Assessing daytime sleepiness and fatigue in recruits …cradpdf.drdc-rddc.gc.ca/PDFS/unc199/p802464_A1b.pdf · Assessing daytime sleepiness and fatigue in recruits at the Canadian

Assessing daytime sleepiness and fatigue in recruits at the Canadian Forces Leadership and Recruit School

Dr. Alexandra Muller-Gass Dr. Deniz Fikretoglu; Dr. Erin Beatty; Dr. Oshin Vartanian; Mr. Michel Paul DRDC – Toronto Research Centre

Defence Research and Development Canada Scientific Report DRDC-RDDC-2015-R118 June 2015

IMPORTANT INFORMATIVE STATEMENTS This work was performed as part of project 04HD05 in support of the Directorate General Health Services. The data collected as part of this study was approved either by Defence Research and Development Canada's Human Research Ethics Board or by the Director General Military Personnel Research & Analysis' Social Science Research Review Board.

© Her Majesty the Queen in Right of Canada, as represented by the Minister of National Defence, 2015

© Sa Majesté la Reine (en droit du Canada), telle que représentée par le ministre de la Défense nationale, 2015

DRDC-RDDC-2015-R118 i

Abstract

The Road to Mental Readiness (R2MR) is a mental health education program that is currently being delivered throughout the Canadian Armed Forces (CAF) career cycle, beginning at the recruit level. DRDC Toronto has undertaken a program of research, the primary purpose of which is to test the efficacy of R2MR through a group randomized control trial (gRCT) among recruits. In preparation for the gRCT, extraneous factors that may affect the uptake and/or retention of the information provided during R2MR need to be addressed. One such factor is the daytime sleepiness and fatigue levels of the recruits during the time period in which the mental health education is provided. This is because daytime sleepiness and fatigue are often accompanied by reduced alertness and compromised functioning of specific brain areas (e.g., prefrontal cortex), consequently hindering a variety of cognitive activities including the learning of new information. The primary purpose of this study was thus to assess daytime sleepiness, fatigue, and cognitive effectiveness in CAF recruits during the first 4 weeks of Basic Military Qualification (BMQ) in order to make recommendations about optimal timing of R2MR delivery. Daytime sleepiness and fatigue were assessed through validated questionnaires at the start of BMQ and again during week 4 of BMQ, on the day of R2MR delivery. Actigraphs were used to monitor sleep/wake activity patterns and these data were used to generate cognitive effectiveness models over the entire 4-week study. The results showed that recruits experienced significantly more fatigue and daytime sleepiness, and obtained significantly fewer hours of nocturnal sleep during the BMQ than in the weeks prior to the BMQ. More importantly, their fatigue and sleepiness levels during BMQ were considered abnormal and akin to those seen in sleep-disordered individuals. The cognitive effectiveness models indicated a precipitous drop in cognitive effectiveness during the first few days of BMQ. Therefore, day 1 or 2 of BMQ would be the ideal time to deliver a training program such as R2MR that demands good cognition. The cognitive effectiveness models also indicated that the morning circadian peak commenced between 08:15 and 08:50, and lasted for about 2 to 2.5 hours. Therefore, 08:00 would be an ideal start time for the R2MR training session in order to take advantage of the morning peak performance. A secondary purpose of this study was to examine whether there was a correlation between the fatigue/sleepiness levels of the recruits and their ability to recall the material presented during the R2MR session. For this purpose, recruits completed a quiz on the day following R2MR that tested their memory for the material presented during the mental health training session. No significant correlation was found between the fatigue/sleepiness scores and the quiz scores. Nevertheless, it is very well established in the scientific literature that poor sleep quality and short sleep duration significantly compromise student learning ability and hamper academic performance.

Significance to defence and security

Mental health in the military sector is currently a top priority for the CAF and the Government of Canada. The successful delivery of a mental health training program, such as R2MR, throughout the CAF career cycle is therefore of critical importance. The results of this study indicate the optimal timing for R2MR delivery in order to maximize the recruits’ ability to uptake and retain the material presented during R2MR training.

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Résumé

En route vers la préparation mentale (RVPM) est un programme d’éducation en santé mentale offert aux militaires durant toute leur carrière au sein des Forces armées canadiennes (FAC), et ce, dès le recrutement. RDDC Toronto a entrepris un programme de recherche dont le principal objectif est de vérifier l’efficacité du programme RVPM à l’aide d’un essai clinique randomisé (ECR) par grappes chez les recrues. En préparation à l’ECR par grappes, on doit tenir compte des facteurs exogènes pouvant influencer la compréhension et/ou la rétention de l’information présentée dans le cadre du programme RVPM, notamment la somnolence diurne et le degré de fatigue des recrues pendant la période où ils suivent la formation en santé mentale. En effet, la somnolence diurne et la fatigue sont souvent accompagnées d’une baisse de la vigilance et d’une altération du fonctionnement de certaines zones du cerveau (p. ex. cortex préfrontal), ce qui gêne diverses activités cognitives, notamment l’acquisition de nouvelles connaissances. La présente étude visait donc principalement à évaluer la somnolence diurne, la fatigue et l’efficacité cognitive chez les recrues des FAC pendant les quatre premières semaines de la qualification militaire de base (QMB), en vue de formuler des recommandations quant au meilleur moment pour offrir le programme RVPM. La somnolence diurne et la fatigue ont été évaluées à l’aide de questionnaires validés au début de la QMB, puis pendant la quatrième semaine de la QMB, le jour de la présentation de la séance RVPM. On a eu recours à des actigraphes pour faire le suivi des cycles veille-sommeil et les données obtenues ont servi à produire des modèles d’efficacité cognitive pour les quatre semaines de l’étude. Les résultats révèlent que la fatigue et la somnolence diurne étaient beaucoup plus grandes et que le nombre d’heures de sommeil nocturne était considérablement plus faible chez les recrues pendant la QMB que pendant les semaines qui la précédaient. Qui plus est, leur degré de fatigue et de somnolence au cours de la QMB était considéré comme anormal et il était semblable à celui observé chez les personnes souffrant de troubles du sommeil. Les modèles de l’efficacité cognitive indiquaient une chute abrupte de l’efficacité cognitive pendant les premiers jours de la QMB. Par conséquent, la première ou la deuxième journée de la QMB constituerait le moment idéal pour offrir une formation qui exige de bonnes capacités cognitives comme le programme RVPM. Les modèles d’efficacité cognitive indiquaient également que le pic circadien du matin commence entre 8 h 15 et 8 h 50 et qu’il dure de 2 à 2,5 heures. Par conséquent, 8 h serait l’heure idéale pour entamer la séance de formation RVPM afin de profiter du rendement maximal matinal. Un des objectifs secondaires de cette étude était de déterminer s’il y avait une corrélation entre le degré de fatigue/somnolence des recrues et leur capacité à se souvenir de la matière présentée au cours de la séance RVPM. À cette fin, les recrues ont répondu à un questionnaire le lendemain de la séance pour vérifier ce qu’ils avaient retenu de la matière présentée pendant la formation en santé mentale. Aucune corrélation significative n’a été décelée entre les scores de fatigue/somnolence et les résultats du questionnaire. Néanmoins, il est amplement démontré dans la littérature scientifique qu’un sommeil de mauvaise qualité et de courte durée nuit considérablement à la capacité d’apprentissage des étudiants et au rendement scolaire.

DRDC-RDDC-2015-R118 iii

Importance pour la défense et la sécurité

La santé mentale dans le secteur militaire est actuellement une priorité absolue pour les FAC et le gouvernement du Canada. La mise en œuvre réussie d’un programme d’éducation en santé mentale, comme le programme RVPM, durant toute la carrière au sein des FAC est donc d’une importance capitale. Les résultats de la présente étude indiquent le meilleur moment pour offrir les séances du programme RVPM en vue de maximiser la capacité des recrues à comprendre et à retenir la matière présentée pendant la formation.

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DRDC-RDDC-2015-R118 v

Table of contents

Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i Significance to defence and security . . . . . . . . . . . . . . . . . . . . . . i Résumé . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ii Importance pour la défense et la sécurité . . . . . . . . . . . . . . . . . . . . iii Table of contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

List of figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . viii 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Research context . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.2 Scientific background . . . . . . . . . . . . . . . . . . . . . . . 1

1.3 The present study . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.1 Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

2.2 Assessment instruments . . . . . . . . . . . . . . . . . . . . . . 4

2.2.1 Subjective measures of sleepiness and fatigue . . . . . . . . . . . 4

2.2.2 Objective measure of sleep . . . . . . . . . . . . . . . . . . 4

2.2.3 R2MR retention test and feedback questions . . . . . . . . . . . . 5

2.3 Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

2.3.1 Part 1: Sleep and fatigue assessments . . . . . . . . . . . . . . 5

2.3.2 Part 2: R2MR retention assessment . . . . . . . . . . . . . . . 5

2.4 Data analyses . . . . . . . . . . . . . . . . . . . . . . . . . . 6

2.4.1 Part 1: Sleep and fatigue assessments . . . . . . . . . . . . . . 6

2.4.2 Part 2: R2MR retention assessment and feedback questions . . . . . . 6

3 Results and discussion . . . . . . . . . . . . . . . . . . . . . . . . . 7

3.1 Self-report sleep and fatigue measures: before BMQ vs after 4 weeks of BMQ . . 7

3.1.1 Fatigue Severity Scale (FSS) . . . . . . . . . . . . . . . . . . 7

3.1.2 Multidimensional Fatigue Inventory (MFI) . . . . . . . . . . . . 7

3.1.3 Epworth Sleepiness Scale (ESS) . . . . . . . . . . . . . . . . 8

3.1.4 Pittsburgh Sleep Quality Index (PSQI) . . . . . . . . . . . . . . 8

3.1.5 Summary findings . . . . . . . . . . . . . . . . . . . . . 9

3.2 Self-report sleepiness measure: daily measurements during week 4 of BMQ . . . 9

3.3 Cognitive effectiveness models derived from actigraph data . . . . . . . . . 11

3.3.1 Mean cognitive effectiveness during the workday . . . . . . . . . . 12

3.3.2 Mean cognitive effectiveness during the morning and afternoon circadian peaks . . . . . . . . . . . . . . . . . . . . . . . . . . 14

3.3.3 Summary findings . . . . . . . . . . . . . . . . . . . . . 16

3.4 The effect of sleep/fatigue levels on the R2MR quiz results and feedback questions 17

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4 Conclusions and recommendations . . . . . . . . . . . . . . . . . . . . 19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Subjective sleep/fatigue measures . . . . . . . . . . . . . . . . . . 25 Annex A Daily Sleep Log . . . . . . . . . . . . . . . . . . . . . . . . . 31 Annex B R2MR quiz and feedback questions . . . . . . . . . . . . . . . . . 33 Annex C Individual models of cognitive effectiveness . . . . . . . . . . . . . . 37 Annex D

D.1 Overview of the features of the cognitive effectiveness model graphs . . . . . 37

D.2 Individual cognitive effectiveness models for the 25 participants who completed the 26-day study. . . . . . . . . . . . . . . . . . . . . . . . . . . 38

D.3 Individual cognitive effectiveness models for the 15 participants who did not complete the entire 26-day study. The number of days for these models ranges from 12 to 23 days. . . . . . . . . . . . . . . . . . . . . . . . . . . 73

List of symbols/abbreviations/acronyms/initialisms . . . . . . . . . . . . . . . . 93

DRDC-RDDC-2015-R118 vii

List of figures

Figure 1: Mean (±SEM) SSS scores for 18 recruits during the hours of 600–2300 over 7 consecutive days during week 4 of BMQ. . . . . . . . . . . . . . . . 10

Figure 2: Mean (±SEM) SSS scores for 34 recruits during the hours of 600–2300 averaged across 7 consecutive days during week 4 of BMQ. . . . . . . . . 11

Figure 3: Mean (±SEM) % cognitive effectiveness (in relation to optimal human performance) averaged over the workday for 25 recruits during the first 26 days of BMQ. . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 4: Mean (±SEM) % of workday during which 25 recruits performed below equivalent to 0.05% BAC during the first 26 days of BMQ. . . . . . . . . 14

Figure 5: Mean (±SEM) start time of morning circadian performance over days (left ordinate, solid squares) and corresponding % cognitive effectiveness over days (right ordinate, half-filled circles). . . . . . . . . . . . . . . . . . . 15

Figure 6: Mean (±SEM) start time of afternoon circadian performance over days (left ordinate, solid squares) and corresponding % cognitive effectiveness over days (right ordinate, half-filled circles). . . . . . . . . . . . . . . . . . . 16

viii DRDC-RDDC-2015-R118

Acknowledgements

A subset of the results presented in this Scientific Report were previously published in the following Letter Report: Muller-Gass, A., Beatty, E., Fikretoglu, D., Vartanian, O. & Paul, M., Sleep deprivation and fatigue among Recruits at the Canadian Forces Leadership and recruit School: implications for the optimal timing of mental health training (R2MR), (U) DRDC Toronto Research Centre LR-2013-10055-1-1404HD0500 to Directorate General Health Services, Directorate of Mental Health, September 5, 2013, Unclassified.

DRDC-RDDC-2015-R118 1

1 Introduction

1.1 Research context

The Road to Mental Readiness (R2MR) is a mental health education program that is currently being delivered throughout the Canadian Armed Forces (CAF) career cycle, beginning at the recruit level. R2MR has three key objectives: first, to increase mental health literacy, second, to change negative attitudes towards mental health problems and mental health treatment, and third, to teach military members skills they can use in the context of stressful training and deployment experiences to decrease psychological distress and to maintain optimal mental health. Despite being the largest mental health education initiative in the CAF, to date R2MR has not been tested for efficacy to see whether meaningful changes in the three outcomes of interest are indeed taking place. DRDC Toronto has undertaken a program of research, the primary purpose of which is to test the efficacy of R2MR through a group Randomized Control Trial (gRCT) among recruits. In preparation for the gRCT, extraneous factors that may affect the uptake and/or retention of the information provided during R2MR need to be addressed. One such factor is the daytime sleepiness and fatigue levels of the recruits during the time period in which the mental health education is provided. Informal observations at two R2MR sessions at the Canadian Forces Leadership and Recruit School (CFLRS) in September 2012 revealed that recruits displayed signs of fatigue, sleepiness, and inattention during R2MR delivery. During a R2MR session at CFLRS in November 2012, recruits were told by their instructor to stand away from their seats as a way to counter sleepiness. In a one hour instruction period, 24% of the class participants elected to stand up for, on average, 12 min at a time (Beatty, Vartanian, Fikretoglu & Muller-Gass, 2012). These data are consistent with informal observations of sleepiness and fatigue among recruits in one-on-one interviews across six separate research studies conducted between January 2012 and February 2013. Overall, these observations suggest that sleepiness and fatigue are pertinent issues during R2MR delivery.

