A quality improvement initiative using tiered Plan-Do-Study-Act cycles increased nightmare disorder diagnosis rates among active duty service members from 0.60% at baseline to 9.12% after three intervention cycles, surpassing the target goal of 5% within 12 months.
Nightmare disorder was substantially underdiagnosed at baseline despite high rates of reported nightmares among referred service members.
Three Plan-Do-Study-Act (PDSA) intervention cycles implemented over seven months increased the nightmare disorder diagnosis rate from 0.60% to 9.12%.
The recognition rate — the percentage of patients screening positive for probable nightmare disorder who were ultimately diagnosed — rose from 3.03% to 55.32%.
Interventions included three main components: standardizing documentation of Nightmare Disorder Index results, targeted provider education, and chart flagging for patients screening positive.
The authors identified nightmare disorder identification as clinically important in military populations due to significant sleep disturbances and heightened mental health risks unique to active duty service members.
This research suggests that nightmare disorder — a condition involving recurrent distressing nightmares that impair daily functioning — is dramatically underdiagnosed among active duty military personnel seen at sleep clinics. Before any changes were made, nearly 60% of referred service members reported nightmares and almost 20% screened positive for probable nightmare disorder, yet less than 1% received an official diagnosis. This gap between screening results and actual diagnoses pointed to a systemic failure in the clinical workflow rather than an absence of the condition. To address this problem, researchers at a military sleep disorders center implemented a series of structured improvement steps over seven months. These steps included adding nightmare disorder screening scores directly onto sleep study reports, educating providers about identifying and diagnosing the condition, and flagging the charts of patients who screened positive so clinicians would be prompted to follow up. After three rounds of these interventions, the diagnosis rate climbed from 0.60% to over 9%, and more than half of patients who screened positive for probable nightmare disorder ultimately received a diagnosis — compared to just 3% before the project began. Importantly, these improvements were achieved without adding delays or extra burden to clinic staff. This research suggests that simple, structured workflow changes in sleep clinics can dramatically improve the identification of nightmare disorder, particularly in high-risk populations like military service members. Because nightmares are closely linked to conditions such as PTSD, anxiety, and depression — which are prevalent in military settings — catching and diagnosing nightmare disorder is an important step toward connecting affected individuals with appropriate treatments. The authors note that their approach could serve as a model for other military and civilian sleep centers facing similar gaps between screening and diagnosis.
Radtke A, Tchopev Z, Cushman P, Kang J, Burch A, Scheuller H, et al.. (2026). Enhancing identification and diagnosis of nightmare disorder in active duty patients at a sleep disorders center: A quality improvement initiative.. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. https://doi.org/10.1007/s44470-025-00016-0