treatments
with these sleep medications to help restore sleep to baseline; behavioral interventions are
recommended for long-term treatment of insomnia.134

8
Table 1. Prescriptions for sleep-related sedative-hypnotics among active duty Service
members
VARIABLE FY 2016 FY 2017 FY 2018 FY 2019
New Prescriptions Filled 45,243 42,107 37,012 34,088
Refills 11,155 11,049 9,684 8,382
TOTAL PRESCRIPTIONS FILLED 56,398 53,156 46,696 42,470
Unique Patients 31,462 29,066 26,123 23,829
Prescriptions Filled per Patient 1.8 1.8 1.8 1.8
Percent of Active Duty Service Members
2.06% 1.91% 1.70% 1.53%
with a Filled Prescription
ESTIMATED PREVALENCE* 3,692.4 3,500.9 3,046.1 2,718.9
*
Reflects prescriptions filled per 100,000 Service members. Data retrieved from the MHS
Management Analysis and Reporting Tool reflect prescriptions in the direct care system for
zolpidem, zaleplon, and eszopiclone. Data also reflect all prescriptions for these medications,
which may include off-label use for non-sleep-related symptoms.

Relationship between Sleep Deprivation and Medical Conditions such as Traumatic

Brain Injury, Posttraumatic Stress Disorder, and Depression
Traumatic Brain Injury
As reviewed herein, sleep deprivation can result in significant physical and neuropsychological
decrements—including deficits in arousal, attention, cognition, and performance—that
contribute to risk for sustaining a TBI.135,136 The majority of TBIs in the military are due to
training accidents, accidental falls, and motor vehicle accidents.137 A systematic review and
meta-analysis found that workers with sleep problems had a 1.6 times higher risk of injury than
workers not reporting sleep problems, and that overall, 13 percent of work injuries were related
to sleep problems.138 Data from the National Transportation Safety Board indicate that 40
percent of motor vehicle accidents are related to fatigue and insufficient sleep.139 In the military,
Service members with duty-related sleep deprivation are far more likely to experience a motor
vehicle accident or work-related injury.140

Clinically, sleep problems are among the most common symptoms following a TBI, including
insomnia, excessive daytime sleepiness, sleep fragmentation (repeated, short sleep interruptions),
and changes in sleep architecture (pattern of sleep between sleep stages).141 These factors, in
turn, contribute to significant partial sleep deprivation.142,143 In the military, estimates of sleep
problems following a TBI range from 25–30 percent.144 Repetitive TBIs also significantly
exacerbate sleep deprivation, with one study showing that 50 percent of Service members with
more than one incident of TBI reported subsequent partial sleep deprivation.145 Sleep
deprivation can exacerbate other symptoms of TBI, resulting in greater impairment and long-
term sequelae.146,147 Failure to address sleep problems and subsequent sleep deprivation

9
following TBI can impede recovery and delay return to work, in turn contributing to the
development of chronic maladaptive sleep behaviors. The Defense and Veterans Brain Injury
Center clinical recommendations, as well as DoD and Department of Veterans Affairs guidelines
indicate that standard sleep interventions should be implemented among Service members and
veterans with a TBI, to include sleep assessment, sleep education, and an emphasis on non-
pharmacologic interventions to address sleep problems.148,149 These clinical recommendations
and guidelines intend to standardize care for Service members with TBI and sleep disorders, and
mitigate the impact of sleep disorders on TBI recovery.

Mental Health Conditions

Partial sleep deprivation is a common symptom and potential risk factor for many mental health
conditions, particularly mood and anxiety disorders.150,151 Compared to those without a
diagnosis, recent combat veterans with a mental health diagnosis report significantly worse sleep
quality, sleep quantity, sleep efficiency, and sleep latency, and more sleep disturbances.152
Data from deployed Service members show a clear relationship between partial sleep deprivation
and reported psychological health problems, with 23 percent of Service members screening
positive for a mental health disorder when sleeping three or fewer hours per night, and 17
percent of Service members screening positive for a mental health disorder when sleeping four
hours per night.153 Overall, partial sleep deprivation shows significant deleterious effects on
mood and emotional reactivity; difficulties with mood and emotional reactivity can be part of
several mental health diagnoses.154,155 Furthermore, a study of U.S. Army Soldiers found those
with poorer subjective sleep quality over an extended period reported higher emotional
exhaustion and feelings of role overload.156 Specific symptoms such as anxiety may also be
more intense and frequent among sleep-deprived individuals.157 In addition to these overall
relationships, sleep deprivation may complicate the general diagnostic and clinical course of
several specific mental health conditions, including PTSD, depression, suicidal behavior, and
TBI.

Posttraumatic Stress Disorder

Sleep deprivation—often through nightmares or insomnia—is a core symptom of PTSD and a
factor than can exacerbate PTSD daytime symptomatology (e.g., hypervigilance, irritability).158
Estimates suggest more than 90 percent of combat veterans with PTSD also experience
significant chronic partial sleep deprivation.159,160,161 Partial sleep deprivation prior to combat
deployment significantly increases the risk of subsequent PTSD.162,163 Similarly, sleep
disruption due to nightmares prior to military deployment can increase the risk of PTSD
symptom onset during the six months following deployment.164 Partial sleep deprivation due to
insomnia is the most common reported PTSD symptom among Service members returning from
deployment.165 Similar to other mental health conditions, individuals diagnosed with PTSD tend
to have significant sleep disruption, including lighter sleep that results in being awakened more
easily; less time in deep slow-wave sleep; and greater density of rapid eye movement sleep
(suggesting greater overall partial sleep deprivation).166,167 Compared to combat-deployed peers
who do not develop PTSD, Service members and veterans diagnosed with PTSD report
significantly greater partial sleep deprivation that results from a combination of lower total sleep
time, worse sleep efficiency, and higher sleep latency.168

10
Several studies demonstrate that partial sleep deprivation can worsen the occurrence of daytime
PTSD symptoms. Sleep deprivation at four months following return from deployment predicts
the severity of PTSD symptoms at 12 months.169 Partial sleep deprivation of less than six hours
of sleep per night served as the strongest predictor of PTSD symptoms among Service members
90–180 days following deployment.170 Service members and veterans with partial sleep
deprivation of less than four hours per night are at greater risk of having persistent PTSD
symptoms that extend over a seven to ten year period.171 Furthermore, sleep-related symptoms
partially account for the relationship between combat exposure and development of PTSD
symptoms; this finding suggests that partial sleep deprivation should be addressed early among
Service members at risk for PTSD.172

Depression
Overall estimates suggest that 60 to 84 percent of patients with depression report insomnia, with
associated sleep deprivation as a primary symptom.173 Across military and civilian population
samples, partial sleep deprivation significantly increases risk of developing depression
symptoms. 174,175,176,177 Risk of sleep deprivation as a secondary effect of insomnia also may
continue after remission of depression symptoms.178 Among Service members, partial sleep
deprivation experienced prior to deployment increases the risk of developing depression
symptoms following deployment.179 Sleep deprivation may also be the primary factor that
determines whether combat-exposed Service members develop depression symptoms, since sleep
deprivation partially accounts for the relationship between combat exposure and depression
symptoms.180 Similarly, sleep deprivation may account for the link between TBI and depression
symptoms among Service members.181

Sleep Deprivation and Suicide Risk

Several meta-analyses demonstrate a clear association between sleep disruptions—resulting in
chronic partial sleep deprivation—and suicidal behavior.182,183,184,185 This includes increased risk
of suicidal ideation, suicide planning, suicide attempts, and death by suicide. The lowest risk of
suicide is associated with eight hours of sleep per night, with an 11 percent increase in risk for
each hour of sleep deprivation.186 Within diagnostic groups at risk of suicide (such as depression
and PTSD), sleep disruption and associated chronic partial sleep deprivation approximately
double the risk of individuals to engage in suicidal behavior.187,188

Findings among military populations have been less clear. One study of U.S. military personnel
showed an association between reported insomnia symptoms and suicidal ideation, when
controlling for other mental health factors.189 However, an analysis of three U.S. military sample
populations receiving mental health care showed no association between severity of chronic
partial sleep deprivation and suicidal ideation, when controlling for reports of depression
symptoms.190 In a study of suicide deaths among U.S. Veterans from Operation ENDURING
FREEDOM and Operation IRAQI FREEDOM, Veterans reporting sleep problems in the
previous year died by suicide significantly sooner (75 days) after their last contact with the
Veterans Health Administration than did those who did not report sleep problems (174 days),
even when controlling for other mental health factors.191 These studies suggest that reporting of
partial sleep deprivation may predict increased risk of suicide, but this relationship may depend
on several additional risk factors, such as co-occurring mental health disorders.