1.2 Scientific background

Obtaining adequate amounts of sleep and rest is critical for optimal mental and physical functioning. A recent report commissioned by the American Academy of Sleep Medicine and the Sleep Research Society suggests that sleeping less than 7 hours per night leads to physiological and neurobehavioural deficits that become increasingly more severe under chronic conditions (Luyster, Strollo, Zee & Walsh, 2012). There are numerous approaches to assessing sleep that vary in complexity and ease of use, and include polysomnography, actigraphy, and self-report measures such as sleep logs and questionnaires. The golden standard of sleep diagnostic procedures is whole-night polysomnography. This technique involves the monitoring of a host of different physiological parameters such the electroencephalogram (EEG), the electrooculogram (EOG), the electromyogram (EMG), the electrocardiogram (ECG), and the respiratory effort. A less expensive and cumbersome alternative, actigraphs are devices that are generally worn on the wrist to record movement and allow the monitoring of rest/activity cycles. The analysis of the wrist movement patterns indicates the periods during which the wearer was most likely awake and asleep, and can also help assess the quality of the sleep. Finally, the most common approach to measuring sleep involves sleep logs and questionnaires. Sleep logs require an individual to give a day-to-day account of the sleep activities (e.g., bedtime, rise time, naps) within a 24-hour

2 DRDC-RDDC-2015-R118

period. On the other hand, sleep questionnaires require an individual to answer a set of questions, and give a better idea of sleep quality rather than sleep duration. Whereas polysomnography, actigraphy and sleep logs are primarily concerned with the actual times the individual is asleep, the questionnaires often assess sleep satisfaction and feelings of being tired during the day. There are over 100 validated sleep-related scales that evaluate different facets of sleep (Shahid, Wilkinson, Marcu & Shapiro, 2012). Many of these scales assess levels of daytime sleepiness and fatigue, two of the most common patient sleep-related symptoms. While the terms “sleepiness” and “fatigue” are commonly used interchangeably, they in fact refer to different and distinct phenomena (Shahid, Shen & Shapiro, 2010; Shen, Barbera & Shapiro, 2006). Generally, sleepiness is defined as an increased propensity to fall asleep, and may be related to low arousal levels. Fatigue in turn refers to an overwhelming sense of exhaustion associated with impaired physical and/or cognitive functioning. Daytime sleepiness and fatigue often co-occur as a consequence of insufficient sleep. Fatigue can occur due to a variety of other causes of physical, physiological and psychological nature (e.g., vigorous workout, illness and medical treatments, or an extended period of mental concentration).

Much of what is known about the consequences of chronic daytime sleepiness and fatigue comes from studies of populations with diagnosed sleeping disorders, but also through the study of populations such as health care workers and military subjects, for whom sleep deprivation and long hours of uninterrupted mental and/or physical work is an accepted, if not expected practice. Chronic insufficient sleep has been linked to numerous negative outcomes, such as mood and anxiety disorders (including PTSD), substance use/abuse, health problems, obesity, work-related accidents, and suicide attempts (Luxton et al., 2011; Rogers, 2008). However, even short-term (e.g., one-night) sleep restrictions can have important deleterious consequences, particularly on mood and cognitive functioning (Killgore, 2010). Alertness, vigilance and attention are the cognitive capacities that have been shown to be most consistently and dramatically affected by chronic and acute sleep restrictions (Lim & Dinges, 2008). As sustained attention is required for most aspects of cognition, it is not surprising that sleep loss has a general effect on a wide variety of cognitive skills, such as the assimilation of changing information, lateral thinking, innovation, risk assessment, mood-appropriate behavior, communication and working memory skills (Durmer & Dinges, 2005). However, above and beyond attention-related effects, sleep restriction may affect specific higher level cognitive systems, such as memory and emotion-processing networks (Killgore, 2010).

Most relevant to the present study is the link between sleep and learning (Walker, 2008). Adequate sleep may improve learning through different cognitive mechanisms that act both before and after the learning session. Sufficient sleep obtained before learning improves alertness and attentional capacity which is essential for the acquisition of the new information. Furthermore, sleep obtained before learning also appears to affect the ability to successfully encode the new information or experiences (Walker, 2008). Adequate sleep obtained after the learning session plays a critical role in memory consolidation that is, how well the newly acquired information is retained (Stickgold, 2005; Walker, 2005). Many studies have found that learning in a classroom setting, such as that used for R2MR, is significantly affected by poor sleep quality, insufficient sleep and daytime sleepiness (for review see Dewald, Meijer, Oort, Kerkhof & Bögels, 2010). Academic performance has also been shown to be clearly related to sleep habits and daytime sleepiness levels (Ahrberg, Dresler, Niedermaier, Steiger & Genzel, 2012; Curcio, Ferrara & De Gennaro, 2006; Meijer & van den Wittenboer, 2004). In fact, in order to improve academic performance and decrease behavioral problems, the American Academy of

http://www.ncbi.nlm.nih.gov/pubmed?term=Shahid%20A%5BAuthor%5D&cauthor=true&cauthor_uid=20630266

http://www.ncbi.nlm.nih.gov/pubmed?term=Shen%20J%5BAuthor%5D&cauthor=true&cauthor_uid=20630266

http://www.ncbi.nlm.nih.gov/pubmed?term=Shapiro%20CM%5BAuthor%5D&cauthor=true&cauthor_uid=20630266


http://www.ncbi.nlm.nih.gov/pubmed?term=Barbera%20J%5BAuthor%5D&cauthor=true&cauthor_uid=16376590


http://www.ncbi.nlm.nih.gov/pubmed?term=Lim%20J%5BAuthor%5D&cauthor=true&cauthor_uid=18591490

http://www.ncbi.nlm.nih.gov/pubmed?term=Dinges%20DF%5BAuthor%5D&cauthor=true&cauthor_uid=18591490

http://www.ncbi.nlm.nih.gov/pubmed?term=Durmer%20JS%5BAuthor%5D&cauthor=true&cauthor_uid=15798944


http://www.ncbi.nlm.nih.gov/pubmed/?term=Ahrberg%20K%5BAuthor%5D&cauthor=true&cauthor_uid=23040161


http://www.ncbi.nlm.nih.gov/pubmed/?term=Niedermaier%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23040161

http://www.ncbi.nlm.nih.gov/pubmed/?term=Steiger%20A%5BAuthor%5D&cauthor=true&cauthor_uid=23040161


http://www.ncbi.nlm.nih.gov/pubmed/?term=Curcio%20G%5BAuthor%5D&cauthor=true&cauthor_uid=16564189

http://www.ncbi.nlm.nih.gov/pubmed/?term=Ferrara%20M%5BAuthor%5D&cauthor=true&cauthor_uid=16564189

http://www.ncbi.nlm.nih.gov/pubmed/?term=De%20Gennaro%20L%5BAuthor%5D&cauthor=true&cauthor_uid=16564189


Pediatrics (2014) recently presented a policy statement recommending later school start times to allow students to obtain more nocturnal sleep. This approach to extending nocturnal sleep has indeed shown positive effects on academic performance (Wahlstrom et al. 2014; Edwards, 2012).

1.3 The present study

The present study was comprised of 2 parts, each of which had a separate but related objective. Part 1 addressed the primary purpose of the study: to determine the daytime sleepiness and fatigue levels of the recruits at R2MR delivery (which occurred during week 4 of BMQ). As a countermeasure to potentially high levels of sleepiness and fatigue during this critical time period, we also determined the optimal time (both in terms of day and time-of-day) for maximal cognitive effectiveness, and therefore also the best time for the presentation of R2MR. The purpose of Part 2 was to assess whether the daytime sleepiness and fatigue levels of the recruits would predict their ability to remember and recall the material presented during R2MR.


2 Methods

2.1 Participants

All participants in this study were CAF recruits at the CFLRS in St. Jean, Quebec, enrolled in BMQ. Sixty-five (54 male and 11 female) recruits with a mean age of 25.2 years (SD 5.2) initially signed up to participate in Part 1 of this study, the fatigue and sleep assessment. Some of the participants did not complete the entire battery of fatigue and sleep assessments as outlined in Sections 2.2.1 and 2.2.2; therefore, the exact number of individuals included in any given analysis is indicated when presenting the results. Subsequently, 86 participants took part in Part 2 of this study, in which R2MR information retention was tested. All participants had attended an R2MR training session prior to recruitment. Of these 86 participants, 43 (36 males and 8 females) with a mean age of 22.7 years (SD 3.8) had previously participated in Part 1 of the study. Only the data pertaining to those 43 participants were retained for the purposes of the present study; the full report on the R2MR testing results including all 86 participants has been published elsewhere (Fikretoglu, Lam & Beatty, 2013).

All participants were assured of the confidential treatment of their data, and were informed that they could withdraw from the study at any time without prejudice. Written informed consent was obtained from each participant prior to the beginning of the study. This study was conducted following the guidelines of the Canadian Tri-Council (Health, Natural, and Social Sciences) on ethical conduct involving humans, and was approved by the DRDC Human Research Ethics Committee (HREC).

2.2 Assessment instruments

2.2.1 Subjective measures of sleepiness and fatigue

The subjective assessment instruments selected for this study were: the Stanford Sleepiness Scale (SSS), the Epworth Sleepiness Scale (ESS), the Pittsburgh Sleep Quality Index (PSQI), the Multidimensional Fatigue Inventory (MFI) and the Fatigue Severity Scale (FSS) (see Annex A). The SSS is composed of 1 question that evaluates state sleepiness at a specific moment in time. The ESS, PSQI, MFI and FSS are composed of 8, 19, 20 and 9 questions respectively and assess sleep and/or fatigue over the course of a much longer period of time (e.g., the previous month). These self-administered paper-and-pencil questionnaires are widely used in clinical and research settings, and have been validated for the measurement of sleep and fatigue in various populations including healthy controls (Shahid, Wilkinson, Marcu & Shapiro, 2012).

2.2.2 Objective measure of sleep

Actigraphy was used in the present study to quantify sleep/wake parameters. The actigraphs can sample movement several times per second for long periods of time, and the time-stamped data are stored for later analysis. Algorithms are used to extract sleep/wake parameters from this data. In this way, actigraphic data provide an indirect but objective assessment of sleep, one that correlates well with polysomnography, a technique considered the gold standard for sleep studies


(De Souza et al., 2003). Participants were also asked to keep a daily sleep log that included the following information: bedtime, wake time, nap time(s), and comments (see Annex B). The sleep log information was used to complete and help interpret the actigraph data analysis.

2.2.3 R2MR retention test and feedback questions

Acquisition and retention of the R2MR material was assessed through a non-validated test composed of 8 multiple-choice and short-answer questions (see Annex C). Questions 1, 2, 3, 7, and 8 assessed recruits’ understanding of the mental health literacy concepts. Question 4 assessed recruits’ understanding of the stress management skills (i.e., the Big 4). Questions 5 and 6 assessed additional stress management skills (i.e., cognitive structuring or “thinking traps” as they are called in R2MR). At the end of this test, participants were asked 4 questions regarding their perception of the relevance of mental health training to their career, the usefulness and clarity of the training material, and their motivation to uptake the information.

2.3 Procedures

2.3.1 Part 1: Sleep and fatigue assessments

Participants were recruited onsite at CFLRS on the first day of BMQ. Following recruitment and completion of consent forms, participants were fitted with wrist actigraphs. They were instructed to wear the actigraphs continuously (except when bathing or at other inappropriate times e.g., gym activities) until the delivery of R2MR, which occurred during week 4 of BMQ. Participants received a sleep log to be filled in on a daily basis during this 4-week time period.

On the first day of BMQ, participants were also asked to complete the ESS, PSQI, MFI and FSS questionnaires in order to assess their baseline sleep and fatigue levels; these baseline measures reflected the extent to which they were sleepy and fatigued prior to the start of BMQ. These same sleep and fatigue questionnaires were given to the participants for a second time during week 4 of BMQ, on the day of R2MR delivery. Furthermore, at the beginning of week 4, the SSS questionnaire was distributed to participants in order to report their sleepiness level every waking hour for 7 consecutive days. The purpose of this scale was to assess time of day effects.

2.3.2 Part 2: R2MR retention assessment

Participants were recruited at CFLRS on the day following R2MR delivery1. Recruits were unaware during the R2MR training session that retention of the material would subsequently be tested as this may have affected the attentional effort expanded to uptake the R2MR material. Following recruitment, participants were asked to complete consent forms; those who had participated in Part 1 of the study (sleep and fatigue assessment) were asked to consent to have their R2MR test scores linked to their sleep/fatigue results. Participants were then given the R2MR retention quiz and asked to complete the feedback questions.

1 Sleep deprivation following a learning activity affects memory consolidation for the learned material (Stickgold, 2005). It was therefore important that the retention test occur on the day after R2MR delivery.


2.4 Data analyses

2.4.1 Part 1: Sleep and fatigue assessments

Sleep and fatigue levels were assessed through actigraphy and questionnaires.

Questionnaires. Questionnaires were scored in compliance with the developer’s instructions. The ESS, PSQI, MFI and FSS questionnaires were completed twice, at the start of the BMQ (T0) and again on the day of the R2MR delivery (T1). Recruits were asked to assess their fatigue and daytime sleepiness levels for the period covering one month prior to the time of testing. Descriptive statistics (i.e., mean scores on questionnaires) were used to describe the study population and paired t-tests were used to assess differences between sleep/fatigue levels at the two measurement times, T0 and T1. The SSS questionnaire was completed every waking hour (i.e., 18 hours, from 600–2400) over 7 consecutive days. Descriptive statistics (i.e., mean scores on SSS) were used to describe the study population and a repeated-measures analysis of variance (ANOVA) with 2 factors (Hours X Days) was used to assess differences between the measurement times. Significant effects were followed by Bonferroni post-hoc testing. When appropriate, a Greenhouse Geisser correction was applied and the adjusted probability level is reported.

Actigraphy. Actigraph data were recorded continuously for 26 days from the beginning of BMQ. Various sleep parameters were extracted from the actigraph data for each individual and on each day, and subjected to the Fatigue Avoidance Scheduling Tool (FAST). FAST generates models that chart variations in the cognitive effectiveness of each individual over time (Paul & Bouak, 2011). When actigraph data was unclear or missing, sleep log data were used to complete the dataset for the analysis. Repeated-measures ANOVAs with 1 factor (Days) were used to assess differences over the 26 days in various measures of cognitive effectiveness across the workday and during morning/afternoon circadian peaks. Tukey’s Honest Significant Difference (HSD) test was used for post hoc analyses following significant effects.

2.4.2 Part 2: R2MR retention assessment and feedback questions

The quiz was scored in a manner such that the items tapping the stress management skills component of R2MR were given a greater weighting than those items tapping mental health literacy concepts. The scores on the eight questions sum up to 25. For interpretability sake, this total score was then multiplied by 4 so that the summary score could range from 0 to 100%. Descriptive statistics (i.e., mean quiz scores and mean scores on the feedback questions) were used to describe the study population which included only those recruits that also completed the sleep and fatigue assessment. Pearson product-moment correlations were computed between R2MR quiz scores and feedback questions scores. Pearson product-moment correlations were also computed between the R2MR quiz scores and the sleep/fatigue results at T1 (from Part 1) for those participants who agreed to have these two datasets linked.


