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NEUROLOGY &
SLEEP DISORDERS

group cognitive-behavioral therapy for insomnia. Historically, this stress disorder (PTSD) and sleep disorders in the deployed setting,
treatment had almost always been delivered to patients on an indi- there was a dearth of data—in fact, not a single clinical trial had
vidual basis. However, with the large number of patients being re- ever been conducted on combat-related PTSD or sleep disorders
ferred for the treatment of insomnia, we developed and evaluated in military personnel in deployed or non-deployed settings.
a group CBT-I program including 42 consecutively treated patients Nonetheless, I modified evidence-based treatment protocols devel-
in the Wilford Hall Insomnia Program (Hryshko-Mullen et al., oped for civilian traumas, collected outcome data, and published
2000). The results indicated that sleep onset latency (time it takes the results, which were very promising (Cigrang, Peterson, & Schob-
to fall asleep) was improved by 53 percent, wake after sleep onset itz, 2005). Several deployed service members with severe PTSD
was decreased by 40 percent, and sleep efficiency (ratio of total time symptoms were able to be treated into remission in about four in-
sleeping compared to time in bed) was improved by 22 percent. dividual prolonged exposure treatment sessions. These individuals
These results compared favorably with data from previous studies were able to return to duty and successfully completed their deploy-
of individual CBT-I. ments rather than being aeromedically evacuated out of theater.
Soon after the publication of our group CBT-I study in 2000, the Upon my return from my deployment to Iraq in 2005, I decided
terrorist attacks on America occurred on September 11, 2001. Be- to retire from active duty after having completed 21 years of service.
fore long, I was deployed with the U.S. Air Force in support of Op- I was greatly impacted both personally and professionally from my
eration Enduring Freedom (OEF). Our deployment was to an deployment to Iraq. I knew that something needed to be done to
undisclosed, classified location that was in the midst of being con- help develop and evaluate evidenced-based treatments for deploy-
structed as we arrived. A few weeks into our deployment, a major ment-related psychological health conditions in active duty military
aircraft accident almost occurred during the takeoff of a fully fueled personnel. At the time, I had two projects funded by the National
KC-135 refueling plane. The subsequent investigation revealed that Institutes of Health (NIH) and three by the Department of De-
sleep deprivation in the pilot was a major factor related to the near fense (DoD) in the areas of behavioral medicine. I interviewed with
miss. Consequently, I was asked to assess the overall sleep condi- the chair of the Department of Psychiatry at UT Health San Anto-
tions in our deployed location and to make recommendations for nio and was offered a faculty position so I could focus fulltime on
possible improvements. my research.
I was able to collect data on the symptoms of sleep disturbance
and insomnia in a group of 156 deployed military personnel (Peter-
son, Goodie, Satterfield, & Brim, 2008). The results indicated that
about three quarters of deployed service members (74 percent) rated
their quality of sleep as significantly worse in the deployed environ-
ment, 40 percent had a sleep efficiency of less than 85 percent, and
42 percent had a sleep onset latency of greater than 30 minutes.
Night-shift workers had significantly worse sleep efficiency and more
problems getting to sleep and staying asleep as compared to day-
shift workers. The results of the study highlighted the need for pro-
grams to help deployed military members get more and better sleep.
In 2004-2005, I deployed as a military clinical psychologist to Iraq
in support of Operation Iraqi Freedom and was assigned to the Air
Force Theater Hospital at Balad Air Base, Iraq. It was during this
deployment that I saw firsthand the impact of combat-related phys-
ical and psychological trauma on the troops deployed to the combat Immediately after arriving at UT Health San Antonio, I began
theater. The combat-related stress disorders and sleep problems I working on NIH, DoD, and private research grant submissions. In
observed in Iraq were even more widespread than what I had ob- 2007, the DoD published a request for applications to fund a Mul-
served during my OEF deployment. tidisciplinary PTSD Research Consortium. This was just the oppor-
When I reviewed the scientific literature to help guide me in the tunity I was looking for, and I compiled a comprehensive grant
use of evidence-based treatments for combat-related post-traumatic application in collaboration with many of the top PTSD investiga-
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