11
Prevalence of Healthcare Encounters to Address Sleep Deprivation
Table 2 details the number of MHS encounters for three different categories coded by providers
in medical records related to sleep deprivation: sleep deprivation, insufficient sleep syndrome,
and insomnia. These data cover FY 2016–FY 2019. As shown in Table 2, the overall
prevalence of sleep deprivation and insufficient sleep syndrome requiring medical care in the
MHS is relatively low. Although excluded from the definition of sleep deprivation in this study,
the prevalence of insomnia cases—the most common sleep-related condition diagnosed among
Service members—is significantly higher and reflects about five to six percent of the overall
Service member population.192 Nonetheless, these rates of insomnia cases are significantly lower
than reported rates of sleep deprivation from surveys of Service member sleep patterns.

A clinic-based study of active duty military members found that 68 percent of Service members
referred for sleep evaluation reported sleeping less than seven hours per night.193 Another study
found that among a cohort of female Service members referred for formal sleep evaluations,
sleep duration on workdays was significantly less than sleep duration on days off.194 Given the
relative frequency of insomnia cases as shown in Table 2, compared to diagnosed cases of sleep
deprivation, it is likely that partial sleep deprivation in the military is due to lifestyle choices and
occupational requirements.195,196

Table 2. Service members seeking medical care for sleep deprivation and related
medical conditions
CONDITION FY 2016 FY 2017 FY 2018 FY 2019
SLEEP DEPRIVATION
Total Cases 2,267 1,863 2,374 2,350
Prevalence Estimate* 148.42 122.70 154.86 150.44
INSUFFICIENT SLEEP SYNDROME
Total Cases 1,186 1,371 1,388 1,407
*
Prevalence Estimate 77.65 90.30 90.54 90.07
INSOMNIA
Total Cases 88,606 85,360 80,654 80,815
*
Prevalence Estimate 5,801.01 5,621.92 5,261.32 5,173.66
ANY CONDITION RELATED TO SLEEP
DEPRIVATION
Total Cases 90,444 87,223 82,889 83,056
*
Prevalence Estimate 5,921.34 5,744.62 5,407.11 5,317.13
*
Cases per 100,000 Service members. Data retrieved from the MHS Management Analysis
and Reporting Tool reflect medical transactions in both the purchased care and direct care
systems across both inpatient and outpatient settings, wherein target diagnoses were recorded
in any available diagnostic position.

Taken together, the findings above consistently show that Service members report significant
rates of chronic partial sleep deprivation. Discrepancies between endorsed sleep deprivation,
care seeking behavior, and reported job performance may show that certain groups of Service
members lack insight into the unanticipated impact of sleep deprivation, particularly given the
body of research reviewed herein that demonstrates its significant impact on functioning.

12
SUMMARY FINDINGS: SLEEP DEPRIVATION RISK MITIGATION
STRATEGIES
Based on the results of this comprehensive review of the impact of sleep deprivation, the
following identified areas reflect strategies to mitigate the risk of sleep deprivation and improve
sleep among Service members:

 To the extent possible, in non-deployed and training units, duty schedules should afford
Service members eight consecutive hours of sleep every 24 hours.

 Duty schedules requiring shift work should implement forward-rotation of changing shifts
(day to evening to night), and utilize eight-hour shifts whenever possible.

 Operational and tactical battle plans should account for the impact of sleep deprivation,
ensuring eight hours of sleep every 24 hours, with sufficient opportunities for sleep banking
and recovery sleep when operational requirements result in less than eight hours of sleep
every 24 hours.

 Establishment of an enlisted unit-level sleep trainer to promote the use of strategies to

mitigate sleep deprivation throughout the unit and advise command on ensuring that Service
members receive adequate opportunity for sleep.

 Provision of leader training in basic officer and non-commissioned officer military

professional education courses on sleep leadership and the impact of sleep deprivation on
physical performance.

 Provision of pre-deployment training for Service members and leaders on developing an

environment conducive to sufficient sleep.

 Provision of health promotion guidance and an educational campaign for Service members
on caffeine consumption limits to include identifying products with excessive caffeine
content.

 Use of well-established strategies for managing travel-related circadian rhythm disturbance

such as those developed by elite athletes.

 Expansion of adoption and training of brief behavioral interventions to address sleep

problems in primary and specialty care.

 Promotion of government-developed mobile application use for sleep management, including

ensuring Service members have an opportunity to download these mobile applications onto
personal mobile devices prior to completion of basic training.

 Establishment of a clearinghouse repository for sleep resources to ensure dissemination and

availability to front-line military leadership.

13
The sections below outline the basis for the above identified risk mitigation strategies.

Commitment to a Duty Schedule that Allows Eight Hours of Sleep

Due to the sustained high OPTEMPO during the past two decades, daily duty requirements have
taken priority over Service members obtaining enough sleep to perform these duties at optimal
levels. The research reviewed herein clearly demonstrates that the majority of Service members
are experiencing partial sleep deprivation, regardless of current duty status (e.g., deployed, in
garrison, in training).197,198,199 Of all factors reviewed in this report that contribute to sleep
deprivation, the most prominent is the need to afford Service members an adequate opportunity
for sleep, in response to operational requirements for unplanned and ad-hoc shift work,
unpredictable schedules, 24-hour duty assignments, manning shortages, and extended duty
hours.200,201 Greatly increasing leadership commitment to promote and encourage Service
members to obtain adequate sleep, and directing command involvement to ensure an adequate
sleep environment, are vital tools to mitigate operational and readiness risks—both physical and
mental—associated with sleep deprivation.202

As the first step toward reducing and mitigating the impact of sleep deprivation in the military,
commanders at all levels should commit to sleep leadership through duty schedules that allow
Service members to get eight hours of sleep per night.203 This would include a specific
requirement to plan eight hours of sleep for every 24-hour period into training and battle plans,
with planned recovery time of two to three consistent nights of sleep, if operational requirements
take precedence for any period of seven or more days.204,205 In the operational environment,
units required to engage in significant sleep deprivation should be placed “off cycle” for at least
three nights to ensure recovery to baseline performance. Pilot studies with brigade combat teams
have shown that limiting the duty day to eight hours, while adapting schedules to account for
family obligations, significantly improved work quality, physical fitness scores, and number of
hours sleep per night without negatively impacting unit mission.206 In this way, transformational
leadership—through proactive strategies that set a good example and promote collective effort—
can mitigate some of the effects of sleep deprivation on work performance in military settings. 207
Sleep leadership should be emphasized as a core competency in readiness, and consideration
given to evaluating leaders based on whether the Service members in their stewardship are
receiving a sufficient number of sleep hours per night.208