3 Results and discussion

3.1 Self-report sleep and fatigue measures: before BMQ vs after 4 weeks of BMQ

The self-report sleep and fatigue questionnaires were used to characterise the fatigue and sleepiness levels of the participants during the month prior to completing the questionnaires. Importantly, there were 2 measurement times: T0 at the start of BMQ, and T1 during week 4 of BMQ, on the day of R2MR delivery. The purpose of this assessment was to determine whether recruits suffered from significantly more fatigue and/or daytime sleepiness in the month after the start of the BMQ when compared to the month prior to the BMQ.

Of the 65 participants recruited at T0, only 44 completed the questionnaires at T1. Dropout rate between T0 and TI was therefore 32%. T-tests revealed no significant differences between dropouts and those that continued to participate in the study with respect to fatigue and daytime sleepiness at T0.

3.1.1 Fatigue Severity Scale (FSS)

The FSS is intended to assess disabling fatigue by asking nine questions about fatigue and function. Questions are given a score of 1 to 7, with lower scores indicating less fatigue. The total score for the FSS is calculated as the average of the individual question scores. Based on several studies of patient population, including those with sleeping disorders, it was recommended that a total FSS score ≥ 4 be interpreted as indicative of abnormal fatigue (Segal et al., 2008). In one study (Valko, Bassetti, Bloch, Held & Baumannn, 2008), patients with sleep-wake disorders scored a total of 4.34 (SD = 1.64) while the healthy controls scored 3.00 (SD = 1.08).

Mean total FSS score for CFLRS recruits significantly increased between T0 and T1. At T0, the mean was 3.35 (SD = 0.92), while at T1 it was 4.30 (SD = 1.26); paired t(43) = 5.0, p < 0.01. More importantly, the FSS scores indicate that recruits were above the cut-off score for abnormal fatigue at T1.

3.1.2 Multidimensional Fatigue Inventory (MFI)

The MFI is used to measure the following five dimensions: General Fatigue, Physical Fatigue, Reduced Activity, Reduced Motivation, and Mental Fatigue. The total score for each dimension is calculated by adding the scores of four individual questions. Total scores for each dimension can range from 4 to 20, with higher scores indicating higher levels of the dimension (e.g., more fatigue). The use of a total score over the five dimensions is not recommended. The best indicator of fatigue in the MFI is the score on the General Fatigue dimension. Reeves et al. (2005) define severe fatigue as a score ≥ 13 on the MFI General Fatigue dimension. In one study (Smets, Garssen, Bonke & De Haes, 1995), 2 groups of army recruits were assessed using the MFI: one group during their stay in the barracks (B), and the other during the second week of a physically intensive military training program (T). In this study, differences in dimension scores were as follows:


Mean (B) Mean (T) General Fatigue 13.51 (SD = 6.5) 16.96 (SD = 6.5) Physical Fatigue 11.40 (SD = 7.1) 13.21 (SD = 6.8) Reduced Activity 11.29 (SD = 5.2) 10.32 (SD = 3.7) Reduced Motivation 10.35 (SD = 5.2) 11.78 (SD = 5.2) Mental Fatigue 12.07 (SD = 7.3) 13.54 (SD = 6.2)

As can be seen from the results below, a similar pattern emerged for the CFLRS participants between T0 and T1. The largest score increase, by over 4 points, was obtained for the General Fatigue dimension. Importantly, the General Fatigue score at T1 was above the proposed cut-off score indicating severe fatigue.

Mean (T0) Mean (T1) paired t(43) General Fatigue 10.14 (SD = 2.69) 14.15 (SD = 2.52) 6.8, p < 0.01 Physical Fatigue 7.73 (SD = 2.85) 9.02 (SD = 3.46) 2.1, p < 0.05 Reduced Activity 8.43 (SD = 3.55) 7.18 (SD = 2.84) 1.9, p = 0.07 Reduced Motivation 8.68 (SD = 3.01) 11.16 (SD = 3.00) 4.5, p < 0.01 Mental Fatigue 9.25 (SD = 3.04) 12.15 (SD = 2.87) 4.5, p < 0.01

3.1.3 Epworth Sleepiness Scale (ESS)

The ESS assesses daytime sleepiness by asking the respondent to rate his or her probability of falling asleep during 8 different situations that most people engage in during their daily lives. Each situation was given a score from 0 (not sleepy at all) to 3 (very sleepy). A total score in the 0–9 range is considered to be normal while a number in the 10–24 range indicates that expert medical advice should be sought. In one study (Johns, 1991) patients with obstructive sleep apnea syndrome scored a total of 11.7 (SD = 4.6) while the normal controls scored 5.9 (SD = 2.2). Mean total ESS score for CFLRS recruits increased significantly between T0 and T1. The score at T0 was 6.24 (SD = 3.2) and at T1, it was 13.76 (SD = 5.04); paired t(43) = 8.4, p < 0.01. Importantly, the score at T1 was above the cut off score to seek medical advice.

3.1.4 Pittsburgh Sleep Quality Index (PSQI)

The PSQI is used to measure the quality and patterns of sleep by assessing 7 domains: Subjective Sleep Quality, Sleep Latency, Sleep Duration, Habitual Sleep Efficiency, Sleep Disturbances, Use of Sleep Medication, and Daytime Dysfunction. One or more individual questions are summed to obtain a total score on each dimension that ranges from 0 to 3, with higher scores reflecting more acute sleep disturbances. The global PSQI score is obtained by summing the individual domain scores. The developers have suggested a cut-off score of 5 for the global PSQI score to distinguish good and poor sleepers (Buysse, Reynolds, Monk, Berman & Kupfer, 1989). While the global PSQI score for CFLRS participants did indeed increase from T0 (Mean = 5.04, SD = 2.81) to T1 (Mean = 5.74, SD = 3.39), this difference did not reach significance; paired t(43) = 1.32, p = 0.19. It should however be noted that both the T0 and T1 scores were at or above the cut off score indicating poor sleepers.

When the different domains of the PSQI were assessed separately, the most important significant differences between T0 and T1 emerged for the Subjective Sleep Quality, Sleep Duration and Daytime Dysfunctions. Subjective Sleep Quality scores increased from 0.98 (SD = 0.55) at T0


to 1.66 (SD = 0.96) at T1; paired t(43) = 4.6, p < 0.01. For this dimension, 1 indicated “fairly good” while 2 indicated “fairly bad”. The Sleep duration dimension score increased from 0.61 (SD = 0.82) at T0 to 2.02 (SD = 0.78) at T1; paired t(41) = 9.2, p < 0.01. In fact, when numbers of hours slept during the night were computed, the mean decreased from 7.54 hours (SD = 1.68) at T0 to 5.17 hours (SD = 0.93) at T1; paired t(41) = 9.1, p < 0.01. Daytime Dysfunction scores increased from 0.97 (SD = 0.53) at T0 to 1.60 (SD = 0.87) at T1; paired t(43) = 3.9, p < 0.01. For this dimension, 1 indicated “only a very slight problem” while 2 indicated “somewhat of a problem”. Scores for CFLRS recruits on these 3 dimensions at T1 are well within the range of those obtained for various sleep disorders (Buysse, Reynolds, Monk, Berman & Kupfer, 1989).

The scores on the Sleep Disturbance dimension also increased from T0 (Mean = 0.68, SD = 0.46) to T1 (Mean = 0.85, SD = 0.56) but this difference just failed to reach significance; paired t(43) = 2.0, p = 0.05. However, sleep disturbances appeared to be, on average, of minimal concern even at T1 because for this dimension, 0 represented “not during the past month” and 1 represented “less than once a week”. The score for the Sleep Latency dimension (i.e., time required to fall asleep after going to bed) significantly decreased from T0 to T1; mean at T0 = 1.19 (SD = 0.86) and mean at T1 = 0.48 (SD = 0.75), paired t(43) = 5.36, p < 0.01. For this dimension, 0 indicates “less than 15 min”, 1 indicates “16–30 min” and 2 indicates “31–60 min”. Recruits therefore fell asleep much faster at T1 than at T0. It is well known that sleep-deprived individuals fall asleep more quickly than their non sleep-deprived counterparts, and therefore sleep deprivation is associated with lower sleep latency scores (Durmer and Dinges, 2005). The remaining PSQI dimensions did not significantly change from T0 to T1. Sleep efficiency (i.e., ratio of time asleep to the total amount of time spent in bed) remained above 75% at T0 and T1, while sleep medication was reportedly used very infrequency at both T0 and T1.

3.1.5 Summary findings

The results from the four self-report questionnaires were all in agreement: participants experienced significantly increased fatigue and sleepiness during the first 4 weeks of the BMQ when compared to the weeks before the start of the BMQ. More specifically, participants suffered from abnormal to severe fatigue during the BMQ, with particularly significant increased mental fatigue and reduced motivation. Furthermore, the results indicated that daytime sleepiness was also of concern during this time period, at levels similar to those seen in sleep-disordered individuals. Participants reported a much increased propensity of falling asleep during the course of typical daytime activities (e.g., watching TV) while at BMQ. These results may in part be due to the changes in patterns and quality of sleep obtained while at CFLRS. Participants were deemed to be poor sleepers and reported sleeping on average only 5.2 hours per night (when compared to 7.5 hours per night before BMQ). They also showed a significant reduction in sleep latency while at BMQ, a finding that is often indicative of sleep deprivation.

3.2 Self-report sleepiness measure: daily measurements during week 4 of BMQ

The Stanford Sleepiness Scale is used to record feelings of sleepiness at various times during the day. This scale was used to assess variations in sleepiness over the course of each day during week 4 of BMQ, the week in which R2MR training was provided. The purpose of this assessment


was to examine whether a particular pattern of sleepiness or alertness emerged (over the day or the week) in order to make recommendations for optimal scheduling of the R2MR training.

Recruits were instructed to assess their sleepiness levels for every waking hour between 06:00 and 24:00 for 7 concurrent days during week 4 of BMQ. They were asked to rate themselves on a scale from 1 to 7, with higher values indicating more sleepiness. Descriptors define each level on the scale. Values that are consistently above 3 (which corresponds to the descriptor “Relaxed; awake; not at full alertness, responsive”) are considered an indication that the respondent has a serious sleep debt and that more sleep is required (Bae & Avidan, 2008).

The sleepiness level at 24:00 was infrequently reported by the recruits and therefore this time point was eliminated from the analysis. Only 18 recruits completed the SSS for every hour during the 06:00–23:00 time period over the 7 days. The mean SSS scores (and standard errors) for these measurement times are depicted in Figure 1.

Figure 1: Mean (±SEM) SSS scores for 18 recruits during the hours of 600–2300 over 7

consecutive days during week 4 of BMQ.

A main effect of Hour emerged from this data, F(17, 289) = 10.68, p < 0.01. Bonferroni post-hoc testing on this main effect indicated that recruits were most alert between 11:00 and 13:00 but this was statistically significant (p < 0.05) only when compared to early morning (06:00) and evening (21:00–23:00) hours. There was also a significant main effect of Day, F(6, 102) = 2.96, p < 0.03. Bonferroni post-hoc testing on this main effect indicated that recruits were most alert on Day 3 of testing when compared to Day 7. The Hour X Day interaction was not significant.

In order to improve the sample size (from n = 18 to n = 34) for this analysis, the dataset was collapsed across Day. Weighted means across days were calculated for each subject at each hour.


A one-way repeated-measures ANOVA was performed on this dataset. The mean SSS scores (and standard errors) for these measurement times are depicted in Figure 2.

Figure 2: Mean (±SEM) SSS scores for 34 recruits during the hours of 600–2300 averaged

across 7 consecutive days during week 4 of BMQ.

The main effect of Hour was again significant, F(17,561) = 16.05, p < 0.01. Bonferroni post-hoc testing on this main effect indicated that recruits were most sleepy between 21:00 and 23:00 (when mean SSS values ranged from 3.9 to 5.0) compared to all other hours of the day (when mean SSS values ranged from 2.8 to 3.5). In addition, they were also significantly more alert during the 12:00–13:00 period than at 20:00. No further significant effects were however noted.

In Summary, the results indicate that no consistent increase in levels of sleepiness was found over days as the fourth week of BMQ progressed. On the other hand, time of day effects showed that recruits were significantly sleepier in the evening than during the remainder of the day. They also reported being more alert during the hours of 11:00–13:00 but this effect only reached significance when compared to early morning or evening hours. Scores on the SSS indicated that recruits were at or above the cut-off of 3 for most of the day, in particular during the late afternoon (after 15:00). This indicates that that they had a serious sleep debt during week 4 of BMQ, and that more sleep would be recommended.

3.3 Cognitive effectiveness models derived from actigraph data

FAST is a program that predicts the joint effects of time of day, biological rhythms, time spent awake, and amount of sleep, on human performance (see Annex D). The actigraph data from each


participant collected over 26 consecutive days during BMQ was analysed using FAST. The resulting individual and grand-average (across all subjects) performance models indicate the variations in cognitive effectiveness over the first 4 weeks of BMQ. The models also indicate variations in cognitive effectiveness over each day, with a period of peak performance in the morning and afternoon. The purpose of this analysis was to identify optimal day(s) and time of day for scheduling the R2MR training session which requires maximum cognitive effectiveness in order to meet the learning objectives. Ideally, the R2MR training would occur on days when recruits have high cognitive effectiveness and coincide with the morning and/or afternoon circadian performance peaks.

Annex D presents the individual FAST models for 40 participants, of which only 25 were deemed to have complete datasets for the 26-day study2. In these individual models, variations in effectiveness during each day are visible, typically with one peak in the morning and one in the afternoon. Cognitive effectiveness is expressed as a percentage of optimal human performance (100%). For the purposes of the group data analysis, only the 25 participants with complete datasets were retained. Analyses were performed on different time periods throughout the day: the entire workday, the morning circadian peak and the afternoon circadian peak.

3.3.1 Mean cognitive effectiveness during the workday

The average workday started at 05:30 (range: 05:00–06:15) and ended at 18:00. The % cognitive effectiveness was averaged across the workday for each subject, and the group results are depicted below in Figure 3, F(25, 600) = 52.08, p < 0.0001. The posthoc test showed that for the first 4 days of BMQ there was a significant daily drop in workday cognitive effectiveness (from 90.5% to 80.4%, mean daily drop = 2.5%). From day 5 to day 7, cognitive effectiveness remained stable at approximately 79.9% (SD = 2.9), after which it further declined. After day 7, participants performed on average at 77.5% (SD = 3.5) of cognitive effectiveness for the remainder of the 26-day study. Two small (non-significant) increases are visible at days 13–14 and again at day 21. These are weekend days during which recruits received approximately one additional hour of sleep. Importantly, a value of 77.5% cognitive effectiveness corresponds to that obtained with a blood alcohol content of 0.05% (legally impaired in some jurisdictions). A value of 70% cognitive effectiveness corresponds to a blood alcohol content of 0.08% (legally impaired in most jurisdictions). These BAC equivalency levels associated with sleep deprivation/fatigue are based on three important studies (Arnedt, Wilde, Munt & MacLean, 2001; Dawson & Reid,1997; Lamond & Dawson, 1999). The results therefore suggest that, from day 8 to 26, participants performed near or under equivalent to 0.05% BAC.

