Clinical Characterization of Insomnia among Veterans with PTSD: Identifying Risk Factors for Diagnosis and Treatment with Sedative-Hypnotics

Abstract

Insomnia is prevalent among Veterans with post-traumatic stress disorder (PTSD), it exacerbates PTSD symptoms, and it contributes to impaired functioning and quality of life. To improve treatment outcomes, it is important to identify risk factors for insomnia and sedative-hypnotic use. Classification and regression trees and logistic regression models were used to identify variables associated with insomnia or sedative-hypnotic use. Key findings include low insomnia diagnosis rates (3.5–5.6%) and high rates of sedative-hypnotics (44.2–49.0%). Younger Veterans and those without a breathing-related sleep disorder (BRSD) were more likely to receive an insomnia diagnosis. Veterans with greater service connection and those with an alcohol/substance use disorder were more likely to be prescribed sedative-hypnotics. Interaction terms may have identified potential groups at risk of being under-diagnosed with insomnia (i.e. non-black Veterans with psychiatric co-morbidity, black Veterans without psychiatric co-morbidity) as well as groups at risk for sedative-hypnotic use (i.e. younger Veterans without BRSD). In sum, Veterans with PTSD have high rates of sedative-hypnotic use despite minimal evidence they are effective. This is counter to recommendations indicating behavioral interventions are the first-line treatment. Policy changes are needed to reduce use of sedative-hypnotics and increase access to behavioral insomnia interventions.     

Moral Aspects of “Moral Injury”: Analyzing Conceptualizations on the Role of Morality in Military Trauma

In clinical circles, the concept of “moral injury” has rapidly gained traction. Yet, from a moral philosophical point of view the concept is less clear than is suggested. That is, in current conceptualizations of moral injury, trauma’s moral dimension seems to be understood in a rather mechanistic and individualized manner. This article makes a start in developing an adequately founded conceptualization of the role of morality in deployment-related distress. It does so by reviewing and synthesizing insights from different disciplines into morality and trauma. This discussion will lead to three positions: (1) values and norms are by definition characterized by conflict, (2) moral conflict may entail important social dimensions, and (3) moral conflict may lead to altered beliefs about previously held values. These insights provide important steps in further developing conceptions of the role of morality in deployment-related suffering.