Commanders who must operate 24-hour duty cycles should leverage existing research on shift
scheduling.209 Eight-hour shifts that synchronize with the 24-hour clock have the least impact on
performance and highest satisfaction among Service members.210 Forward shift rotation (day to
evening to night) has been well established as preferable for both performance and sleep
cycles.211 Longer intervals between shift rotations generally promote better sleep and allow for
less circadian disruption.212 Furthermore, crew briefings, meals, and other mandatory tasks
should account for sleep cycles to avoid interrupting Service member sleep.213

As part of mission planning, military researchers recommend the establishment of specific unit-
level sleep plans for use during training and sustainment operations.214 Researchers furthermore
recommend the establishment of a “sleep trainer” at the unit level to facilitate sleep plans,
monitor individual sleep performance, and train unit members on behavioral strategies for
minimizing and mitigating sleep deprivation.215

14
Environmental Considerations
Military leaders and commanders should consider several specific environmental factors when
planning where Service members will sleep in training and operational settings.216 An optimal
sleep environment should include complete darkness, good ventilation, ambient temperatures
ranging between 17 degrees Celsius (°C) and 28°C at 40–60 percent relative humidity, and noise
levels below 35 decibels (dB).217,218 Air conditioning for barracks and operational settings is
crucial for ensuring that sleep environments remain within optimal levels.219 Non-invasive
monitoring of sleep areas should be conducted regularly for factors such as decibel levels from
machinery, temperature, and light contamination.220 Service members should be provided with
supplies such as eye masks and earplugs to counteract suboptimal sleep settings.221

Tactical Naps and Sleep Banking

When periods of total sleep deprivation are required due to operational necessity, planning
specific periods of sleep before or during sustained operations may be of benefit equal to
caffeine.222,223 Planned naps are effective in maintaining performance during periods of more
than 24 hours of total sleep deprivation,224 and are most effective when occurring about two-
thirds of the way through a period of sleep deprivation and lasting about 20 minutes.225,226
Consumption of approximately 100mg of caffeinated gum after waking can minimize grogginess
after waking from a scheduled nap during a shift.227 Based on this research, it is recommended
that military commanders consider planned or rotational naps for their personnel during
identified periods of sleep deprivation.

A recent body of research suggests that getting extended sleep prior to known periods of sleep
deprivation (“sleep banking”) can have benefits on performance among sleep-deprived
individuals. 228 For example, by getting ten hours of sleep per night prior to a period of partial
sleep deprivation, participants in one study showed better alertness and performance during sleep
deprivation (sleeping three hours per night) than individuals who did not get additional sleep
prior to the known disruption.229 In the military context, U.S. Army Soldiers who had better
subjective sleep quality prior to a period of occupationally mandated sleep loss had greater
physical resilience to the sleep loss, suggesting Soldiers with better quality sleep may have
naturally obtained banked sleep.230 In order to implement significant sleep banking, military
commanders must ensure that additional sleep is allowed and encouraged during the ramp-up
preparation and OPTEMPO period prior to a mission.231 Following periods of high OPTEMPO,
commanders should support sleep extension (i.e., affected Service members sleeping more than
eight hours per night) in order to restore baseline sleep.232

Mitigating the Effect of Sleep Deprivation on Physical Performance

Sleep loss affects physical performance and capabilities. A study of a sample of U.S. Army
Soldiers who train others on mountain warfare techniques found that the trainers had poorer
balance (a proxy of higher injury risk) following sustained operations (SUSOPS).233
Furthermore, findings from two samples of U.S. Army Rangers demonstrated a significant
reduction in testosterone, which is critical for muscle recovery after physical activity, following
military exercises requiring sleep loss.234

15
A variety of factors may contribute to the degree to which sleep deprivation influences physical
performance, such as the timing of the sleep restriction, and whether opportunities exist for sleep
restoration. For example, athletes who had a single night of partial sleep deprivation at the end
of the night (i.e., rising four hours early) experienced reduced muscle strength and power the
following afternoon; however, those whose sleep deprivation occurred at the beginning of the
night (i.e., delayed bedtime by four hours) experienced no such reductions.235 Napping prior to
physical training might help restore cognitive function and maintain lifting performance in
compound movements after sleep deprivation.236 For example, preliminary research with
Swedish Armed Forces cadets who had undergone partial sleep deprivation (five hours of sleep
during a 51-hour period) found that taking a 30-minute nap prior to exercise was associated with
significant increases in the number of lunges completed in two minutes.237 Preliminary research
(typically lacking proper experimental controls) on extending time in bed prior to specific events
among athletes has shown beneficial effects on reaction times, sprint times, accuracy of tennis
serves, and successful three-point basketball shots.238 Thus, prior sleep extension may benefit
Service members who engage in a military operation that requires peak physical performance.

Addressing Caffeine Use

Caffeine consumption, particularly through energy drinks, is pervasive in the military.239,240,241
Although potential short-term benefits exist when using caffeine as a countermeasure for the
effects of total and partial sleep deprivation, the effectiveness of caffeine supplement use on the
battlefield to augment wakefulness during periods of sleep deprivation is unclear, if combined
with the typical amount of caffeine consumed by Service members through coffee, energy
drinks, and other supplements.242 Most studies of operational use of stimulants tightly control
the amount of caffeine consumed by participants.243,244 Similar to flight medicine, commanders
must be aware of the amount of caffeine consumed by their Service members in operational
settings, and enforce limits when acute or chronic consumption of this drug exceeds the cost-
benefit threshold.245 The most consistent findings indicate that limiting controlled administration
to 200mg per dose is the most effective in maintaining performance during partial sleep
deprivation.246 Routine daily caffeine use should not exceed 400mg, and emergency use of
caffeine to combat total sleep deprivation due to operational necessity should not exceed
1000mg.247,248,249 Caffeine countermeasures cannot replace the need for sleep; the overuse of
this stimulant drug in military settings will disrupt chronic sleep patterns and increase levels of
sleep deprivation.250,251

Mitigating Travel-Related Circadian Rhythm Disturbances

Research literature includes a number of specific, well-established techniques to mitigate effects
of travel-related circadian rhythm disturbances.252 These include maintaining hydration prior to
travel, shifting early to the destination sleep schedule, adhering to destination sleep timing upon
arrival, limiting naps to 20–30 minutes in duration, and aligning light exposure with travel
direction (morning for eastward, evening for westward).253 Units deploying across six or more
time zones should allow at least two weeks of adaptation time to mitigate any physical and
cognitive effects of circadian rhythm disturbances.254 Despite some inconsistent results,
melatonin taken one to two hours before sleep may help facilitate time zone transitions for
eastward travel, when taken as part of a comprehensive sleep plan.255 Furthermore, melatonin

16
use has relatively low occurrence of adverse events, indicating it is a safer option for adjusting
circadian rhythms than sedative-hypnotics.256

Interventions to Improve Sleep

Several interventions are available to restore a regular sleep cycle for Service members who are
experiencing chronic partial sleep deprivation. Behavioral interventions are preferred as a first-
line treatment in both primary and secondary care settings, and have more lasting effects than
pharmaceutical interventions.257 Brief Behavioral Treatment for Insomnia258 and Cognitive-
Behavioral Therapy for Insomnia259 are empirically supported techniques for mitigating chronic
partial sleep deprivation and re-establishing a regular sleep cycle. These behavioral
interventions are also the front-line intervention for sleep disruption related to mental health
conditions, including depression, TBI, and PTSD.260,261 The Defense Health Agency has piloted
and will further implement a specific Primary Care Sleep Improvement Clinical Pathway that
ensures training for all primary care behavioral health consultants in the delivery of behaviorally
based treatments for insomnia. Initial results show these interventions can be effectively
modified for the military operational environment, including use of remote consultation via
internet or telephone.262,263,264 Furthermore, addressing sleep-related issues in primary care
settings may be a pathway for preventing the onset of depression or anxiety symptoms among
Service members who may hesitate to seek mental health treatment.265

Mobile Applications for Sleep Management

To enable direct use of sleep management tools by Service members, military leaders should
actively promote existing mobile applications developed by the DoD and the Department of
Veterans Affairs.266 Service members should not leave basic training without these sleep
management mobile applications installed on their smartphones. The following mobile
applications and related digital tools are available at no cost, and are based on empirically
supported interventions:

 The Breathe2Relax mobile application can promote sleep onset by decreasing physiological
arousal through relaxation exercises.267 Its parallel version—the Tactical Breather—was
designed specifically for use in military field settings.