2 Three of these 25 subjects were missing an entry on only 1 day, and these entries were extrapolated by computing the mean value(s) of the adjacent day(s).


Figure 3: Mean (±SEM) % cognitive effectiveness (in relation to optimal human performance)

averaged over the workday for 25 recruits during the first 26 days of BMQ.

The next analysis was more specifically concerned with the % of the workday that the participants performed below the criterion for equivalence to 0.05% BAC. The results are depicted in Figure 4, F(25, 600) = 11.4, p < 0.0001. The posthoc test showed that during day 1 to day 7, there were no significant differences; during this time period, while cognitive effectiveness declined dramatically (as seen in Figure 3), it still mostly remained above the criterion (cognitive effectiveness = 77.5%) for equivalence to 0.05% BAC. More specifically, during the day 1–7 period, participants spent only on average 9.5% (SD = 19.1) of their workday performing below the criterion for equivalence to 0.05% BAC. During the subsequent 19 days (with the exception of weekend days 13 and14), recruits performed significantly worse, with 44.9% (SD = 85.4) of their workday scoring below the criterion for equivalence to 0.05% BAC.


Figure 4: Mean (±SEM) % of workday during which 25 recruits performed below equivalent to

0.05% BAC during the first 26 days of BMQ.

3.3.2 Mean cognitive effectiveness during the morning and afternoon circadian peaks

The start of the morning circadian peak times over the 26 days, and the corresponding % cognitive effectiveness are illustrated in Figure 5. The repeated measures ANOVAs for ‘start time of morning circadian peak’ F(25, 600) = 3.80, p < 0.0001 and ‘corresponding morning peak % cognitive effectiveness’ F(25, 600) = 48.039, p < 0.0001 were both significant. The significant post hoc differences are indicated in Figure 5. The post hoc analysis of the ‘start time of morning circadian peak’ illustrates that the 25 participants phase advanced by about 30 minutes over the first 4 days with smaller alternating delays and advances over the next 18 days, again followed by a final advance over the final four days. This yielded a net phase advance in the timing of the morning peak modeled cognitive effectiveness of about 35 minutes from about 08:50 to about 08:15 over the 26 day study period. The post hoc analysis of the ‘mean start time of morning circadian peak of cognitive effectiveness’ illustrates the largest drop in mean cognitive effectiveness during the morning peak occurred over the first 4 days and continued dropping for the next 7 days with a slight rebound on weekend days 13 and 14. The following day, cognitive effectiveness again started to deteriorate, rising again on the following weekend then falling again slightly over the final 4 days of the study.


Figure 5: Mean (±SEM) start time of morning circadian performance over days

(left ordinate, solid squares) and corresponding % cognitive effectiveness over days (right ordinate, half-filled circles).

The start of the afternoon circadian peak times over the 26 days, and the corresponding % cognitive effectiveness are illustrated in Figure 6. The repeated measures ANOVAs for ‘start time of afternoon circadian peak’ F(25, 600) = 2.0308, p < 0.002 and ‘corresponding afternoon peak % cognitive effectiveness’ F(25, 600) = 48.798, p < 0.0001 were both significant. The significant post hoc differences are indicated in Figure 6. The post hoc analysis of the ‘start time of afternoon circadian peak’ illustrates that the participants phase advanced their afternoon circadian peak by about 15 minutes on days 4 and 5. From day 6 until the end of the study, there were small alternating delays and advances in the timing of the afternoon circadian peak. This yielded a net phase advance in timing of the afternoon peak performance of about 15 minutes from about 18:05 to about 17:50 over the 26 day study period. The post hoc analysis of the ‘corresponding afternoon peak % cognitive effectiveness’ illustrates that the largest drop in cognitive effectiveness during the afternoon peak occurred over the first 5 days and continued dropping for the next 5 days with a slight rebound by weekend days 13 and 14. The following day, cognitive effectiveness again started to deteriorate, rising again on the following weekend then falling again slightly over the final 5 days of the study.


Participants had morning and late afternoon peaks in cognitive effectiveness that generally ranged from 2 to 2.5 hours in duration. The start time of each of the morning and afternoon periods of peak performance is dependent on various sleep parameters such as bedtime, rise time and quality/quantity of night sleep. The start time of the circadian peaks tended to advance during the weekdays and then delay somewhat over the weekend days when participants obtained additional night sleep. In the first few days of BMQ, the morning peak commenced at about 08:50 but cyclically advanced to about 08:15 each week. The net phase advance for the periods of peak performance were 35 minutes and 15 minutes for the morning and afternoon peaks, respectively (see Figures 5 and 6). The average cognitive effectiveness for each of the daily morning and afternoon circadian peaks indicated precipitous drops from day 1 to days 4–5 and then again to days 10–11, after which cognitive effectiveness varied both up and down in small excursions.

3.4 The effect of sleep/fatigue levels on the R2MR quiz results and feedback questions

The participants completed the R2MR quiz and the feedback questions on the day following the R2MR training session. Of the 86 participants, only 43 had previously participated in Part 1 of the study (the sleep and fatigue assessments) and were retained for this analysis3. The purpose of this assessment was to determine whether recruits who were less fatigued or sleepy would performed better on the quiz, and whether a more positive attitude towards the R2MR training (as indexed by the feedback questions) would lead to better uptake and memory for the R2MR material.

The mean score on the quiz was 61% (SD = 23) and the mean scores on the feedback questions (reproduced below) were as follows: 1.4 (SD = 0.5), 1.7 (SD = 0.7), 1.8 (SD = 0.7) and 1.8 (SD = 0.7), where 1 corresponded to “strongly agree” and 2 corresponded to “agree”:

1. I think that the mental health training is very important and relevant to my career in the CF.

2. I feel like I made a very strong effort in understanding the material taught during the mental health training.

3. I think that the material taught during the mental health training will help me deal with mental health issues that I (or my CF buddies) may face in the future.

4. I think that the mental health training education was interesting, and easy to follow and understand.

None of the Pearson product-moment correlations between the feedback questions and the quiz scores were significant. There were also no significant correlation between any of the 4 self-report sleep/fatigue questionnaires completed at T1 (i.e., on the day of R2MR delivery) and performance on the quiz. There was a moderate negative correlation between the scores on the Fatigue Severity Scale and the quiz scores; this correlation however just failed to reach significance r(41) = -0.28, p = .07.

3 A more detailed analysis of the quiz performance that included all 86 participants has already been disseminated in a project update meeting with stakeholders in May 2013 and in a Letter Report dated July 2013.


In summary, the participants’ attitude regarding the R2MR training was not predictive of their performance on the R2MR quiz. Furthermore, the participants’ scores on the self-report sleep/fatigue questionnaires measured on the day of R2MR delivery were also not predictive of their subsequent R2MR quiz scores. Caution should however be heeded in interpreting these latter non-significant findings. Much of the variance on the quiz scores may be accounted for by individual differences in the recruits’ cognitive abilities (Fikretoglu, Beatty & Liu, 2014). This analysis therefore would have benefited from using a baseline cognitive performance measurement as a covariate in order to increase the statistical power to detect the relationship between sleep/fatigue levels and the quiz scores.


4 Conclusions and recommendations

Four main conclusions can be drawn from the results of the present study:

1. CFLRS recruits reached alarming levels of sleepiness and fatigue during the first 4 weeks of BMQ. They experienced significantly higher levels of daytime sleepiness and fatigue during the first 4 weeks of BMQ compared to the weeks leading up to BMQ. During BMQ, participants were considered to have abnormal to severe levels of fatigue (particularly mental fatigue), reduced motivation, and daytime sleepiness levels akin to those seen in sleep disordered individuals. Their patterns of night sleep also changed: they reported sleeping only 5.2 hours per night (compared to 7.5 hours before BMQ) and had a significantly reduced sleep latency (i.e., time to fall asleep) which is often indicative of sleep deprivation.

2. CFLRS recruits experienced a dramatic and sustained drop in cognitive effectiveness right from the start of BMQ. On day 1 of BMQ, the overall workday cognitive effectiveness was over 90%, with 100% representing optimal cognitive performance. Cognitive effectiveness then dropped approximately by 2.5% each day for the next 4 days. From day 5 to day 7, it averaged just below 80% and then declined further to 77.5% for days 8–26. Importantly, a value of 77.5% cognitive effectiveness corresponds to that obtained with a BAC of 0.05% (legally impaired in some jurisdictions). During days 1 to 7, recruits spent only on average 9.5% of their workday performing below the equivalent to 0.05% BAC. After day 7, recruits performed significantly worse, with 44.9% of their workday scoring below the equivalent to 0.05% BAC.

3. CFLRS recruits’ cognitive effectiveness during the morning and afternoon circadian peak times also dramatically declined over the first few days of BMQ. Participants had morning and late afternoon peaks in cognitive effectiveness that generally ranged from 2 to 2.5 hours in duration. In the first few days of BMQ, the morning peak performance commenced at about 08:50 but phase advanced to about 08:20 by day 4, after which the timing of the morning peak showed small alternating delays and advances over the remainder of the study period. For the afternoon peak performance, there was only a small net phase advance in timing from about 18:05 to about 17:50 over the 26 day study period. The average cognitive effectiveness at the start time for each of the daily morning and afternoon circadian peaks indicated precipitous drops from day 1 to days 4–5 and then again to days 10–11.

4. CFLRS recruits’ daytime sleepiness and fatigue levels were not predictive of their scores on the R2MR quiz. Participants who were particularly sleepy and fatigued were not found to perform worse on the quiz than their less fatigued colleagues. It is quite possible that most of the variance in this analysis could have been accounted for by individual differences in cognitive ability. The research design should therefore have included this variable as a covariate in order to increase the statistical power to detect the relationship between sleep/fatigue levels and the quiz results. Importantly however, despite these results, it has been very well established in the scientific literature that daytime sleepiness and reduced sleep duration significantly compromise student learning ability and hamper academic performance (Curcio, Ferrara & De Gennaro, 2006; Dewald, Meijer, Oort, Kerkhof & Bögels, 2010).





Based on these findings, the following recommendations are proposed:

1. Recruits should be encouraged to get as much night sleep as possible, preferably at least 7 hours. Based on the results of the SSS questionnaire, this would best be achieved by advancing bedtime to 22:00. The benefits of an early bedtime include better cognitive performance, but also improved mood (Nota & Coles, 2015).

2. The R2MR training should be offered during the first few days of the BMQ, preferable on day 1 or 2 when cognitive effectiveness is still above 86%. Given that R2MR is focused on teaching stress management skills to recruits, this would have the added advantage of teaching the recruits these skills early on so that they can use them throughout the BMQ.

3. The R2MR training should start at 08:00 (finishing at 11:40) to take advantage of the morning circadian peak performance. This optimum time identified in the present study is in fact identical to one of the two current start times for R2MR.

4. Since the afternoon circadian peak starts during normal messing hours, it may not be practical to attempt to delay the evening meal to accommodate R2MR training. However, if there is interest in engaging the recruits in didactics in the afternoon when optimum cognitive effectiveness is required, an appropriate start time would be between 17:45 to 18:15 for up to 2 hours.


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Subjective sleep/fatigue measures Annex A








Daily sleep log Annex B




R2MR quiz and feedback questions Annex C

1. What is the most common mental health condition in the Canadian Forces?

a. Depression b. Alcohol Abuse c. Posttraumatic Stress Disorder d. Bipolar Disorder e. None of the above

2. Mental health is an all or nothing state: you are either mentally healthy or sick. a. True b. False

3. Please review the following case.

Joe is a member of the CF. He recently came back from a tour of duty. Joe has been reacting with anger to minor inconveniences. He has been very negative at his job recently and has had trouble focusing. At night he has trouble sleeping due to his nightmares. He has been avoiding meeting up with his friends. He has been gambling online and is losing more than he can afford.

Thinking back to the Mental Health Continuum model, try to remember where in the

continuum this person’s symptoms fall:

a. Green (Healthy) b. Yellow (Reacting) c. Orange (Injured) d. Red (Ill) e. Purple (Permanently sick)

4. What are the 4 key strategies (i.e., the Big 4) in managing stress? List and describe (if you do

not remember what the strategy was called then just describe it. If you are having a hard time describing a key strategy, you can also give an example).Remember these were also taught during the health promotion lecture during your first week of basic training and discussed yesterday.

a. Strategy 1: ___________________. Describe in your own words what it is:

b. Strategy 2: ___________________. Describe in your own words what it is:


c. Strategy 3: ___________________. Describe in your own words what it is:

d. Strategy 4: ___________________. Describe in your own words what it is:

5. These are five common “thinking traps” that may prevent you from being successful in your basic training and in your military career. Please chose two and describe in your own words what each of these two thinking traps are:

Mind-reading Personalization Shoulds Catastrophizing Black and white thinking

a. __________________________________________________________________

__________________________________________________________________ b. __________________________________________________________________ __________________________________________________________________

6. Another common thinking trap that may prevent you from being successful in your basic training and in your military career is “Over-generalizing”. Over-generalizing is seeing a single negative event as a never ending pattern of defeat by using such words as “always” or “never”. Because something happened once or a few times, you assume it will happen over and over again.

For example: After failing a test Joe kept saying to himself that: “this always happens

to me, I am never going to pass this course”. How would you challenge that thought (if you were Joe) so you are not overgeneralizing? I would challenge this thought by:


7. There are helpful and unhelpful ways of coping. List four of each type. Helpful Unhelpful 1. 1.

2. 2. 3. 3. 4. 4.

8. Whether to seek help or not for mental health symptoms is a personal judgment call; we would suggest seeking help when you are in the following range of the Mental Health Continuum Model:

a. Green b. Red c. Yellow to orange d. Purple e. Never, deal with it on your own.

Feedback questions Please answer the following questions as honestly as possible by making an X in the appropriate box to indicate the degree to which you agree or disagree with the following statements. This feedback from you will be very important in helping future recruits to maximally benefit from the mental health training.

1. I think that the mental health training is very important and relevant to my career in the CF.

Strongly Agree

Agree Agree Slightly

Neither Agree nor disagree

Disagree Slightly

Disagree Strongly Disagree

2. I feel like I made a very strong effort in understanding the material taught during

the mental health training.

Strongly Agree



Disagree Slightly


3. I think that the material taught during the metal health training will help me deal

with mental health issues that I (or my CF buddies) may face in the future.


Strongly Agree



Disagree Slightly


4. I think that the mental health training education was interesting, and easy to follow and understand.

Strongly Agree



Disagree Slightly



Individual models of cognitive effectiveness Annex D

D.1 Overview of the features of the cognitive effectiveness model graphs

The vertical axis on the left side of the FASTTM graphs represents human cognitive performance effectiveness as a percentage of optimal performance (100%). The oscillating line in the diagram represents average performance (cognitive effectiveness) as determined by time of day, biological rhythms, time spent awake, and amount of sleep.

