conditions yielded slightly lower, but still significantly elevated, relative risks.

Several potential mechanisms could explain the link between sleep loss and cardiovascular events, including blood pressure increases, sympathetic hyperactivity, or impaired glucose tolerance. Experimental data, showing that acute sleep loss (3.6 hours sleep) for one night results in increased blood pressure in healthy young males, may provide a biological mechanism for the observed associations between sleep loss and cardiovascular disease (Tochikubo et al., 1996; Meier-Ewert et al., 2004).

Sleep Loss, Mood, Anxiety, and Alcohol Use

Sleep loss is associated with adverse effects on mood and behavior. Adults with chronic sleep loss report excess mental distress, depressive symptoms, anxiety, and alcohol use (Baldwin and Daugherty, 2004; Strine and Chapman, 2005; Hasler et al., 2005). A meta-analysis of 19 original articles found that partial sleep deprivation alters mood to an even greater extent that it does cognitive or motor functions (Pilcher and Huffcutt, 1996).

Several studies of adolescents, including one with more than 3,000 high school students, found that inadequate sleep is associated with higher levels of depressed mood, anxiety, behavior problems, alcohol use (Carskadon, 1990; Morrison et al., 1992; Wolfson and Carskadon, 1998), and attempted suicide (Liu, 2004). Nevertheless, it is not clear from cross-sectional studies whether sleep influences mood or anxiety level, or vice versa. On the other hand, a large, 3-year longitudinal study of more than 2,200 middle school students (ages 11 to 14) found that self-reported sleep loss was associated with more depressive symptoms and lower self-esteem over time (Fredriksen et al., 2004). The study measured sleep loss using a single question about sleep duration on school nights and measured depressive symptoms and self-esteem by the Children’s Depressive Inventory and the Self-Esteem Questionnaire, respectively. Therefore, although this study suggests an association, the evidence is still limited.

Sleep Loss and Disease Mortality

Sleep loss is also associated with increased age-specific mortality, according to three large, population-based, prospective studies (Kripke et al., 2002; Tamakoshi et al., 2004; Patel et al., 2004). The studies were of large cohorts, ranging from 83,000 to 1.1 million people. In three studies, respondents were surveyed about their sleep duration, and then they were followed for periods ranging from 6 to 14 years. Deaths in short or long sleepers were compared with those who slept 7 hours (the reference group), after adjusting for numer-



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