 The Military Meditation Coach podcast similarly provides Service members with relaxation
scripts to promote better sleep for use in any setting. These scripts were developed
specifically as part of the Navy Mind-Body Medicine program.268

 The CBT-I Coach mobile application allows Service members to track nightly sleep, identify
patterns of sleep deprivation, and receive useful feedback to improve sleep behavior.269

 The DreamEZ mobile application assists Service members in Imagery Rehearsal Therapy, an
empirically supported treatment for reducing nightmares related to traumatic events.270

 The 2B-Alert web and smartphone application was specifically designed to predict the effects
of sleep deprivation and provide guidance on how to optimize sleep schedules and caffeine
dosing for any given sleep/wake schedule.271

17
Current Lines of Effort in Military Sleep Research
Military research labs and academic partners are engaged in several ongoing lines of research
aimed at mitigating the occurrence and impact of sleep deprivation among military personnel.
These efforts include:

 Enhanced fatigue management tools intended for use at the individual Service member and
squad levels.

 Cutting-edge assessment of the effects of sleep deprivation on brain physiology (to identify
highly specific targets for development of next-generation interventions to sustain
performance and brain health).

 Nutritional supplements and pharmacology that facilitate fatigue management, including

novel formulations of existing products.

 Transcranial electrical stimulation to mitigate performance degradation and improve

recovery time following sleep deprivation.

 Acoustic stimulation to mitigate performance degradation and improve recovery time

following sleep deprivation.

 Ruggedized technologies to track sleep and performance in operational environments.

 Command policy and training to enhance sleep leadership.

Future research priorities include:

 Optimization of interventions to promote a healthy sleep-wake cycle in operational

environments.

 Development of sleep strategy interventions (e.g., tactical combination of nocturnal sleep and
daytime napping schedules) to maximize performance and alertness in operational
environments.

 Identification of novel biomarkers that reflect and quantify an individual’s extant level of
sleep debt, and its implications for health and performance.

 Further development of ruggedized technologies for fatigue management on the battlefield.

 Development of individualized and unit-level technology for non-intrusive and non-invasive

monitoring, prediction, and prevention of fatigue-related performance decrements.

 Development of countermeasures to prevent and/or reverse circadian misalignment to

18
 maximize human performance during Multi-Domain Operations.

CONCLUSION

Sleep deprivation is common in the military, and impacts military performance and readiness.
Numerous factors, alone or in combination, can result in sleep deprivation, including operations
in austere environments not conducive to sleep, nighttime operations, sleep pathologies, and
several psychiatric conditions. It is recommended that the DoD establish policy to promote a
culture shift with regard to prioritizing adequate sleep in the military. In summary:

 Duty schedules must be adopted to ensure eight hours of sleep.

 Unit-level sleep trainer positions should be established.

 Training in sleep leadership should be implemented.

 Education and other steps should be taken to decrease caffeine use.

 Existing research-based strategies should be adopted to address travel-related circadian

rhythm disruption.

 Use of brief behavioral interventions and mobile applications for sleep disruption should be
expanded.

 A clearinghouse for military sleep-related resources should be established.

Adequate sleep is a key component of readiness. Although military leaders are increasingly
recognizing the importance of adequate sleep, further shifts in cultural attitudes regarding sleep
deprivation will help ensure the optimization and sustainment of Service member performance
and health.

19
 ACRONYMS

BIISS behaviorally-induced insufficient sleep syndrome

DoD Department of Defense
FY fiscal year
MHS Military Health System
OPTEMPO operations tempo
PTSD posttraumatic stress disorder
TBI traumatic brain injury

20
 DEFINITIONS

Operations Tempo The rate of U.S. military involvement in all military activities or unit
activity. Tempos are too high or low if they cause forces to lose their
capacity to sustain operations and meet crises. The most significant
negative impact of tempos that are too high is the reduction in time and
resources for relevant, necessary training—the basis of readiness and long-
term effectiveness.

Sleep Inadequate sleep that negatively impacts a Service member’s military

Deprivation effectiveness due to a reduced ability to execute complex cognitive tasks,
(Military) communicate effectively, quickly make appropriate decisions, maintain
vigilance, and/or sustain a level of alertness required to carry out assigned
duties.

Sleep At least one night of interrupted or partial sleep, typically

Deprivation operationalized as less than seven hours of sleep per night for adults.
(Partial)

Sleep A period of continuous wakefulness that exceeds 24 hours, or getting

Deprivation zero sleep time during the typical sleep-wake cycle.
(Total)

Sleep Partial sleep deprivation with at least one week during which an individual
Deprivation receives less than seven hours of sleep on most nights and is unable to get
(Chronic) sufficient recovery sleep to make up for lost sleep time.

Sleep Disruption Fragmented sleep due to periods of brief arousal, breathing interruptions,
or other mid-sleep awakening.

Sleep Banking Receiving extended sleep prior to known periods of sleep deprivation.

Sleep Trainer Unit-level personnel trained to facilitate sleep plans, monitor individual
sleep performance, and train unit members on behavioral strategies for
minimizing and mitigating sleep deprivation.

21
 ATTACHMENT 1: SUBTYPES OF SLEEP DEPRIVATION

Total Sleep Deprivation

Human studies demonstrate that total sleep deprivation negatively affects almost all cognitive
domains.272 Total sleep deprivation worsens performance the longer an individual goes without
sleep, and is related to deficits in attention, processing speed, accuracy, short-term and long-term
memory, decision-making, and reaction time.273 A meta-analysis shows that each successive day
of total sleep deprivation results in a 22 percent decrement in task accuracy at night and a seven
percent decrement in task accuracy during daylight hours.274 In addition, total sleep deprivation
significantly increases acute anxiety, decreases the ability to regulate emotions, and increases the
stress response, with worsening effects over 24–36 hours of total sleep deprivation.275
Neuroimaging studies suggest that total sleep deprivation has the same overall effects on the
brain as clinically significant symptoms of attention-deficit/hyperactivity disorder.276
Occupational studies indicate that total sleep deprivation decreases self-control, while increasing
hostility, risk-taking behavior, and deviant workplace behaviors (such as theft).277 Furthermore,
studies show that total sleep deprivation negatively affects several domains related to routine
work duties, such as receptive and expressive speech, memory, and verbal arithmetic.278 Thus, a
Service member with total sleep deprivation may be at greater risk of not fully comprehending
verbal instructions, remembering what was said in mission briefings, and having greater
difficulties articulating instructions when giving orders.