The dotted line which is below the cognitive effectiveness curve and follows a similar oscillating pattern as the cognitive effectiveness represents the lower 10th percentile of cognitive effectiveness.

The green band (from 90% to 100%) represents acceptable cognitive performance effectiveness for workers conducting safety sensitive jobs (flying, driving, weapons operation, command and control, etc.).

The yellow band (from 65% to 90%) indicates caution. Personnel engaged in skilled performance activities such as aviation should not be allowed to operate in this performance band.

The area from the dotted line to the pink area represents the cognitive effectiveness equivalent to the circadian nadir and a 2nd day without sleep.

The pink performance band (below 65%) represents performance effectiveness after 2 days and a night of sleep deprivation. Under these conditions, no one can be expected to function well on any task.

The vertical axis on the right side of FAST™ graphs represents the Blood Alcohol Content (BAC) equivalency throughout the spectrum of cognitive effectiveness. A value of 77.5% cognitive effectiveness corresponds to a blood alcohol content of 0.05% (legally impaired in some jurisdictions). A value of 70% cognitive effectiveness corresponds to a blood alcohol content of 0.08% (legally impaired in most jurisdictions).

The abscissa (x-axis) illustrates periods of work (black bars), sleep (blue bars), darkness (gray bars) and time of day in hours.


D.2 Individual cognitive effectiveness models for the 25 participants who completed the 26-day study.

Participant 14:

The sleep hygiene of this subject results in modeled performance ranging from 93% on day 1, falling to below equivalence to BAC 0.05% (77.5%) on day 6, and to as low as 67% (well in excess of BAC 0.08%). This subject spends 100% of 10 of the 26 daily work periods, performing beyond criterion line (BCL) for 0.05% and sometimes beyond 0.08% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 76.77% and 67.02% respectively.

Day Date Start Time

End Time

% Cognitive Effectiveness

% of day spent

performing BCL for

0.05% BAC

Mon 1/28/2013 5:15 17:45 91.07 0.00 Tue 1/29/2013 5:15 17:45 85.77 0.00 Wed 1/30/2013 5:15 17:45 84.68 0.00 Thu 1/31/2013 5:15 17:45 82.94 0.00 Fri 2/1/2013 5:15 17:45 80.16 0.00 Sat 2/2/2013 5:15 17:45 81.27 0.00 Sun 2/3/2013 5:15 17:45 77.32 52.20 Mon 2/4/2013 5:15 17:45 77.50 48.67 Tue 2/5/2013 5:15 17:45 75.55 93.73 Wed 2/6/2013 5:15 17:45 71.30 100.00 Thu 2/7/2013 5:15 17:45 71.44 100.00


Day Date Start Time

End Time


% of day spent

performing BCL for

0.05% BAC

Fri 2/8/2013 5:15 17:45 73.07 100.00 Sat 2/9/2013 5:15 17:45 73.42 100.00 Sun 2/10/2013 5:15 17:45 76.57 67.80 Mon 2/11/2013 5:15 17:45 76.82 62.13 Tue 2/12/2013 5:15 17:45 77.37 51.47 Wed 2/13/2013 5:15 17:45 75.36 93.07 Thu 2/14/2013 5:15 17:45 75.56 90.93 Fri 2/15/2013 5:15 17:45 73.73 100.00 Sat 2/16/2013 5:15 17:45 68.92 100.00 Sun 2/17/2013 5:15 17:45 73.30 100.00 Mon 2/18/2013 5:15 17:45 76.01 90.15 Tue 2/19/2013 5:15 17:45 74.18 100.00 Wed 2/20/2013 5:15 17:45 75.58 92.27 Thu 2/21/2013 5:15 17:45 73.14 100.00 Fri 2/22/2013 5:15 17:45 73.93 100.00 Grand means

76.77 67.02


Participant 25:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 10, and down as low as 75% and but never falling to 70% (equivalence to BAC 0.08%). This subjects spends some portions (ranging from 1% to 54%) of 14 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average % BCL across all work days are 80.90% and 14.83% respectively.

Day Date Start Time

End Time


% of day spent

performing BCL for

0.05% BAC

Mon 1/28/2013 5:15 18:00 90.74 0.00 Tue 1/29/2013 5:15 18:00 87.11 0.00 Wed 1/30/2013 5:15 18:00 84.50 0.00 Thu 1/31/2013 5:15 18:00 82.83 0.00 Fri 2/1/2013 5:15 18:00 80.82 0.00 Sat 2/2/2013 6:00 18:00 84.24 0.00 Sun 2/3/2013 6:00 18:00 83.67 0.00 Mon 2/4/2013 5:15 18:00 81.32 0.00 Tue 2/5/2013 5:15 18:00 80.21 0.78 Wed 2/6/2013 5:15 18:00 79.63 2.09 Thu 2/7/2013 5:15 18:00 78.35 33.86 Fri 2/8/2013 5:15 18:00 78.45 32.29 Sat 2/9/2013 6:00 18:00 82.37 0.00


Day Date Start Time

End Time


% of day spent

performing BCL for

0.05% BAC

Sun 2/10/2013 6:00 18:00 82.94 0.00 Mon 2/11/2013 5:15 18:00 81.41 0.00 Tue 2/12/2013 5:15 18:00 80.02 1.44 Wed 2/13/2013 5:15 18:00 78.51 30.98 Thu 2/14/2013 5:15 18:00 78.56 30.20 Fri 2/15/2013 5:15 18:00 78.50 31.50 Sat 2/16/2013 6:00 18:00 80.92 0.00 Sun 2/17/2013 5:15 18:00 79.57 1.57 Mon 2/18/2013 5:15 18:00 78.06 39.48 Tue 2/19/2013 5:15 18:00 77.31 53.20 Wed 2/20/2013 5:15 18:00 78.57 30.33 Thu 2/21/2013 5:15 18:00 77.62 47.19 Fri 2/22/2013 5:15 18:00 77.67 46.27 Grand means

80.90 14.83

Participant 28:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 13, and to as low as 74% and but never falling to 70% (equivalence to BAC 0.08%). This subject spends small portions (ranging from 1% to 45%) of 14 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 81.37% and 4.04% respectively.

Day Date Start Time

End Time


% of day spent performing BCL for 0.05% BAC

Mon 1/28/2013 5:15 18:00 90.74 0.00 Tue 1/29/2013 5:15 18:00 86.33 0.00 Wed 1/30/2013 5:15 18:00 84.90 0.00 Thu 1/31/2013 5:15 18:00 83.83 0.00 Fri 2/1/2013 5:15 18:00 82.16 0.00 Sat 2/2/2013 6:00 18:00 84.35 0.00 Sun 2/3/2013 6:00 18:00 80.31 1.11


Day Date Start Time

End Time



Mon 2/4/2013 5:15 18:00 80.11 3.01 Tue 2/5/2013 5:15 18:00 79.86 3.53 Wed 2/6/2013 5:15 18:00 79.92 2.75 Thu 2/7/2013 5:15 18:00 80.00 2.22 Fri 2/8/2013 5:15 18:00 80.06 1.83 Sat 2/9/2013 6:00 18:00 77.58 47.36 Sun 2/10/2013 6:00 18:00 80.49 0.00 Mon 2/11/2013 5:15 18:00 79.55 4.18 Tue 2/12/2013 5:15 18:00 79.44 4.44 Wed 2/13/2013 5:15 18:00 79.62 3.40 Thu 2/14/2013 5:15 18:00 79.77 2.75 Fri 2/15/2013 5:15 18:00 79.88 2.22 Sat 2/16/2013 6:00 18:00 81.17 0.00 Sun 2/17/2013 6:00 18:00 78.80 24.44 Mon 2/18/2013 5:15 18:00 79.83 4.58 Tue 2/19/2013 5:15 18:00 80.87 0.00 Wed 2/20/2013 5:15 18:00 81.36 0.00 Thu 2/21/2013 5:15 18:00 82.88 0.00 Fri 2/22/2013 5:15 18:00 81.54 0.00 Grand means

81.37 4.04


Participant 59.5:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, reaching equivalence to BAC of 0.05% (77.5% cognitive effectiveness) at the beginning of the daily work period on several days, and as low as 75% but never falling to 70% (equivalence to BAC 0.08%). This subjects spends only 1% to 2% of 11 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 82.10% and 0.36% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:15 18:00 90.74 0.00 Tue 1/29/2013 5:15 18:00 87.11 0.00 Wed 1/30/2013 5:15 18:00 85.28 0.00 Thu 1/31/2013 5:15 18:00 84.02 0.00 Fri 2/1/2013 5:15 18:00 83.08 0.00 Sat 2/2/2013 5:15 18:00 82.37 0.00 Sun 2/3/2013 5:15 18:00 81.83 0.00 Mon 2/4/2013 5:15 18:00 81.42 0.00 Tue 2/5/2013 5:15 18:00 81.11 0.00 Wed 2/6/2013 5:15 18:00 80.88 0.00 Thu 2/7/2013 5:15 18:00 80.70 0.39 Fri 2/8/2013 6:00 18:00 82.98 0.00 Sat 2/9/2013 6:00 18:00 84.03 0.00 Sun 2/10/2013 5:15 18:00 82.25 0.00 Mon 2/11/2013 5:15 18:00 81.47 0.00


Day Date Start Time

End Time



Tue 2/12/2013 5:15 18:00 81.12 0.00 Wed 2/13/2013 5:15 18:00 80.88 0.13 Thu 2/14/2013 5:15 18:00 80.71 0.39 Fri 2/15/2013 5:15 18:00 80.58 0.65 Sat 2/16/2013 5:15 18:00 80.48 0.78 Sun 2/17/2013 5:15 18:00 80.41 0.92 Mon 2/18/2013 5:15 18:00 80.35 1.05 Tue 2/19/2013 5:15 18:00 80.30 1.18 Wed 2/20/2013 5:15 18:00 80.27 1.18 Thu 2/21/2013 5:15 18:00 80.25 1.31 Fri 2/22/2013 5:15 18:00 80.23 1.31 Grand means

82.10 0.36

Participant 62:

The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, reaching equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 8, and to as low as 75% on day 13 but never quite reaching 70% (equivalence to BAC 0.08%). This subjects spends portions (ranging from 1% to 52%) of 13 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.84% and 8.24% respectively.


Day Date Start Time

End Time



Mon 1/28/2013 5:30 18:00 90.08 0.00 Tue 1/29/2013 5:30 18:00 88.30 0.00 Wed 1/30/2013 5:30 18:00 85.13 0.00 Thu 1/31/2013 5:30 18:00 83.15 0.00 Fri 2/1/2013 5:30 18:00 81.89 0.00 Sat 2/2/2013 5:30 18:00 80.46 0.00 Sun 2/3/2013 5:30 18:00 77.77 44.13 Mon 2/4/2013 5:30 18:00 78.69 26.93 Tue 2/5/2013 5:30 18:00 79.17 15.87 Wed 2/6/2013 5:30 18:00 79.46 1.60 Thu 2/7/2013 5:30 18:00 79.67 0.93 Fri 2/8/2013 5:30 18:00 79.81 0.53 Sat 2/9/2013 6:00 18:00 77.31 52.36 Sun 2/10/2013 6:00 18:00 79.04 17.78 Mon 2/11/2013 5:30 18:00 78.57 28.80 Tue 2/12/2013 5:30 18:00 78.75 25.47 Wed 2/13/2013 5:30 18:00 81.41 2.00 Thu 2/14/2013 5:30 18:00 80.67 0.00 Fri 2/15/2013 5:30 18:00 80.34 0.00 Sat 2/16/2013 5:30 18:00 80.29 0.00 Sun 2/17/2013 5:30 18:00 80.28 0.00 Mon 2/18/2013 5:30 18:00 80.27 0.00 Tue 2/19/2013 5:30 18:00 80.27 0.00 Wed 2/20/2013 5:30 18:00 80.26 0.00 Thu 2/21/2013 5:30 18:00 80.25 0.00 Fri 2/22/2013 5:30 18:00 80.25 0.00 Grand means

80.84 8.24


Participant 70.1:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to below 77% on day 5 (below the equivalence to BAC of 0.05%), to as low as 64% at the beginning of the work period on Day 23. The cognitive effectivess is well below the equivalence to BAC 0.08% during parts of the work periods over the last 4 days of this model. This subject spends portions (ranging from 3% to 100%) of 19 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC where 100% of the work day is spent at or below BAC 0.05%. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 77.70% and 44.33% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:00 18:00 90.67 0.00 Tue 1/29/2013 5:00 18:00 83.77 0.00 Wed 1/30/2013 5:00 18:00 83.62 0.00 Thu 1/31/2013 5:00 18:00 81.72 0.00 Fri 2/1/2013 5:00 18:00 76.68 66.41 Sat 2/2/2013 6:00 18:00 76.91 60.69 Sun 2/3/2013 6:00 18:00 80.44 0.00 Mon 2/4/2013 5:00 18:00 78.27 34.62 Tue 2/5/2013 5:00 18:00 78.55 29.10 Wed 2/6/2013 5:00 18:00 78.96 20.51 Thu 2/7/2013 5:00 18:00 79.26 10.13 Fri 2/8/2013 5:00 18:00 79.48 5.00 Sat 2/9/2013 6:00 18:00 82.18 0.00


Day Date Start Time

End Time



Sun 2/10/2013 6:00 18:00 82.96 0.00 Mon 2/11/2013 5:00 18:00 79.62 3.33 Tue 2/12/2013 5:00 18:00 77.15 56.28 Wed 2/13/2013 5:00 18:00 78.62 28.72 Thu 2/14/2013 5:00 18:00 75.76 88.59 Fri 2/15/2013 5:00 18:00 74.37 97.05 Sat 2/16/2013 5:00 18:00 71.29 100.00 Sun 2/17/2013 7:00 18:00 77.86 43.03 Mon 2/18/2013 5:00 18:00 73.03 100.00 Tue 2/19/2013 5:00 18:00 67.10 100.00 Wed 2/20/2013 5:00 18:00 69.75 100.00 Thu 2/21/2013 5:00 18:00 70.92 100.00 Fri 2/22/2013 5:00 18:00 72.32 100.00 Grand means

77.70 44.33

Participant 101.73:

The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5, to as low as 72% at the beginning of the work period on Day 23 and on the last day of this model, but never reaches BAC 0.08% during any work periods. This subject spends portions (ranging from 1% to 55%) of 19 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.58% and 10.36% respectively.


