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We appreciate the insightful commentary from Drs Mysliwiec and Roth on our article (September 2012),¹ and agree that many patients in our study potentially had insomnia that was refractory to pharmacotherapy. Given the retrospective nature of this study and complex nature of the included patients, the evaluation of insomnia was challenging. We acknowledge that our categorization of these patients potentially led to an underestimation of the rate of insomnia in our population. This was, in part, by intent, as we felt that using more stringent diagnostic criteria provided a more realistic assessment of our population. Sleep fragmentation and difficulties initiating and maintaining sleep were nearly universal in our population. By nature of the cohort, several had chronic pain, anxiety, psychiatric disease, polypharmacy, and underlying sleep-disordered breathing that could contribute to their sleep disruptions. Given that most insomnia is comorbid, it would have been reasonable for us to report a much higher prevalence in our cohort. However, we chose to use a narrow definition that reflected those we felt had true insomnia and not just a manifestation of some other, more likely factor (ie, subjective sleep latency ≥30 min during the majority of nights or subjective sleep fragmentation associated with daytime impairment not better explained by sleep disordered breathing, pain, or other more identifiable factors).¹

The contribution from polypharmacy is likewise a challenge in a retrospective study where there is near universal use of psychoactive medications. Because multiple specialties are involved at varying points in time in prescribing these medications, and because most are indicated for psychiatric disease and pain, it is difficult to assess their impact in regard to treating the intended condition, and potential harms.

As discussed in our study¹ and much of the literature on sleep disturbances in returning soldiers, this is a complicated population and will be for some time. Several health-care challenges are at play: chronic pain and ongoing rehabilitation from complex traumatic injuries; a military-wide culture that contributes to short sleep duration²; substance abuse; comorbid insomnia; sleep-disordered breathing; comorbid psychiatric disease including posttraumatic stress disorder, depression, nightmare disorder, and generalized anxiety; and polypharmacy. Insomnia is often difficult to treat effectively and adversely impacts multiple aspects of patients’ care. In particular, comorbid insomnia is known to adversely impact CPAP compliance,^3,4 limiting effective treatment of sleep-disordered breathing in an already compromised population. Given the limitations of pharmacotherapy in treating insomnia in returning soldiers, it may be more valuable to focus on nonpharmacologic therapies such as cognitive behavioral therapy and imagery rehearsal therapy. This has been used successfully in recent populations of veterans.⁵ A comprehensive sleep-medicine evaluation including polysomnography is critical given the high prevalence of obstructive sleep apnea in this population. Another potential option would be multidisciplinary clinics. Simultaneous input from pain medicine physicians, physical medicine and rehabilitation specialists, psychiatry, and sleep medicine would offer the most efficient route to managing polypharmacy. As these patients leave the care of the military health-care system and return to civilian life, they will be increasingly treated by nonmilitary physicians. Knowledge of the factors that impact their disease process is critical in providing effective care and will be for years to come.