Studies of Service members demonstrate an association between significant declines in military

performance and total sleep deprivation. Overall estimates suggest that each 24-hour period of
total sleep deprivation results in a 25–35 percent degradation of cognitive task
performance.279,280 Among Navy SEAL Candidates, marksmanship speed and accuracy
significantly worsen after three days of total sleep deprivation.281 Soldiers with two days of total
sleep deprivation show significant decreases in marksmanship accuracy (61 percent overall) and
vigilance during urban operations (44 percent overall), with delayed reaction time for all tasks.282
A study of active duty military personnel demonstrated that more than 48 hours of total sleep
deprivation resulted in significant judgment impairment in moral scenarios, particularly in
emotionally charged situations.283 One night of sleep deprivation among F-117 pilots degrades
basic piloting skills by more than 40 percent.284 Other research shows that United States Military
Academy cadets undergoing 24 hours of total sleep deprivation demonstrate significant deficits
in learning to differentiate stimuli, which can have implications for differentiating types of
intelligence data or identifying whether a battlefield target is an ally or adversary.285 Over a 53-
hour training period with only three hours of sleep, Soldiers showed significant decreases in
cognitive functioning, to include attention, memory, and reasoning, as well as significant
symptoms of confusion and depression.286 Research conducted with Australian Army personnel
undergoing 40 hours of total sleep deprivation also replicated previous findings, which
demonstrated that several executive functions—to include inhibitory control, task-switching, and
vigilance—deteriorate with total sleep deprivation.287 These results indicate that sleep
deprivation can compromise core capabilities underlying military decision-making. Total sleep
deprivation can also have consequences that are more serious; reports from Norwegian officers
show that hallucinations are common during extended periods of total sleep deprivation.288
Taken together, these findings clearly demonstrate that sustained operations involving total sleep
deprivation negatively affect military performance.

22
Partial Sleep Deprivation
Partial sleep deprivation, also called sleep restriction, is more common than total sleep
deprivation. It can have noticeable effects following sleep reduction by only one hour per night;
these effects become far more pronounced when sleep is restricted to less than four to five hours
per night.289 Chronic partial sleep deprivation has been linked to a number of neurobehavioral
deficits, including attention lapses, slowed working memory, longer reaction time, thought
perseveration, and depressed mood, which can accumulate over several days to the same levels
after one–three nights of total sleep deprivation.290,291,292 A meta-analysis shows that partial
sleep deprivation primarily affects executive functioning, sustained attention, and long-term
memory, but may have more variable impact on multitasking, impulsive decision making, and
problem solving.293 The overall effect of partial sleep deprivation on cognitive functioning is
more pronounced if sleep deprivation is a loss of five or more hours of sleep per night (an 11
percent decrement), compared to a loss of two to five hours of sleep (a nine percent decrement),
and a loss of less than two hours of sleep (a three percent decrement).294 This meta-analysis also
indicates that over the course of one week, individuals typically experience a one percent loss in
task accuracy for each night of partial sleep deprivation, when getting five to six hours of sleep
per night, and a seven percent loss in task accuracy for each night of partial sleep deprivation,
when getting three to four hours of sleep per night.295 Demographic factors may affect overall
decrements associated with partial sleep deprivation. Within the military age range, cognitive
deficits due to partial sleep deprivation significantly increase with age, while partial sleep
deprivation has a lesser effect on sustained attention among women than men.296

Partial sleep deprivation compromises an individual’s emotional self-regulation abilities.297

Those with partial sleep deprivation experience greater levels of stress and anger when engaging
in low stressor tasks than those who are not sleep deprived.298 Other research shows that
complex cognitive task performance, such as working memory and team performance,
deteriorates the longer individuals undergo sleep deprivation, which creates a specific risk for the
impact of sleep deprivation when managing unexpected emergencies.299 This is especially
concerning in a military operational environment, where unit leaders often face significant and
unexpected crises. If these leaders are sleep deprived, it is likely that their reasoning abilities,
problems solving skills, and communication abilities are compromised, placing the mission and
Service members’ lives at risk.300

Specific to military contexts, partial sleep deprivation has a significant impact on mission-related
performance. In the combat environment, 28 percent of Service members reported falling asleep
during convoy operations, 13 percent reported falling asleep during mission briefings, and eight
percent of Service members reported falling asleep while on guard duty.301 Drowsiness is also a
significant cause of accidents in combat and training environments. For example, 46 percent of
Army drill sergeants reported falling asleep while supervising trainees, which could lead to
injuries and accidents during rifle marksmanship, obstacle courses, or land navigation.302
Approximately 40 percent of deployed Service members with less than seven hours sleep per
night reported a safety-related accident due to sleepiness, of which 21.7 percent of Service
members reported three hours of sleep or less.303 In a sample of Army aviation personnel who
received an average of less than seven hours of sleep per night, 72 percent reported they had
flown when drowsy enough to compromise safety, while 45 percent reported they had “dozed
off” while flying or in the cockpit.304 A subsequent study of Army aviation personnel also

23
identified that 49 percent of the study sample slept less than necessary, while 21 percent reported
“dozing off” while flying.305 In a field training environment, increased sleep deprivation among
Marines directly predicted worse performance on obstacle course tasks.306 U.S. Army field
training data suggest that effectiveness in key combat task performance degrades by 15–25
percent for each hour of partial sleep deprivation per night; an estimated 15 percent of total
combat effectiveness results when Soldiers sleep only four hours per night.307 Sleep deprivation
may also affect military leadership. Norwegian officer cadets averaging two to three hours of
sleep per night during combat survival exercises showed significant decreases in transformation
and transactional leadership behavior, but significant increases in passive-avoidant leadership
behavior.308

24
 ATTACHMENT 2: IMPACT OF SLEEP DEPRIVATION IN SPECIFIC MILITARY
CONTEXTS

A number of specific military contextual factors relate to the prevalence of sleep deprivation.
These factors include travel crossing multiple time zones, maladaptive sleep practices in
operational settings, and inhospitable sleep environments.

Travel Crossing Multiple Time Zones

Approximately 60 percent of individuals crossing at least two time zones experience circadian
rhythm disturbances or “jet lag” for at least one day following travel.309 When travelling east, an
individual will typically experience problems with falling and staying asleep; for westbound
travel, individuals typically experience problems staying asleep for the entire night.310 This
circadian rhythm disturbance results in partial sleep deprivation, typically between 30 minutes
and two hours.311,312,313 A number of factors predict the severity and duration of circadian
rhythm disturbance and accompanying partial sleep deprivation. A more significant effect is
seen for westbound travel, longer flight duration, greater number of time zones crossed, and
more hours of sleep lost during travel, as well as among older individuals.314 Total sleep time
and fatigue also may increase after travel across multiple time zones due to travel-related
disruptions and poor sleep environment.315 Scheduling of flights also plays a role in sleep
deprivation related to crossing multiple time zones. If passengers travel on overnight eastbound
flights (i.e., “red-eye” flights, or international flights that arrive early in the morning in the
destination time zone), then they will tend to have a greater number of hours of sleep deprivation
before sleeping the next night than typical westbound flights (which arrive late in the day).316
Travel-related circadian rhythm disturbances most frequently result in poor sleep and appetite
loss, with consequent tiredness during the day and poorer occupational performance.317,318
Studies consistently show that jet lag results in diminished performance on physical tasks,
particularly during the first 72 hours, even with sufficient sleep time.319,320,321 Studies among
high-performance athletes suggest that physical and mental adaptation to the new time zone
requires one half day per hour of time difference when traveling west, and one full day per hour
of time difference when traveling east.322,323 As a corrective strategy, reviews of the literature
differ on whether exogenous melatonin facilitates adjustment to new time zones.324,325,326

Mission-Related Maladaptive Sleep Practices

Occupational duty requirements may be the most prominent factor driving chronic partial sleep
deprivation among Service members. Unplanned and ad-hoc shift work, unpredictable
schedules, 24-hour duty assignments, and manning shortages all can result in sleep deprivation
among Service members.327 In both deployed and garrison settings, military personnel face
extended duty hours in order to accomplish all maintenance, training, and administrative duty
requirements.328 When deployed, between 15 and 21 percent of Soldiers report that high
operations tempo (OPTEMPO) results in partial or total sleep deprivation.329 Service members
in all branches report significantly greater rates of sleep deprivation during duty days (65 percent
reporting less than seven hours of sleep per night) compared to weekends (21 percent reporting
less than seven hours of sleep per night), indicating that the planned duty day plays a significant
role in sleep deprivation.330 A significant percent of Service members (36–38 percent of Soldiers
and 27–33 percent of Marines) indicate that the length of the duty day provides insufficient time
to complete personal business, resulting in restricted opportunity to sleep.331 Related to this