Day Date Start Time

End Time




80.58 10.36


Participant 104.75:

The sleep hygiene of this subject results in modeled performance ranging from about 91% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 8, to as low as 72% at the beginning of the work period on Day 19 but never reaches BAC 0.08% during any work periods. This subject spends portions (ranging from 1% to 88%) of 19 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 79.51% and 28.30% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:00 18:00 89.26 0.00 Tue 1/29/2013 5:00 18:00 85.52 0.00 Wed 1/30/2013 5:00 18:00 83.67 0.00 Thu 1/31/2013 5:00 18:00 82.31 0.00 Fri 2/1/2013 5:00 18:00 81.27 0.00 Sat 2/2/2013 5:00 18:00 80.46 1.41 Sun 2/3/2013 5:00 18:00 79.84 2.82 Mon 2/4/2013 5:00 18:00 79.36 10.00 Tue 2/5/2013 5:00 18:00 78.99 21.54 Wed 2/6/2013 5:00 18:00 78.71 27.44 Thu 2/7/2013 5:00 18:00 78.50 31.54 Fri 2/8/2013 5:15 18:00 79.23 15.56 Sat 2/9/2013 5:15 18:00 79.55 2.61 Sun 2/10/2013 5:15 18:00 79.71 2.35


Day Date Start Time

End Time



Mon 2/11/2013 5:15 18:00 79.83 2.09 Tue 2/12/2013 5:00 18:00 78.17 37.44 Wed 2/13/2013 5:00 18:00 77.31 53.08 Thu 2/14/2013 5:00 18:00 76.10 86.41 Fri 2/15/2013 5:00 18:00 76.13 86.03 Sat 2/16/2013 5:00 18:00 75.84 87.69 Sun 2/17/2013 6:00 18:00 80.00 0.00 Mon 2/18/2013 5:00 18:00 77.89 42.31 Tue 2/19/2013 5:00 18:00 76.87 61.79 Wed 2/20/2013 5:00 18:00 76.46 72.05 Thu 2/21/2013 5:00 18:00 76.19 85.51 Fri 2/22/2013 6:00 18:00 80.29 0.00 Grand means

79.51 28.30

Participant 108.25:

The sleep hygiene of this subject results in modeled performance ranging from 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 7, to as low as 71% at the beginning of the work periods on days 12 and 13, but never reaches BAC 0.08% during any work periods. This subject spends portions (ranging from 1% to 78%) on 16 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.11% and 21.86% respectively.


Day Date Start Time

End Time




80.11 21.86


Participant 113.6:

The sleep hygiene of this subject results in modeled performance ranging from 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 14, to as low as 72% at the beginning of the work period on day 14, but never reaches BAC 0.08% during any work periods. This subject spends portions (ranging from 9% to 99% of the work period) on 11 of the 26 daily work periods performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 78.37% and 33.33% respectively.

Day Date Start Time

End Time



Sun 1/27/2013 5:30 6:00 91.05 0.00 Mon 1/28/2013 5:30 18:00 90.81 0.00 Tue 1/29/2013 5:30 18:00 87.04 0.00 Wed 1/30/2013 5:30 18:00 85.16 0.00 Thu 1/31/2013 5:30 18:00 82.30 0.00 Fri 2/1/2013 6:15 18:00 85.29 0.00 Sat 2/2/2013 6:00 18:00 83.27 0.00 Sun 2/3/2013 5:30 18:00 81.79 0.00 Mon 2/4/2013 5:30 18:00 81.18 0.00 Tue 2/5/2013 5:30 18:00 80.93 0.00 Wed 2/6/2013 5:30 18:00 80.77 0.00 Thu 2/7/2013 5:30 18:00 80.64 0.00 Fri 2/8/2013 6:15 18:00 82.21 0.00 Sat 2/9/2013 6:15 18:00 80.33 0.00


Day Date Start Time

End Time



Sun 2/10/2013 5:30 18:00 74.83 98.80 Mon 2/11/2013 5:30 18:00 76.55 69.07 Tue 2/12/2013 5:30 18:00 77.73 45.20 Wed 2/13/2013 5:30 18:00 77.55 48.53 Thu 2/14/2013 5:30 18:00 77.58 47.87 Fri 2/15/2013 5:30 18:00 77.67 46.27 Sat 2/16/2013 5:30 18:00 79.40 9.20 Sun 2/17/2013 5:30 18:00 78.69 27.07 Mon 2/18/2013 5:30 18:00 78.36 33.60 Tue 2/19/2013 5:30 18:00 78.24 35.73 Wed 2/20/2013 5:30 18:00 78.17 37.07 Thu 2/21/2013 6:00 18:00 80.08 0.00 Grand means

78.37 33.33

Participant 123.66:

The sleep hygiene of this subject results in modeled performance ranging from about 90% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5, to as low as 70% (equivalent to BAC 0.08%) at the beginning of the work period on day 22. This subject spends portions (ranging from 50% to 95%) of the work daily work period on 11 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 76.73% and 68.26% respectively.


Day Date Start Time

End Time




76.73 68.26


Participant 131:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 17, to as low as 72% at the beginning of the work period on day 18. This subject spends portions (ranging from 0.4% to 32%) of the daily work period on 6 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 82.16% and 5.01% respectively.

Day Date Start Time

End Time





Day Date Start Time

End Time



Tue 2/12/2013 5:30 18:00 80.76 0.00 Wed 2/13/2013 5:30 18:00 78.46 31.60 Thu 2/14/2013 5:30 18:00 78.75 26.40 Fri 2/15/2013 5:30 18:00 79.37 10.53 Sat 2/16/2013 5:45 18:00 81.96 0.00 Sun 2/17/2013 5:45 18:00 83.84 0.00 Mon 2/18/2013 5:30 18:00 81.98 0.00 Tue 2/19/2013 5:30 18:00 82.03 0.00 Wed 2/20/2013 5:30 18:00 80.55 0.00 Thu 2/21/2013 5:30 18:00 78.42 32.27 Fri 2/22/2013 5:30 18:00 78.63 28.53 Grand Means

82.16 5.01

Participant 137.74:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5, to as low as 72% at the beginning of the work period on days 9 and 18. This subject spends portions (ranging from 1% to 100%) of the daily work period on 23 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 77.95% and 55.10% respectively.


Day Date Start Time

End Time




77.95 55.10


Participant 139:

The sleep hygiene of this subject results in modeled performance ranging from about 94% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 6, to as low as 74% at the beginning of the work period also on day 6. This subject spends portions (ranging from 01% to 52%) of the work daily work period on 11 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 82.15% and 13.29% respectively.

Day Date Start Time

End Time





Day Date Start Time

End Time




82.15 13.29

Participant 160.29:

The sleep hygiene of this subject results in modeled performance ranging from about 96% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 6, to as low as 67% (well below equivalent of BAC 0.08%) at the beginning of the work periods on days 21 and 26. This subject spends portions (ranging from 2% to 100%) of the work daily work period on 22 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 77.62% and 56.45% respectively.


Day Date Start Time

End Time




77.62 56.45


Participant 168.98:

The sleep hygiene of this subject results in modeled performance ranging from about 94% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 15, to as low as 68% (well below equivalence to BAC 0.08%) at the beginning of the work period on day 17. This subject spends portions (ranging from 1% to 100%) of the daily work period on 19 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 79.47% and 33.80% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 6:00 18:00 91.63 0.00 Tue 1/29/2013 6:00 18:00 87.81 0.00 Wed 1/30/2013 6:00 18:00 84.60 0.00 Thu 1/31/2013 6:00 18:00 82.35 0.00 Fri 2/1/2013 6:00 18:00 82.33 0.00 Sat 2/2/2013 6:15 18:00 82.02 0.00 Sun 2/3/2013 6:15 18:00 81.58 0.00 Mon 2/4/2013 6:00 18:00 81.15 1.28 Tue 2/5/2013 6:00 18:00 80.88 1.79 Wed 2/6/2013 6:00 18:00 80.68 2.18 Thu 2/7/2013 6:00 18:00 80.54 2.44 Fri 2/8/2013 6:00 18:00 80.43 2.56 Sat 2/9/2013 6:15 18:00 80.42 0.92 Sun 2/10/2013 6:15 18:00 80.36 1.05


Day Date Start Time

End Time




79.47 33.80

Participant 172.46:

The sleep hygiene of this subject results in modeled performance ranging from about 94% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 9, to as low as 65% (well below equivalence of BAC 0.08%) at the beginning of the work period on day 19. This subject spends portions (ranging from 24% to 100%) of the daily work period on 18 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 71.18% and 45.65% respectively.


Day Date Start Time

End Time




78.18 45.65


Participant 174.142:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 7, to as low as 71% at the beginning of the work period on day 14. This subject spends portions (ranging from 1% to 100%) of the daily work period on 18 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.22% and 25.90% respectively.

Day Date Start Time

End Time





Day Date Start Time

End Time




80.22 25.90

Participant 176.47:

The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 9, to as low as 60% (in excess of BAC 0.08%) at the beginning of the work period on day 15. This subject spends portions (ranging from 0.4% to 100%) of the daily work period on 20 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 74.78% and 67.21% respectively.


Day Date Start Time

End Time




74.78 67.21


Participant 177.52:

The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 6, to as low as 72% at the beginning of the work period on day 19. This subject spends portions (ranging from 1% to 100%) of the daily work period on 19 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.54% and 12.85% respectively.

Day Date Start Time

End Time





Day Date Start Time

End Time




80.54 12.85

Participant 8.65:

The sleep hygiene of this subject results in modeled performance ranging from about 91% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5, to as low as 68% (in excess of BAC 0.08%) at the beginning of the work period on day 26. This subject spends portions (ranging from 1% to 100%) of the daily work period on 20 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 77.87% and 55.40% respectively.


Day Date Start Time

End Time



Mon 1/28/2013 5:00 18:00 88.84 0.00 Tue 1/29/2013 5:00 18:00 85.19 0.00 Wed 1/30/2013 5:00 18:00 81.99 0.00 Thu 1/31/2013 5:00 18:00 80.44 1.15 Fri 2/1/2013 5:00 18:00 79.32 11.15 Sat 2/2/2013 6:00 18:00 82.60 0.00 Sun 2/3/2013 6:00 18:00 78.98 20.83 Mon 2/4/2013 5:00 18:00 77.73 44.74 Tue 2/5/2013 5:00 18:00 76.52 68.85 Wed 2/6/2013 5:00 18:00 76.14 84.87 Thu 2/7/2013 5:00 18:00 75.24 91.15 Fri 2/8/2013 5:00 18:00 75.50 89.36 Sat 2/9/2013 6:00 18:00 80.45 0.56 Sun 2/10/2013 6:00 18:00 80.26 0.00 Mon 2/11/2013 5:00 18:00 76.75 64.10 Tue 2/12/2013 5:00 18:00 76.17 81.67 Wed 2/13/2013 5:00 18:00 76.04 86.79 Thu 2/14/2013 5:00 18:00 75.90 87.05 Fri 2/15/2013 5:00 18:00 75.78 87.44 Sat 2/16/2013 6:00 18:00 74.52 98.47 Sun 2/17/2013 6:00 18:00 76.36 74.44 Mon 2/18/2013 5:00 18:00 75.13 94.10 Tue 2/19/2013 5:00 18:00 75.53 90.64 Wed 2/20/2013 5:00 18:00 74.46 96.92 Thu 2/21/2013 5:00 18:00 71.36 100.00 Grand means

77.87 55.40


Participant 82.43:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 7, to as low as 75% at the beginning of the work period on each of days 7 and 26. This subject spends portions (ranging from 1% to 52%) of the daily work period on 16 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 81.06% and 5.47% respectively.

Day Date Start Time

End Time



Tue 1/29/2013 5:30 18:15 90.83 0.00 Wed 1/30/2013 5:30 18:15 87.22 0.00 Thu 1/31/2013 5:30 18:15 85.40 0.00 Fri 2/1/2013 5:30 18:15 84.13 0.00 Sat 2/2/2013 6:30 18:15 82.51 0.00 Sun 2/3/2013 6:30 18:15 79.32 8.37 Mon 2/4/2013 5:30 18:15 78.78 24.18 Tue 2/5/2013 5:30 18:15 78.92 21.83 Wed 2/6/2013 5:30 18:15 79.27 12.94 Thu 2/7/2013 5:30 18:15 79.55 1.96 Fri 2/8/2013 5:30 18:15 79.76 1.05 Sat 2/9/2013 6:30 18:15 82.35 0.00 Sun 2/10/2013 6:30 18:15 80.45 0.00 Mon 2/11/2013 5:30 18:15 79.60 2.48 Tue 2/12/2013 5:30 18:15 79.51 3.01


Day Date Start Time

End Time



Wed 2/13/2013 5:30 18:15 79.69 1.70 Thu 2/14/2013 5:30 18:15 79.85 0.92 Fri 2/15/2013 5:30 18:15 79.97 0.39 Sat 2/16/2013 6:30 18:15 80.69 0.00 Sun 2/17/2013 6:30 18:15 81.24 0.00 Mon 2/18/2013 5:30 18:15 80.14 0.78 Tue 2/19/2013 5:30 18:15 79.93 1.44 Wed 2/20/2013 5:30 18:15 80.01 0.65 Thu 2/21/2013 5:30 18:15 80.09 0.26 Fri 2/22/2013 5:30 18:15 77.31 52.81 Grand means

81.06 5.47

Participant 125.11:

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5, to as low as 69% (below BAC 0.08%) at the beginning of the work period on day 12. This subject spends portions (ranging from 17% to 100%) of the daily work period on 21 of the 26 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 76.93% and 68.93% respectively.


Day Date Start Time

End Time



Mon 1/28/2013 5:30 18:00 90.79 0.00 Tue 1/29/2013 5:30 18:00 85.57 0.00 Wed 1/30/2013 5:30 18:00 84.01 0.00 Thu 1/31/2013 5:30 18:00 81.01 0.00 Fri 2/1/2013 5:30 18:00 77.08 58.13 Sat 2/2/2013 6:00 18:00 75.37 91.94 Sun 2/3/2013 6:00 18:00 77.53 48.33 Mon 2/4/2013 5:30 18:00 74.22 100.00 Tue 2/5/2013 5:30 18:00 75.53 90.80 Wed 2/6/2013 5:30 18:00 74.51 97.87 Thu 2/7/2013 5:30 18:00 75.02 93.33 Fri 2/8/2013 5:30 18:00 74.58 97.47 Sat 2/9/2013 6:00 18:00 76.46 72.22 Sun 2/10/2013 6:00 18:00 73.80 100.00 Mon 2/11/2013 5:30 18:00 75.02 93.87 Tue 2/12/2013 5:30 18:00 74.05 100.00 Wed 2/13/2013 5:30 18:00 72.54 100.00 Thu 2/14/2013 5:30 18:00 71.75 100.00 Fri 2/15/2013 5:30 18:00 72.39 100.00 Sat 2/16/2013 5:30 13:30 74.88 100.00 Sun 2/17/2013 5:30 18:00 79.10 16.53 Mon 2/18/2013 5:30 18:00 76.72 65.33 Tue 2/19/2013 5:30 18:00 77.02 58.80 Wed 2/20/2013 5:30 18:00 76.54 69.47 Thu 2/21/2013 5:30 18:00 76.04 88.67 Grand means

76.93 68.93


D.3 Individual cognitive effectiveness models for the 15 participants who did not complete the entire 26-day study. The number of days for these models ranges from 12 to 23 days.

