1. SLEEP: A Core Component of Mental Readiness Anne Germain, Ph.D. Associate Professor of Psychiatry & Psychology University of Pittsburgh School of Medicine Military Sleep Tactics and Resilience Research Team germax@upmc.edu 24 June 2014 Anne Germain, Ph.D. 24 June, 2014

2. M ILITARY S LEEP T ACTICS AND R ESILIENCE R ESEARCH T EAM : Robin Richardson, Ryan Stocker, Oommen Mammen, Rachel Good, Tyler Conrad, Becky McNamee, John Skicki, Noelle Rode, Hassen Khan WPIC/UPMC R ESOURCES : NCTRC, WPIC Pharmacy, UPMC Central Lab, UPMC MR Center. UPMC PET Center F UNDING AGENCIES : Department of Defense; National Institutes of Health Anne Germain, Ph.D. 24 June, 2014

3. “In peace and war, the lack of sleep works like termites in a house: Below the surface, gnawing quietly and unseen to produce gradual weakening, which can lead to sudden and unexpected collapse.” Maj. Gen. Aubrey “Red” Newman, Follow Me, 1981 Anne Germain, Ph.D. 24 June, 2014

4. Building Mental Readiness through Sleep CHALLENGES The good ones The not so good ones The bad ones RESOURCES Training /expertise Equipment Reliable Team External Support PROBLEMS when: Unavoidable insult Overuse/abuse Poor maintenance Wrong team Cut from support Anne Germain, Ph.D. 24 June, 2014

5. Sleep: a fundamental brain function Serves a basic biological needs Essential for survival and sustaining homeostasis Alertness and vigilance Emotion regulation and executive functions Learning and memory Cardiovascular & immune functions Can (temporarily) adapt to demands and conditions: Like (mal)nutrition, chronic sleep deficiency and fatigue will compromise health, fitness, readiness, and performance, and lead to organ (brain) failure. Anne Germain, Ph.D. 24 June, 2014

6. Sleep Across the Deployment Cycle Adapted from Seelig, et al., 2010 Anne Germain, Ph.D. 24 June, 2014

7. Non-Deployed Service Members Sleep LESS than Civilians Anne Germain, Ph.D. 24 June, 2014

8. TBIPTSD Anne Germain, Ph.D. 24 June, 2014

9. Stress Pre-existing Sleep Disturbances Poor Outcomes SLEEP : Core Component of Brain Health Sleep Consolidation Mental Readiness PTSD Anxiety disorders Depression/Suicidality Addictive disorders Chronic mTBI Sleep Disturbances Anne Germain, Ph.D. 24 June, 2014

10. Sleep disturbances are VISIBLE Operational Stress Injuries OEF/OIF with PTSD > OEF/OIF without PTSD NREM (deep) Sleep> Wakefulness Anne Germain, Ph.D. 24 June, 2014 OEF/OIF with PTSD > OEF/OIF without PTSD REM (dream) SLEEP Germain et al., 2011  Threat detection  Vigilance  Goal-oriented behaviors  Threat detection  Vigilance  Goal-oriented behaviors

11. Germain et al., J Psychosom Res, 2012 Sleep: A modifiable risk factor & treatable OSI Diary Nightmare Frequency d= 0.9Insomnia Severity Index d= 2.14 PTSD Checklist d=.85 Anne Germain, Ph.D. 24 June, 2014

12. Sleep: A modifiable risk factor & treatable OSI To distill principles of sleep regulation into 4 sleep-promoting behaviors, 1. Get up at the same time every day 2. Don’t nap 3. Don’t go to bed unless sleepy 4. Don’t stay in bed unless asleep Develop an intervention package, based on empirical findings and specifically aimed at enhancing resilience through sleep and fatigue management in deployed military personnel. Brief behavioral treatment of insomnia (BBTI-MV; 2 sessions/4 weeks) Warfighter Sleep Kit Anne Germain, Ph.D. 24 June, 2014

13. Self- management Diary and tracking BBTI IRT Monitoring Reinforcing Case-by-case modifications Thought control Reminders Courtesy of Dr. Bambang Parmanto, University of Pittsburgh Mindfulness User appClinician Portal Anne Germain, Ph.D. 24 June, 2014

14. Army Medicine, 2013

15. TEAM-TBI (PI: Okonkwo, University of Pittsburgh) Anne Germain, Ph.D. 24 June, 2014

16. Software Digital Sleep Diary IREST mHealth Tools Physical Fit Bit Sleep Mask Ear plugs Software Breathe 2 Relax Mindfulness Techniques Physical Fit Bit Vestibular Exercise Videos OCULAR MOTOR ANXIETY/MOOD VESTIBULAR SLEEP COGNITIVE MIGRAINES/ CERVICAL ? Ocular motor Exercise Videos Good Days Ahead Stick N Find GENERAL iPad Mini IMAGING Software HDFT Report App TEAM TBI Trajectory Map

17. Summary 1. Sleep is a core component of mental readiness. 2. Sleep disturbances compromise mental readiness. 3. Sleep disturbances are a modifiable risk factor. Evidence -based behavioral or pharmacological strategies. 4. Interventions focused on promoting sleep health can enhance brain health and resilience, and accelerate recovery from operational stress injuries. Need to package intervention tools into military-relevant tools. Germain, Ph.D. 24 June, 2014