25
finding, only five to six percent of Service members report that off-duty leisure activities (such
as video games) contributed to sleep loss in deployed settings.332 Certain leader assignments
also may impose sleep deprivation due to occupational demands. For example, 93 percent of
U.S. Army drill sergeants report getting six or fewer hours of sleep per night while typically
working more than 14 hours per day for at least six days per week.333

Although sleep deprivation in the military has been compared to related occupational categories,
military Service members (55–76 percent) report significantly greater rates of partial sleep
deprivation than firefighters (46 percent), law enforcement officers (40 percent), and healthcare
professionals (40 percent).334 In fact, active duty military personnel were excluded from the
nationwide American Time Use Survey that assessed sleep due to the fact that military
occupational requirements would disrupt normal sleep schedules, when compared to the general
U.S. population.335 Culturally, maximum performance while sleep deprived has been touted as a
key skill for military personnel, and that operating on restricted sleep demonstrates
toughness.336,337 Attitudes toward sleep among military commands range from viewing sleep as
a controlled ration to asserting that a need for sleep is a sign of weakness.338 Despite reporting
significant sleep deprivation, only a minority of Service members indicate sleep deprivation
affects their overall job performance.339 Army surveys from 2009–2013 show that 27–34 percent
of Soldiers reported significant concern about not getting enough sleep, although this rate has
significantly decreased over time.340 Nonetheless, 56 percent of Service members indicate that
they get less sleep than needed to perform their military duties well.341 Leadership also plays a
significant role in whether Service members in a given unit suffer from partial sleep deprivation.
U.S. Army surveys indicate that only 26 percent of leaders encourage Service members to get
adequate sleep, 24 percent work to ensure an adequate sleep environment, and 35 percent
consider sleep as an important factor in operational planning, such as establishing an adequate
shift rotation that ensures sufficient sleep.342
A number of studies investigated the impact of shift work in military populations. While
deployed, between 32 and 40 percent of Soldiers report that nighttime duties significantly affect
sleep.343 Air Force night shift workers report significantly greater sleep problems than day shift
workers.344 A comparison of duty watch schedules among Navy personnel showed that the five-
hour on ten-hour off duty watch schedule resulted in significantly more sleep per day (6.9 hours
of sleep) compared to six-hour on/six-hour off (5.9 hours of sleep) or modified six-hour
on/eighteen-hour off (5.7 hours) duty watch schedule, but equivalent to a three-hour on/nine-
hour off (6.5 hours of sleep) duty watch schedule.345 However, the rotating circadian pattern of
the five-hour on/ten-hour off duty watch schedule caused a recurrent pattern of changing sleep
time that also resulted in repeated instances of Sailors getting only four hours of sleep prior to a
20–22 hour period of sustained wakefulness.346 Furthermore, Sailors on the five-hour on/ten-
hour off and six-hour on/six-hour off duty watch schedules showed decrements in psychomotor
vigilance compared to the other schedules.347 Another evaluation showed that Navy personnel
preferred eight-hour duty shifts to twelve-hour duty shifts, with eight-hour shifts associated with
fewer errors in tasks requiring psychomotor vigilance, although both shifts generally entail less
than seven hours of sleep per day.348 Similar research examined shift cycles and sleep onboard
submarines. Without light controls on an 18-hour duty submarine cycle, Service members did
not show regular sleep and wake patterns, demonstrating that social cues (e.g., meals, clocks)
were insufficient to establish circadian rhythm.349 However, a comparison of the 18-hour duty
schedule (6-hour on/12-hour off) to a compressed schedule designed to synchronize with the 24-

26
hour clock demonstrated that crew members tended to sleep more on the 18-hour schedule (7.1
hours per night) than the 24-hour schedule (6.3 hours per night).350 A study of a French
submarine crew on a three-day (72 hour) shift rotation that included 28 hours set aside for sleep
with specific light level controls showed that members were able to maintain total sleep time
between 6.5–7 hours of sleep per night throughout a 70-day period.351 Other evaluations have
shown that Army aviation personnel assigned to the night shift frequently report working
between 10–14 hours per shift, and typically get less than six hours of sleep per night.352 In
contrast, adhering to strict safety standards to ensure adequate sleep between duty shifts can
significantly affect reported sleep deprivation. Data from the Behavioral Risk Factor
Surveillance System show that air transportation workers in the United States, who must adhere
to federal standards for sleep between shifts, have one of the lowest rates (21 percent) of reported
sleep deprivation.353 Taken together, these findings suggest that scheduling specific time in the
duty day for sufficient sleep may be the best method of maintaining 24-hour operations without
contributing to sleep deprivation.

A specific type of military readiness involves the ability to execute sustained operations
(SUSOPS), which involve exposure to extreme situations and severe environmental conditions
for several days without the opportunity for full physical recovery to baseline (i.e., sleep or
nutrition).354 The intent of SUSOPS is to simulate the demands of potential combat situations
that would not allow for scheduled rest or meals for a period of two to seven days.355 Studies on
the effects of SUSOPS typically have examined partial to total sleep deprivation, with less than
three hours of uninterrupted sleep over a period of up to nine days.356 Reviews show that
SUSOPS exercises significantly decrease task vigilance, reaction time, reasoning ability, and
working memory, with a consistent decrement in performance by 25 percent for each day of
near-total sleep deprivation.357,358 In addition, SUSOPS increase risk of bone fractures, loss of
muscle mass, and sleep-related physical decrements.359 Although 24-hour operations have
become the norm for the U.S. military over the past two decades, it is important to note that 24-
hour operations are not analogous with SUSOPS.360 Whereas SUSOPS training may be required
to establish capability, it must not be assumed that Service members can function regularly in a
SUSOPS environment. Regular 24-hour operations require sufficient sleep periods to ensure that
Service member performance and readiness do not degrade.361,362,363 If a period of SUSOPS is
required for two to three days due to emergency or disaster relief situations, Service members
require at least a 12-hour sleep recovery period during nighttime hours to restore normal
functioning.364 In a mature battlespace, SUSOPS should not be required except in emergency
situations, and military commanders should be able to establish regular sleep cycles for their
units.365,366

Uncomfortable and Inhospitable Sleep Environments

Due to the nature of military operations in austere locations worldwide, a number of
environmental factors in combat, training, and operational settings may contribute to sleep
deprivation.367 Between 27 and 35 percent of deployed Army personnel surveyed during 2010–
2013 reported that poor sleep environment impacted their ability to get sufficient sleep.368
Although Service members may be encouraged to “sleep whenever you can” in operational
settings, it is unlikely that sleeping in tactical vehicles, military aircraft, large transient tents or
hangars, or near machinery is restorative.369 Deployed Air Force personnel reported that loud
noise outside sleeping tents, uncomfortable beds, loud noise inside sleeping tents, and

27
uncomfortable heat/cold were the most common environmental factors that affected sleep.370 A
study among deployed aircrews from the Royal New Zealand Air Force similarly reported that
decibel levels and temperatures in the sleeping quarters exceeded comfortable levels frequently
overnight and regularly during the daytime.371

Ambient temperature is an important environmental factor that can contribute to partial sleep
deprivation.372 When deployed to warmer climates, Service members may require several days
for the regulation of their core body temperature to normalize, which results in partial sleep
deprivation.373, Summer nighttime temperatures in Iraq and Afghanistan during Operation
IRAQI FREEDOM and Operation ENDURING FREEDOM frequently exceeded ideal ranges
for sleep initiation.374,375 When daytime temperatures in the deployed environment exceed 90°F,
most base construction projects occur at night; however, this causes significant noise that
disrupts the sleep of Service members in tents.376 Furthermore, most U.S. military basic training
sites are in locations with daytime temperatures exceeding 90°F for more than 50 days per year,
potentially contributing to sleep deprivation among trainees.377 Due to the impact of extreme
temperatures on sleep deprivation among Service members, air conditioning infrastructure is
critical in deployed and field settings.378 Conversely, military trainees also report they receive
insufficient bedding to stay warm during the night in barracks, which contributes to partial sleep
deprivation.379