Participant 91.42 (23 days of data):

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5 and after a very short, broken sleep on night 10, cognitive effectiveness drops to as low as 52% at the beginning of the work period on day 11. Cognitive effectiveness recovers progressively over the next 4 days and then drops over the final 6 monitored days. This subject spends portions (ranging from 81% to 100%) of the daily work period on 19 of the 23 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 72.65% and 81.08% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:30 0.74 90.76 0.00 Tue 1/29/2013 5:30 0.74 86.64 0.00 Wed 1/30/2013 5:30 0.74 84.95 0.00 Thu 1/31/2013 5:30 0.74 82.98 0.00 Fri 2/1/2013 5:30 0.74 75.36 95.10 Sat 2/2/2013 6:15 0.74 74.17 100.00 Sun 2/3/2013 6:30 0.74 71.49 100.00 Mon 2/4/2013 5:30 0.74 71.80 100.00


Day Date Start Time

End Time



Tue 2/5/2013 5:30 0.74 70.61 100.00 Wed 2/6/2013 5:30 0.74 70.53 100.00 Thu 2/7/2013 5:30 0.74 57.02 100.00 Fri 2/8/2013 5:30 0.74 65.79 100.00 Sat 2/9/2013 5:30 0.74 69.08 100.00 Sun 2/10/2013 7:00 0.66 76.23 80.95 Sun 2/10/2013 17:15 0.74 79.83 0.00 Mon 2/11/2013 5:30 0.74 74.68 99.59 Tue 2/12/2013 5:30 0.74 71.23 100.00 Wed 2/13/2013 5:30 0.74 74.90 95.10 Thu 2/14/2013 5:30 0.74 68.66 100.00 Fri 2/15/2013 5:30 0.74 65.19 100.00 Sat 2/16/2013 5:30 0.74 66.86 100.00 Sun 2/17/2013 5:30 0.74 68.29 100.00 Mon 2/18/2013 5:30 0.74 67.46 100.00 Tue 2/19/2013 5:30 0.74 66.94 100.00 Grand means

72.65 81.08


The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 10 and after very limited sleep on nights 10 and 11, cognitive effectiveness drops to a low of 67% at the beginning


of the work period on day 12. Cognitive effectiveness recovers progressively over the next 2 days and 2 days later starts to drop over the final 8 monitored days. This subject spends portions (ranging from 13% to 100%) of the daily work period on 8 of the 23 days, performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.98% and 24.21% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 6:00 18:00 90.87 0.00 Tue 1/29/2013 6:00 18:00 87.26 0.00 Wed 1/30/2013 6:00 18:00 85.43 0.00 Thu 1/31/2013 6:00 18:00 83.35 0.00 Fri 2/1/2013 6:00 18:00 82.65 0.00 Sat 2/2/2013 6:00 18:00 81.68 0.00 Sun 2/3/2013 6:45 18:00 87.14 0.00 Mon 2/4/2013 6:00 18:00 83.46 0.00 Tue 2/5/2013 6:00 18:00 80.88 0.00 Wed 2/6/2013 6:00 18:00 79.29 12.50 Thu 2/7/2013 6:00 18:00 70.45 100.00 Fri 2/8/2013 6:00 18:00 68.93 100.00 Sat 2/9/2013 6:15 18:00 77.41 50.78 Sun 2/10/2013 6:15 18:00 86.03 0.00 Mon 2/11/2013 6:00 18:00 85.79 0.00 Tue 2/12/2013 6:00 18:00 82.34 0.00 Wed 2/13/2013 6:00 18:00 82.08 0.00 Thu 2/14/2013 6:00 18:00 82.97 0.00 Fri 2/15/2013 6:00 18:00 82.24 0.00 Sat 2/16/2013 6:00 18:00 78.22 35.28 Sun 2/17/2013 6:00 18:00 76.97 59.72 Mon 2/18/2013 6:00 18:00 72.98 100.00 Tue 2/19/2013 6:00 18:00 74.62 97.08 Grand means

80.98 24.21



The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5 and remains below 77.5% (below equivalent to BAC 0.05%) and often also below 70% (equivalent to BAC 0.08%). Cognitive effectiveness reaches its lowest point of 53% cognititve effectiveness at the beginning of the work day on day 23. This subject spends 100% of the work daily work period on 19 of the 23 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 69.81% and 82.52% respectively. This is one of the worst models of cognitive effectiveness of the entire data set.

Day Date Start Time

End Time



Mon 1/28/2013 5:15 18:00 90.04 0.00 Tue 1/29/2013 5:15 18:00 85.97 0.00 Wed 1/30/2013 5:15 18:00 83.36 0.00 Thu 1/31/2013 5:15 18:00 80.38 0.00 Fri 2/1/2013 5:15 18:00 70.34 100.00 Sat 2/2/2013 5:45 18:00 72.82 100.00 Sun 2/3/2013 6:00 18:00 63.43 100.00 Mon 2/4/2013 5:15 18:00 66.11 100.00 Tue 2/5/2013 5:15 18:00 68.49 100.00 Wed 2/6/2013 5:15 18:00 69.02 100.00 Thu 2/7/2013 5:15 18:00 60.42 100.00 Fri 2/8/2013 5:15 18:00 65.29 100.00


Day Date Start Time

End Time



Sat 2/9/2013 5:15 18:00 64.54 100.00 Sun 2/10/2013 5:30 18:00 72.47 100.00 Mon 2/11/2013 5:15 18:00 66.65 100.00 Tue 2/12/2013 5:15 18:00 68.36 100.00 Wed 2/13/2013 5:15 18:00 70.43 100.00 Thu 2/14/2013 5:15 18:00 73.39 100.00 Fri 2/15/2013 5:15 18:00 69.63 100.00 Sat 2/16/2013 5:15 18:00 64.88 100.00 Sun 2/17/2013 5:15 18:00 62.32 100.00 Mon 2/18/2013 5:15 18:00 60.12 100.00 Tue 2/19/2013 5:15 18:00 56.94 100.00 Grand means

69.81 82.52


The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5. After very limited sleep on nights 18 and 19, cognitive effectiveness drops to a low of 61% at the beginning of the work period on day 20. This subject spends portions (ranging from 2% to 100%) of the work daily work period on 19 of the 23 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 76.07% and 67.17% respectively.


Day Date Start Time

End Time



Mon 1/28/2013 5:30 18:00 90.40 0.00 Tue 1/29/2013 5:30 18:00 84.48 0.00 Wed 1/30/2013 5:30 18:00 83.59 0.00 Thu 1/31/2013 5:30 18:00 81.71 0.00 Fri 2/1/2013 5:30 18:00 76.29 77.20 Sat 2/2/2013 5:45 18:00 76.25 75.37 Sun 2/3/2013 6:00 18:00 75.69 93.61 Mon 2/4/2013 5:30 18:00 77.10 56.53 Tue 2/5/2013 5:30 18:00 75.21 94.93 Wed 2/6/2013 5:30 18:00 74.12 100.00 Thu 2/7/2013 5:30 18:00 70.13 100.00 Fri 2/8/2013 5:30 18:00 70.96 100.00 Sat 2/9/2013 6:15 18:00 74.06 100.00 Sun 2/10/2013 5:45 18:00 80.14 1.63 Mon 2/11/2013 5:30 18:00 78.52 30.13 Tue 2/12/2013 5:30 18:00 76.40 75.33 Wed 2/13/2013 5:30 18:00 74.58 96.80 Thu 2/14/2013 5:30 18:00 77.29 54.27 Fri 2/15/2013 5:30 18:00 72.66 100.00 Sat 2/16/2013 5:30 18:00 63.49 100.00 Sun 2/17/2013 5:30 18:00 68.56 100.00 Mon 2/18/2013 5:30 18:00 72.85 100.00 Tue 2/19/2013 5:30 18:00 75.09 91.07 Grand means

76.07 67.17



The sleep hygiene of this subject results in modeled performance ranging from about 91% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 3. After a series of nights of very limited sleep, modeled cognitive effectiveness reaches its nadir of 25% on day 12 and while slowly improving for the rest of the monitored time, performance remains equivalent to well below BAC 0.08% (70% cognitive effectiveness); it remains in the pink zone where no one can function well on any task. This subject spends portions (ranging from 8% to 100%) of the work daily work period on 21 of the 23 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 56.10% and 86.30% respectively. This is absolutely the worst models of the entire data set.

Day Date Start Time

End Time





Day Date Start Time

End Time



Sat 2/9/2013 5:30 18:00 40.75 100.00 Sun 2/10/2013 5:15 18:00 37.68 100.00 Mon 2/11/2013 5:15 18:00 41.36 100.00 Tue 2/12/2013 5:15 18:00 48.83 100.00 Wed 2/13/2013 5:15 18:00 52.85 100.00 Thu 2/14/2013 5:15 18:00 57.36 100.00 Fri 2/15/2013 5:15 18:00 51.26 100.00 Sat 2/16/2013 5:15 18:00 55.70 100.00 Sun 2/17/2013 5:15 18:00 59.37 100.00 Mon 2/18/2013 5:15 18:00 59.31 100.00 Tue 2/19/2013 5:15 18:00 60.47 100.00 Grand means

56.10 86.30


The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, dropping through equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5. After a series of nights of limited sleep, modeled cognitive effectiveness reaches its nadir of 39% on day 15 and while improving somewhat for the rest of the monitored time, performance remains equivalent to well below equivalent to BAC 0.08%; it remains in the pink zone where no one can function well on any task. This subject spends 100% of the work daily work period on 18 of the 22 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 63.09% and 81.72% respectively. This is one of the worst models of the entire data set.


Day Date Start Time

End Time



Mon 1/28/2013 5:30 18:00 89.68 0.00 Tue 1/29/2013 5:30 18:00 86.03 0.00 Wed 1/30/2013 5:30 18:00 84.61 0.00 Thu 1/31/2013 5:30 18:00 82.75 0.00 Fri 2/1/2013 5:30 18:00 73.17 100.00 Sat 2/2/2013 6:15 18:00 71.64 100.00 Sun 2/3/2013 6:15 18:00 66.23 100.00 Mon 2/4/2013 5:30 18:00 64.31 100.00 Tue 2/5/2013 5:30 18:00 64.12 100.00 Wed 2/6/2013 5:30 18:00 69.16 100.00 Thu 2/7/2013 5:30 18:00 54.58 100.00 Fri 2/8/2013 5:30 18:00 56.42 100.00 Sat 2/9/2013 5:30 18:00 49.02 100.00 Sun 2/10/2013 5:30 18:00 50.13 100.00 Mon 2/11/2013 5:30 18:00 43.30 100.00 Tue 2/12/2013 5:30 18:00 49.71 100.00 Wed 2/13/2013 5:30 18:00 53.14 100.00 Thu 2/14/2013 5:30 18:00 60.91 100.00 Fri 2/15/2013 5:30 18:00 58.47 100.00 Sat 2/16/2013 5:30 18:00 53.55 100.00 Sun 2/17/2013 5:30 18:00 50.61 100.00 Mon 2/18/2013 5:30 18:00 57.18 100.00 Grand means

63.09 81.72



The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 3. After 2 nights of limited sleep, modeled cognitive effectiveness reaches its nadir of 60% on day 4 and slowly improves to non-impaired (i.e., above 77.5%) performance by day 12. Due to inadequate sleep, performance falls to below 70% (below equivalent of BAC 0.08%) on day 16. This subject spends portions (ranging from .3% to 100%) of them daily work period on 15 of the 17 days, performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 74.79% and 66.86% respectively.

Day Date Start Time

End Time





Day Date Start Time

End Time



Sat 2/9/2013 6:00 18:00 80.03 1.25 Sun 2/10/2013 5:30 18:00 79.16 13.73 Mon 2/11/2013 5:30 18:00 77.80 43.87 Tue 2/12/2013 5:30 18:00 66.51 100.00 Wed 2/13/2013 5:30 18:00 71.63 100.00 Grand means

74.79 66.86


The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5. Modeled cognitive effectiveness reaches its nadir of 67% on days 6 and 11. Due to inadequate sleep on night 11, performance falls to below 70% (below equivalent to BAC 0.08%) on day 11. This subject spends portions (ranging from 55% to 100%) of the daily work period on 15 of the 17 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 77.83% and 57.87% respectively.


Day Date Start Time

End Time



Mon 1/28/2013 5:15 17:45 90.71 0.00 Tue 1/29/2013 5:15 17:45 86.29 0.00 Wed 1/30/2013 5:15 17:45 84.06 0.00 Thu 1/31/2013 5:15 17:45 81.74 0.00 Fri 2/1/2013 5:15 17:45 77.22 54.53 Sat 2/2/2013 5:15 17:45 72.15 100.00 Sun 2/3/2013 5:15 17:45 74.21 100.00 Mon 2/4/2013 5:15 17:45 75.21 93.73 Tue 2/5/2013 5:15 17:45 75.70 90.27 Wed 2/6/2013 5:15 17:45 77.09 57.47 Thu 2/7/2013 5:15 17:45 70.27 100.00 Fri 2/8/2013 5:15 17:45 72.89 100.00 Sat 2/9/2013 5:45 17:45 73.38 100.00 Sun 2/10/2013 5:15 17:45 78.39 32.67 Mon 2/11/2013 5:15 17:45 77.92 41.07 Grand means

77.83 57.87


The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5. After 4 nights of inadequate sleep, modeled cognitive effectiveness reaches its nadir of 34% on day 15. This subject spends portions (ranging from 89% to 100%) of the daily work period on 11


of the 15 days performing beyond criterion line (BCL) for 0.05% BAC . For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 70.01% and 71.27% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:30 18:00 90.79 0.00 Tue 1/29/2013 5:30 18:00 87.45 0.00 Wed 1/30/2013 5:30 18:00 84.84 0.00 Thu 1/31/2013 5:30 18:00 82.25 0.00 Fri 2/1/2013 5:30 18:00 75.94 90.93 Sat 2/2/2013 5:30 18:00 75.96 89.60 Sun 2/3/2013 5:30 18:00 75.89 88.53 Mon 2/4/2013 5:30 18:00 66.35 100.00 Tue 2/5/2013 5:30 18:00 71.75 100.00 Wed 2/6/2013 5:30 18:00 70.26 100.00 Thu 2/7/2013 5:30 18:00 73.36 100.00 Fri 2/8/2013 5:30 18:00 59.62 100.00 Sat 2/9/2013 5:30 18:00 53.17 100.00 Sun 2/10/2013 5:30 18:00 42.74 100.00 Mon 2/11/2013 5:30 18:00 39.83 100.00 Grand means

70.01 71.27


Participant 38 (13 days of data):

The sleep hygiene of this subject results in modeled performance ranging from about 93% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 4. Modeled cognitive effectiveness reaches its nadir of 74% on days 4, 11, 12, and 13. This subject spends portions (ranging from .1% to 70%) of the daily work period on 10 of the 13 days, performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.86% and 23.01% respectively.

