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Volume 14 No. 07
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Accepted Papers

Letters to the Editor

Nightmares in United States Military Personnel Are Multifactorial and Require Further Study

Jennifer L. Creamer, MD1; Matthew S. Brock, MD2; Vincent Mysliwiec, MD2
1Martin Army Community Hospital, Sleep Medicine Center, Fort Benning, Georgia; 2San Antonio Military Medical Center, Department of Sleep Medicine, JBSA-Lackland, Texas

We appreciate the thoughtful commentary on our article evaluating nightmares in United States military personnel with sleep disturbances.1,2 At the San Antonio Military Health System Sleep Disorders Center, which is the largest sleep laboratory in the Department of Defense, we are aware of the high rate of patients affected by nightmares and the associated clinical and nocturnal distress that nightmares cause. This has led us to having a focus on this sleep disorder in our clinical practice and research on parasomnias to include nightmares and a novel parasomnia, trauma associated sleep disorder.3,4

In our clinical experience, as well as the other sleep physicians who work in our sleep disorders center, none of us have diagnosed a patient with a persistent clinical sleep disorder, nightmares or otherwise, related to mefloquine toxicity. It is relevant to point out that the United States military recognized the neuropsychiatric side effects associated with mefloquine and use of this medication has decreased dramatically since 2008.5 Further, as noted by the lead author of the Cochrane Review,6 Dr. Tickell-Painter, “the review clarifies that these are symptoms reported by people taking mefloquine and not formal psychiatric diagnoses. Serious side effects with mefloquine seem to be rare, less than 1% of users.”7 Thus, while the symptoms of bad dreams or nightmares are a well-known side effect of this medication, their persistence is rare.

We did not specifically evaluate the impact of medications which are commonly associated with nightmares (ie, bupropion, selective serotonin reuptake inhibitors, selective norepinephrine reuptake inhibitors, propranolol, etc.). In the article cited by Dr. Nevin regarding the persistence of nightmares after taking mefloquine, this study included a total of 73 patients from a Danish national registry who self-reported symptoms.8 After 3 years, 9 (12%) of the respondents noted nightmares; however, as the frequency, severity, and associated characteristics were not delineated, to include the criteria for nightmares, it is unknown if this finding represented a persistent side effect or was within the spectrum of bad dreams that occur in a general population.

Ultimately, in order to better address nightmares, which are an under-reported, under-addressed disorder,9 and increased in individuals with war experiences,10 a systematic study in both military personnel and veterans is indicated. This is especially relevant noting the association with nightmares and suicidality.11 This study should account for trauma exposure and deployments, military duties, and comorbid disorders (ie, posttraumatic stress disorder, traumatic brain injury, anxiety, depression, etc.) as well as medications.


All work was performed at Wilford Hall Ambulatory Surgical Center, JBSA-Lackland, Texas. All authors have seen and approved the manuscript. The auithors report no conflicts of interest. The opinions and assertions in this manuscript are those of the authors and do not represent those of the Department of the Air Force, Department of the Army, Department of Defense, or the United States government.


Creamer JL, Brock MS, Mysliwiec V. Nightmares in United States military personnel are multifactorial and require further study. J Clin Sleep Med. 2018;14(7):1275–1276.



Nevin RL. Measurement of mefloquine exposure in studies of veterans' sleep disorders. J Clin Sleep Med. 2018;14(7):1273–1274


Creamer JL, Brock MS, Matsangas P, Motamedi V, Mysliwiec V. Nightmares in United States Military personnel with sleep disturbances. J Clin Sleep Med. 2018;14(3):419–426. [PubMed Central][PubMed]


Mysliwiec V, O'Reilly B, Polchinski J, Kwon HP, Germain A, Roth BJ. Trauma associated sleep disorder: a proposed parasomnia encompassing disruptive nocturnal behaviors, nightmares, and REM without atonia in trauma survivors. J Clin Sleep Med. 2014;10(10):1143–1148. [PubMed Central][PubMed]


Mysliwiec V, Brock MS, Creamer JL, O'Reilly BM, Germain A, Roth BJ. Trauma associated sleep disorder: a parasomnia induced by trauma. Sleep Med Rev. 2018;37:94–104. [PubMed]


Kersgard CM, Hickey PW. Adult malaria chemoprophylaxis prescribing patterns in the military health system from 2007-2011. Am J Trop Med Hyg. 2013;89(2):317–325. [PubMed Central][PubMed]


Tickell-Painter M, Maayan N, Saunders R, Pace C, Sinclair D. Mefloquine for preventing malaria during travel to endemic areas. Cochrane Database Syst Rev. 2017;10:CD006491[PubMed]


Cochrane review looks at the effectiveness and side effects of mefloquine. Published October 30, 2017. Accessed May 3, 2018.


Ringqvist Å, Bech P, Glenthø j B, Petersen E. Acute and long-term psychiatric side effects of mefloquine: a follow-up on Danish adverse event reports. Travel Med Infect Dis. 2015;13(1):80–88. [PubMed]


Nadorff MR, Nadorff DK, Germain A. Nightmares: under-reported, undetected, and therefore untreated. J Clin Sleep Med. 2015;11(7):747–750. [PubMed Central][PubMed]


Sandman N, Valli K, Kronholm E, Ollila HM, Revonsuo A, Laatikainen T, Paunio T. Nightmares: prevalence among the Finnish general adult population and war veterans during 1972-2007. Sleep. 2013;36(7):1041–1050. [PubMed Central][PubMed]


Sjöström N, Waern M, Hetta J. Nightmares and sleep disturbances in relation to suicidality in suicide attempters. Sleep. 2007;30(1):91–95. [PubMed]