Occupational factors also can interact with environmental factors to worsen sleep deprivation.
Problems caused by shift work during 24-hour operations can be exacerbated by light and noise
contamination, if crew sleeping areas are not set aside from daytime operation personnel, not
adequately blacked out to ensure darkness, or are still used for mission-related tasks (such as
obtaining keys or log books).380 In initial entry settings, trainees reported several factors that
disrupt sleep, such as excessive noise in communal sleeping areas, light contamination from
security lights, and rotational nighttime duties that woke both the trainees and their
bunkmates.381 Furthermore, co-location of crew sleeping areas with work areas—such as flight
crews sleeping near the airfield—tends to contribute to significant sleep disruption due to noise
in 24-hour operational environments.382 All of these factors suggest that maintaining adequate
sleep for personnel should be a primary consideration in establishing operational rotations, work
locations, and standard operating procedures.

28
 ATTACHMENT 3: PHARMACOLOGICAL INTERVENTION TO SUPPORT
OPERATIONS TEMPO

Caffeine
On average, Service members consume approximately 212mg to 285mg of caffeine per day, with
significantly greater consumption among men than women.383,384,385 In comparison, U.S. adults
consume an average of 165mg–210mg of caffeine per day.386,387,388 However, rates of caffeine
consumption among military recruits appear to be generally comparable to high school and
college samples.389 Reviews on the health effects of caffeine suggest that daily consumption of
400mg of caffeine or less is typically safe.390,391 Military recommendations for maximum daily
caffeine intake range from 400mg–1000mg, but acknowledge that subsequent side effects may
occur.392,393,394 Caffeine can be lethal at overdose levels of 10,000mg or higher.395 Doses of
400mg of caffeine have been shown to cause partial sleep deprivation of at least one hour, if
consumed up to six hours before bedtime.396

Evidence synthesized from across military and civilian studies demonstrates some support that
moderate doses of caffeine (approximately 300mg) can maintain levels of alertness, attention,
vigilance, and reasoning during sleep deprivation.397,398 Nonetheless, caffeine may not have
comparably positive effects on memory, judgement, or decision making during sleep
deprivation.399,400 In addition, caffeine doses over 200mg show positive effects on physical
performance, including time-trial or sprint speed, muscle strength and endurance, and time-to-
exhaustion.401 Caffeine use may need to be monitored or limited during periods of prolonged
sleep deprivation. For example, although caffeine can improve functioning temporarily during
sleep deprivation, 300mg of caffeine is generally no better than 200mg for restoring cognitive
performance during 48 hours of total sleep deprivation.402 This suggests that for most people and
under most conditions, a dose of 200mg caffeine may occupy the majority of available adenosine
receptors in the brain, so that doses in excess of 200mg provide diminishing returns. A number
of military studies examined the use of caffeine to ameliorate the effects of partial and total sleep
deprivation during training and operational tasks. In field training settings, several positive
effects of caffeine have been identified. In a study of SEAL candidates with 72 hours of near-
total sleep deprivation, doses of 100mg to 300mg of caffeine did not improve marksmanship, but
doses of 200mg and 300mg of caffeine significantly improved vigilance, reaction time, and
alertness compared to a placebo condition.403 Similarly, in studies of special forces personnel
undergoing field training, 200mg doses of caffeine maintained vigilance during overnight field
observation tasks compared to placebo, as well as improving four-mile run times; however,
marksmanship accuracy and speed were not affected by caffeine.404,405,406,407 Several of these
findings also have been replicated in international military settings.408 Physical performance
during field tasks while sleep deprived also can be maintained with caffeine, such as findings
that a 600mg dose of caffeine helps sustain performance during a forced march, treadmill run,
and sandbag piling task.409 In contrast to studies showing no effect of caffeine on
marksmanship, only one study has shown that caffeine maintained marksmanship performance
compared to placebo during sleep deprivation, although this may have been due to factors such
as caffeine-related enhancement of “sighting time” or “target selection” (i.e., factors that vary
from study to study) rather than differences in shooting accuracy, per se.410,411,412,413

29
Caffeine formulation may also be an important consideration for military operations, especially
when caffeinated drinks are unavailable. Studies using caffeine gum have shown that
administration can be effective for minimizing fatigue after being awakened in the middle of the
night, and that caffeine gum can significantly reduce the negative effects of partial sleep
deprivation on alertness and performance for at least three days.414,415 Several studies among the
French Armed Forces suggest that slow-release caffeine capsules are effective in maintaining
cognitive performance during total sleep deprivation of 2–3 days, including positive effects on
reaction time, attention, and executive functioning without negative effects on subsequent
recovery sleep. 416,417,418

Studies among aviation personnel have shown less consistent results. A study of 111 combat
operation sorties showed that 86 percent of F-15E aircrew regularly used caffeine (with typical
daily doses of 200–300mg), 63 percent of sorties were conducted after consuming caffeine, and
caffeine was used during flight in 13 percent of sorties.419 In a study of U.S. Air Force pilots in a
U2 simulator, two doses of 200mg of caffeine (400mg total) allowed pilots to maintain cognitive
task performance during a 9-hour total sleep deprivation period.420 However, 200mg doses of
caffeine did not reverse the decrements in flight simulator performance among Finnish military
pilots after 37 hours of sleep deprivation; although pilots receiving caffeine reported
overconfidence in performance, and overestimated their own performance level.421,422
These findings notwithstanding, the intent of controlled caffeine administration in these settings
is to maintain operational performance at typical levels when Service members are sleep
deprived.423 The efficacy of caffeine and other psychostimulants is transient, and can delay—but
not replace—the need for sleep.424 The positive effect of caffeine on performance maintenance
during sleep deprivation has only been identified over a 48–72 hour period of continuous
wakefulness. Thus, the findings reviewed should not be generalized to settings in which Service
members are continuously ingesting caffeine at the same levels (such as through energy drinks)
over extended periods of partial sleep deprivation.425,426 Other studies suggest reduced
effectiveness of caffeine following consistent dosing for three days of partial sleep
deprivation.427 High doses of caffeine also can affect subsequent recovery sleep following total
sleep deprivation.428 Overuse or misuse (e.g., too close to bedtime) of stimulants in military
environments can disrupt sleep patterns, resulting in a greater need for caffeine during the day to
stay awake, potentially creating a “vicious circle” of increasing use of caffeine in the daytime
prompted by increasingly caffeine-disrupted nighttime sleep.429

Energy Drinks
Although coffee is the most prevalent source of daily caffeine among Service members overall,
energy drinks are the most common source among younger Service members.430 Energy drinks
are considered dietary supplements, with caffeine content typically ranging from 80–300mg per
serving.431 Data from the National Health and Nutrition Examination Survey (NHANES) shows
that 2.7 percent of the general U.S. population regularly consumes energy drinks, with the
highest use (7.6 percent) among younger men (ages 19–30).432 In contrast, studies show
significantly higher rates of energy drink consumption in the U.S. military. For example, a
survey of military personnel in operational, training, and medical settings found that 53 percent
of Service members consumed at least one energy drink in the past 30 days, and 38 percent
consumed an energy drink one or more times per week.433 U.S. Army personnel are the most
frequent users of energy drinks (54 percent), and U.S. Air Force personnel (26 percent) are the