Day Date Start Time

End Time



Mon 1/28/2013 5:15 18:00 90.74 0.00 Tue 1/29/2013 5:15 18:00 86.33 0.00 Wed 1/30/2013 5:15 18:00 84.90 0.00 Thu 1/31/2013 5:15 18:00 76.58 69.80 Fri 2/1/2013 5:15 18:00 79.40 8.50 Sat 2/2/2013 6:00 18:00 82.71 0.00 Sun 2/3/2013 5:15 18:00 81.61 0.13 Mon 2/4/2013 5:15 18:00 79.19 14.64 Tue 2/5/2013 5:15 18:00 79.06 18.95 Wed 2/6/2013 5:15 18:00 77.83 43.53 Thu 2/7/2013 5:15 18:00 77.11 57.25 Fri 2/8/2013 5:15 18:00 76.88 61.96 Sat 2/9/2013 5:15 18:00 78.92 23.01 Grand means

80.86 23.01



The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 5. Modeled cognitive effectiveness reaches its nadir of 68% on day 13. This subject spends portions (ranging from 2% to 100%) of the daily work period on 8 of the 13 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.17% and 23.68% respectively.

Day Date Start Time

End Time



Mon 2/11/2013 5:00 18:00 89.98 0.00 Tue 2/12/2013 5:00 18:00 85.10 0.00 Wed 2/13/2013 5:00 18:00 83.46 0.00 Thu 2/14/2013 5:00 18:00 80.53 0.00 Fri 2/15/2013 5:00 18:00 79.49 3.46 Sat 2/16/2013 5:00 18:00 78.63 29.23 Sun 2/17/2013 6:00 18:00 82.06 0.00 Mon 2/18/2013 5:00 18:00 79.50 2.31 Tue 2/19/2013 5:00 18:00 78.97 21.79 Wed 2/20/2013 5:00 18:00 78.74 26.79 Thu 2/21/2013 5:00 18:00 78.53 31.03 Fri 2/22/2013 5:00 18:00 75.31 91.41 Sat 2/23/2013 5:00 18:00 72.02 100.00 Grand means

80.17 23.68



The sleep hygiene of this subject results in modeled performance ranging from about 92% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 7. Modeled cognitive effectiveness reaches its nadir of 68% on day 12. This subject spends portions (ranging from 2% to 51%) of the daily work period on 7 of the 12 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 80.18% and 14.76% respectively.

Day Date Start Time

End Time




81.18 14.76



The sleep hygiene of this subject results in modeled performance ranging from about 90% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 4. Modeled cognitive effectiveness reaches its nadir of 69% on day 10. This subject spends portions (ranging from .1% to 100%) of the aily work period on 10 of the 12 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject, the average daily cognitive effectiveness and average %BCL across all work days are 78.38% and 53.92% respectively.

Day Date Start Time

End Time




78.38 53.92



The sleep hygiene of this subject results in modeled performance ranging from about 96% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) at the beginning of day 6. Modeled cognitive effectiveness reaches its nadir of 72% on day 9. This subject spends portions (ranging from 2% to 54%) of the daily work period on 5 of the 12 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject the average daily cognitive effectiveness and average %BCL across all work days are 82.41% and 12.75% respectively.

Day Date Start Time

End Time




82.41 12.75



The sleep hygiene of this subject results in modeled performance ranging from about 90% on day 1, dropping to equivalence to BAC of 0.05% (77.5% cognitive effectiveness) on day 6. Modeled cognitive effectiveness reaches its nadir of 70% on days 7 and 8. This subject spends portions (ranging from .1% to 100%) of the daily work period on 8 of the 12 days performing beyond criterion line (BCL) for 0.05% BAC. For this subject the average daily cognitive effectiveness and average %BCL across all work days are 78.18% and 53.28% respectively.

Day Date Start Time

End Time



Sun 2/10/2013 5:30 18:00 88.58 0.00 Mon 2/11/2013 5:30 18:00 84.21 0.00 Tue 2/12/2013 5:30 18:00 82.29 0.00 Wed 2/13/2013 5:30 18:00 82.21 0.00 Thu 2/14/2013 5:30 18:00 79.72 0.13 Fri 2/15/2013 5:30 18:00 77.20 55.33 Sat 2/16/2013 5:30 18:00 72.78 100.00 Sun 2/17/2013 5:30 18:00 73.09 100.00 Mon 2/18/2013 5:30 18:00 74.59 96.53 Tue 2/19/2013 5:30 18:00 74.58 96.40 Wed 2/20/2013 5:30 18:00 73.76 100.00 Thu 2/21/2013 5:30 18:00 75.11 90.93 Grand means

78.18 53.28




List of symbols/abbreviations/acronyms/initialisms

ANOVA Analysis of Variance

BAC Blood Alcohol Content

BMQ Basic Military Qualification

CAF Canadian Armed Forces

CF Canadian Forces

CFLRS Canadian Forces Leadership and Recruit School

ECG Electrocardiogram

EEG Electroencephalogram

EMG Electromyogram

EOG Electrooculogram

ESS Epworth Sleepiness Scale

FAST Fatigue Avoidance Scheduling Tool

FSS Fatigue Severity Scale

gRCT Group Randomized Control Trial

HREC Human Research Ethics Committee

MFI Multidimensional Fatigue Inventory

PSQI Pittsburgh Sleep Quality Index

PTSD Posttraumatic Stress Disorder

R2MR Road to Mental Readiness

SEM Standard Error of the Mean

SD Standard Deviation

SSS Stanford Sleepiness Scale



DOCUMENT CONTROL DATA (Security markings for the title, abstract and indexing annotation must be entered when the document is Classified or Designated)

1. ORIGINATOR (The name and address of the organization preparing the document. Organizations for whom the document was prepared, e.g., Centre sponsoring a contractor’s report, or tasking agency, are entered in Section 8.) DRDC – Toronto Research Centre Defence Research and Development Canada 1133 Sheppard Avenue West P.O. Box 2000 Toronto, Ontario M3M 3B9 Canada

2a. SECURITY MARKING (Overall security marking of the document including special supplemental markings if applicable.)

UNCLASSIFIED

2b. CONTROLLED GOODS

(NON-CONTROLLED GOODS) DMC A REVIEW: GCEC DECEMBER 2013

3. TITLE (The complete document title as indicated on the title page. Its classification should be indicated by the appropriate abbreviation (S, C or U) in

parentheses after the title.) Assessing daytime sleepiness and fatigue in recruits at the Canadian Forces Leadership and Recruit School

4. AUTHORS (last name, followed by initials – ranks, titles, etc., not to be used) Muller-Gass, A.; Fikretoglu, D.; Beatty, E.; Vartanian, O.; Paul, M.

5. DATE OF PUBLICATION (Month and year of publication of document.) June 2015

6a. NO. OF PAGES (Total containing information, including Annexes, Appendices, etc.)

107

6b. NO. OF REFS (Total cited in document.)

35 7. DESCRIPTIVE NOTES (The category of the document, e.g., technical report, technical note or memorandum. If appropriate, enter the type of report,

e.g., interim, progress, summary, annual or final. Give the inclusive dates when a specific reporting period is covered.) Scientific Report

8. SPONSORING ACTIVITY (The name of the department project office or laboratory sponsoring the research and development – include address.) DRDC – Toronto Research Centre Defence Research and Development Canada 1133 Sheppard Avenue West P.O. Box 2000 Toronto, Ontario M3M 3B9 Canada

9a. PROJECT OR GRANT NO. (If appropriate, the applicable research and development project or grant number under which the document was written. Please specify whether project or grant.)

9b. CONTRACT NO. (If appropriate, the applicable number under which the document was written.)

10a. ORIGINATOR’S DOCUMENT NUMBER (The official document number by which the document is identified by the originating activity. This number must be unique to this document.) DRDC-RDDC-2015-R118

10b. OTHER DOCUMENT NO(s). (Any other numbers which may be assigned this document either by the originator or by the sponsor.)

11. DOCUMENT AVAILABILITY (Any limitations on further dissemination of the document, other than those imposed by security classification.)

Unlimited

12. DOCUMENT ANNOUNCEMENT (Any limitation to the bibliographic announcement of this document. This will normally correspond to the Document Availability (11). However, where further distribution (beyond the audience specified in (11) is possible, a wider announcement audience may be selected.)) Unlimited

13. ABSTRACT (A brief and factual summary of the document. It may also appear elsewhere in the body of the document itself. It is highly desirable that the abstract of classified documents be unclassified. Each paragraph of the abstract shall begin with an indication of the security classification of the information in the paragraph (unless the document itself is unclassified) represented as (S), (C), (R), or (U). It is not necessary to include here abstracts in both official languages unless the text is bilingual.)

The Road to Mental Readiness (R2MR) is a mental health education program that is currently being delivered throughout the Canadian Armed Forces (CAF) career cycle, beginning at the recruit level. DRDC Toronto has undertaken a program of research, the primary purpose of which is to test the efficacy of R2MR through a group randomized control trial (gRCT) among recruits. In preparation for the gRCT, extraneous factors that may affect the uptake and/or retention of the information provided during R2MR need to be addressed. One such factor is the daytime sleepiness and fatigue levels of the recruits during the time period in which the mental health education is provided. This is because daytime sleepiness and fatigue are often accompanied by reduced alertness and compromised functioning of specific brain areas (e.g., prefrontal cortex), consequently hindering a variety of cognitive activities including the learning of new information. The primary purpose of this study was thus to assess daytime sleepiness, fatigue, and cognitive effectiveness in CAF recruits during the first 4 weeks of Basic Military Qualification (BMQ) in order to make recommendations about optimal timing of R2MR delivery. Daytime sleepiness and fatigue were assessed through validated questionnaires at the start of BMQ and again during week 4 of BMQ, on the day of R2MR delivery. Actigraphs were used to monitor sleep/wake activity patterns and these data were used to generate cognitive effectiveness models over the entire 4-week study. The results showed that recruits experienced significantly more fatigue and daytime sleepiness, and obtained significantly fewer hours of nocturnal sleep during the BMQ than in the weeks prior to the BMQ. More importantly, their fatigue and sleepiness levels during BMQ were considered abnormal and akin to those seen in sleep-disordered individuals. The cognitive effectiveness models indicated a precipitous drop in cognitive effectiveness during the first few days of BMQ. Therefore, day 1 or 2 of BMQ would be the ideal time to deliver a training program such as R2MR that demands good cognition. The cognitive effectiveness models also indicated that the morning circadian peak commenced between 08:15 and 08:50, and lasted for about 2 to 2.5 hours. Therefore, 08:00 would be an ideal start time for the R2MR training session in order to take advantage of the morning peak performance. A secondary purpose of this study was to examine whether there was a correlation between the fatigue/sleepiness levels of the recruits and their ability to recall the material presented during the R2MR session. For this purpose, recruits completed a quiz on the day following R2MR that tested their memory for the material presented during the mental health training session. No significant correlation was found between the fatigue/sleepiness scores and the quiz scores. Nevertheless, it is very well established in the scientific literature that poor sleep quality and short sleep duration significantly compromise student learning ability and hamper academic performance.

---------------------------------------------------------------------------------------------------------------

En route vers la préparation mentale (RVPM) est un programme d’éducation en santé mentale offert aux militaires durant toute leur carrière au sein des Forces armées canadiennes (FAC), et ce, dès le recrutement. RDDC Toronto a entrepris un programme de recherche dont le principal objectif est de vérifier l’efficacité du programme RVPM à l’aide d’un essai clinique randomisé (ECR) par grappes chez les recrues. En préparation à l’ECR par grappes, on doit tenir compte des facteurs exogènes pouvant influencer la compréhension et/ou la rétention de l’information présentée dans le cadre du programme RVPM, notamment la somnolence diurne et le degré de

fatigue des recrues pendant la période où ils suivent la formation en santé mentale. En effet, la somnolence diurne et la fatigue sont souvent accompagnées d’une baisse de la vigilance et d’une altération du fonctionnement de certaines zones du cerveau (p. ex. cortex préfrontal), ce qui gêne diverses activités cognitives, notamment l’acquisition de nouvelles connaissances. La présente étude visait donc principalement à évaluer la somnolence diurne, la fatigue et l’efficacité cognitive chez les recrues des FAC pendant les quatre premières semaines de la qualification militaire de base (QMB), en vue de formuler des recommandations quant au meilleur moment pour offrir le programme RVPM. La somnolence diurne et la fatigue ont été évaluées à l’aide de questionnaires validés au début de la QMB, puis pendant la quatrième semaine de la QMB, le jour de la présentation de la séance RVPM. On a eu recours à des actigraphes pour faire le suivi des cycles veille-sommeil et les données obtenues ont servi à produire des modèles d’efficacité cognitive pour les quatre semaines de l’étude. Les résultats révèlent que la fatigue et la somnolence diurne étaient beaucoup plus grandes et que le nombre d’heures de sommeil nocturne était considérablement plus faible chez les recrues pendant la QMB que pendant les semaines qui la précédaient. Qui plus est, leur degré de fatigue et de somnolence au cours de la QMB était considéré comme anormal et il était semblable à celui observé chez les personnes souffrant de troubles du sommeil. Les modèles de l’efficacité cognitive indiquaient une chute abrupte de l’efficacité cognitive pendant les premiers jours de la QMB. Par conséquent, la première ou la deuxième journée de la QMB constituerait le moment idéal pour offrir une formation qui exige de bonnes capacités cognitives comme le programme RVPM. Les modèles d’efficacité cognitive indiquaient également que le pic circadien du matin commence entre 8 h 15 et 8 h 50 et qu’il dure de 2 à 2,5 heures. Par conséquent, 8 h serait l’heure idéale pour entamer la séance de formation RVPM afin de profiter du rendement maximal matinal. Un des objectifs secondaires de cette étude était de déterminer s’il y avait une corrélation entre le degré de fatigue/somnolence des recrues et leur capacité à se souvenir de la matière présentée au cours de la séance RVPM. À cette fin, les recrues ont répondu à un questionnaire le lendemain de la séance pour vérifier ce qu’ils avaient retenu de la matière présentée pendant la formation en santé mentale. Aucune corrélation significative n’a été décelée entre les scores de fatigue/somnolence et les résultats du questionnaire. Néanmoins, il est amplement démontré dans la littérature scientifique qu’un sommeil de mauvaise qualité et de courte durée nuit considérablement à la capacité d’apprentissage des étudiants et au rendement scolaire.

14. KEYWORDS, DESCRIPTORS or IDENTIFIERS (Technically meaningful terms or short phrases that characterize a document and could be helpful in cataloguing the document. They should be selected so that no security classification is required. Identifiers, such as equipment model designation, trade name, military project code name, geographic location may also be included. If possible keywords should be selected from a published thesaurus, e.g., Thesaurus of Engineering and Scientific Terms (TEST) and that thesaurus identified. If it is not possible to select indexing terms which are Unclassified, the classification of each should be indicated as with the title.) daytime sleepiness, fatigue, recruit training, learning, mental health, actigraphy, self-report questionnaires

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Assessing daytime sleepiness and fatigue in recruits …cradpdf.drdc-rddc.gc.ca/PDFS/unc199/p802464_A1b.pdf · Assessing daytime sleepiness and fatigue in recruits at the Canadian