30
least frequent.434 Studies of U.S. Army and U.S. Marine Corps personnel stationed in
Afghanistan showed that 45 to 60 percent of Service members consumed at least one energy
drink per day, with five percent consuming five or more energy drinks per day.435,436 Other
deployed samples show that 43 percent of Soldiers increase consumption of energy drinks while
deployed.437 However, this trend may be the result of increased availability of certain brands of
energy drinks in deployed settings, often due to contract purchasing.438 Increases in energy drink
consumption during deployment also may continue after Service members return home.439
Although the Navy and Marine Corps prohibit consuming energy drinks prior to flying military
aircraft, a significant proportion of pilot candidates report a history of utilizing energy drinks to
stay alert.440 Similarly, 41 percent of surveyed Army pilots reported regular use of energy
drinks.441

Energy drink consumption also carries significant health risks for those who are sensitive to the
effects of caffeine, or who consume excessive amounts of caffeine. Several cases of acute
cardiovascular events (including cardiac arrest, myocardial infarction, spontaneous coronary
dissection, and coronary vasospasm) related to energy drink consumption have been identified in
the past several years, with the majority of these cases showing no prior risk of cardiac
disease.442,443 Randomized trials of energy drink consumption show that they increase blood
pressure, heart rate, QTc interval, and cerebrovascular resistance, significantly stressing overall
cardiovascular function.444,445,446 Nationwide emergency room visits related to consumption of
energy drinks number in the tens of thousands, and at least 34 deaths have been attributed to
energy drink consumption (frequently in combination with other drugs).447 Caffeine
consumption at the levels commonly found in energy drinks also can significantly contribute to
insomnia and associated partial sleep deprivation.448 Service members who regularly use energy
drinks frequently report problems sleeping, although it is unclear whether this energy drink use is
the cause of partial sleep deprivation or in response to partial sleep deprivation.449 Among
Service members in Afghanistan, those consuming three or more energy drinks per day were
significantly more likely to report sleeping four or less hours per night.450 Sixty percent of
Soldiers who report being on sleep medications also report consuming at least one energy drink
per day, compared to a significantly lower proportion of Soldiers (43 percent) who are not on
sleep medications but report daily energy drink consumption.451 In contrast to studies on
carefully dosed caffeine during military tasks, energy drinks likely provide an irregular dose of
caffeine at various intervals, possibly nullifying potential benefits and exacerbating operational
risk. Furthermore, given that many energy drinks contain several active substances in addition to
caffeine, the effects of these supplements, either alone or in combination with caffeine, have yet
to be fully identified.452

Modafinil and Dextroamphetamine

The prescription drug dextroamphetamine is approved for use under the direction of a flight
surgeon in U.S. Army, U.S. Navy, U.S. Air Force, and U.S. Marine Corps aviation.453,454,455,456
The prescription drug modafinil is also approved for use under the direction of a flight surgeon in
the U.S. Air Force, depending on specific Major Command guidance.457 A recent study on the
prevalence of these drugs in combat aviation operations showed that pilots used either
dextroamphetamine or modafinil in 35 percent of combat sorties.458 Research on these
psychostimulants generally shows that they are safe and effective in counteracting fatigue during
combat or other emergency situations, especially when strict dosing and recovery sleep

31
guidelines are followed.459 Studies on the use of modafinil have generally shown that this drug
restores and sustains (for several hours) performance during total sleep deprivation. Doses of
modafinil from 200mg to 400mg have been effective in maintaining performance on cognitive
tasks after 48 hours of total sleep deprivation.460 In a study of U.S. Army helicopter pilots, a
200mg dose of modafinil maintained flight simulator performance after 40 hours of total sleep
deprivation.461 A similar study of U.S. Air Force F-117 pilots showed that three 100mg doses of
modafinil maintained flight performance during 37 hours of total sleep deprivation.462 A
combined analysis of five studies of military pilots across various settings showed that modafinil
and dextroamphetamine each were effective in counteracting the performance decrementing
effects of sleep deprivation.463 Similarly, a study of military helicopter pilots during flight
operations with total sleep deprivation of 40 hours showed that modafinil and
dextroamphetamine each were effective in maintaining alertness, cognitive functioning, and
overall performance.464 When directly comparing modafinil to dextroamphetamine and caffeine,
research has shown that each of these drugs is effective in counteracting fatigue associated with
total sleep deprivation, but also that each remains effective for different durations, and each is
differentially effective for restoring performance on different subsets of tasks.465,466,467 These
results notwithstanding, because of the abuse potential and side effects associated with these
relatively strong stimulants, they should only be applied as a last resort—that is, after all other
options for ensuring adequate aircrew rest (especially protected sleep time) have been
exhausted.468 Caffeine remains the only stimulant allowed for military aviation use in several
countries.469,470 Despite the consistent use of these pharmacological interventions to maximize
human performance in limited military aviation settings, ethics principles advocate that such
means should only be employed in emergency situations, arguing against expansion of such
interventions in other military settings. 471,472,473

Sedative-Hypnotics
Prescription sedative-hypnotic drugs have been used in military contexts. These drugs are most
effective for short-term use to promote sleep in inhospitable military environments, to counteract
circadian adjustment associated with jet lag, or to facilitate work shift transitions.474
Approximately 11 percent of Service members report the use of prescribed sedative-hypnotics to
facilitate sleep in deployed settings.475 In one study of combat aviation missions, 23 percent of
sorties were flown after aircrew members had used sedative-hypnotic drugs to facilitate sleep
prior to missions.476 Another study of remotely piloted aircraft operators during combat
operations showed that sedative-hypnotics were effective in facilitating rapid shift changes
associated with a capacity surge without significant side effects or mission impact.477 Studies on
workplace and operational applications of short-term sedative-hypnotic drug use have shown
some benefits. A study of U.S. Army pilots working night shift showed that assisting daytime
sleep with sedative-hypnotics resulted in better nighttime alertness and psychomotor vigilance.478
Several other studies have shown similar benefits to sedative-hypnotic sleep facilitation prior to
periods of total sleep deprivation.479,480,481 In addition, a military study showed that sedative-
hypnotic drugs significantly improved sleep under noise interference conditions.482 These
findings suggest that sedative-hypnotic medications may be useful for facilitating sleep and
subsequent alertness and performance under a variety of conditions. However, these effects may
not be realized with short sleep periods (less than eight hours), because performance-impairing
“drug hangover” effects may outweigh the benefits obtained from the shortened, hypnotic-
induced sleep.483,484

32
Sedative-hypnotics are often used to treat partial sleep deprivation related to clinical sleep
conditions. Between 2009 and 2015, approximately 2.4 million prescriptions for sedative-
hypnotic medications were given to active duty Service members.485 The adjusted rate of
sedative-hypnotic use significantly increased over this period among active duty Service
members from approximately 6 to 8 percent.486 This is also significantly higher than the rate of
three percent among a nationally representative study sample.487 Long-term use of sedative-
hypnotic drugs by Service members to decrease sleep deprivation is not recommended.488
Recent guidelines recommend only brief treatments with these sleep medications to help restore
sleep to baseline; behavioral interventions are recommended for long-term treatment of
conditions that contribute to sleep deprivation.489 Sedative-hypnotic drugs have a wide range of
side effects that can directly impact mission readiness, including daytime fatigue, dizziness,
anxiety, drowsiness, depression, disinhibition, sleepwalking, impaired cognition, learning
deficits, and increased risk of motor vehicle accidents.490,491,492,493 For this reason, any use of
sedative-hypnotics (other than single administration for operational transition) is typically
disqualifying for deployment.494

33
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Meadows, S. O., Engel, C. C., Collins, R. L., Beckman, R. L., Cefalu, M., Hawes-Dawson, J.,
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Heaton, K. J., Maule, A. L., Maruta, J., Kryskow, E. M., & Ghajar, J. (2014). Attention and
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