SLEEP DISORDERS AND SLEEP DEPRIVATION

AN UNMET PUBLIC HEALTH PROBLEM

Committee on Sleep Medicine and Research

Board on Health Sciences Policy

Harvey R. Colten and Bruce M. Altevogt, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, DC
www.nap.edu



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SLEEP DISORDERS AND SLEEP DEPRIVATION AN UNMET PUBLIC HEALTH PROBLEM Committee on Sleep Medicine and Research Board on Health Sciences Policy Harvey R. Colten and Bruce M. Altevogt, Editors THE NATIONAL ACADEMIES PRESS Washington, DC www.nap.edu

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by contracts between the National Academy of Sciences and the American Academy of Sleep Medicine, the Department of Health and Human Services (con- tract No. N01-OD-4-2139), the National Sleep Foundation, and the Sleep Research Society. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Sleep disorders and sleep deprivation : an unmet public health problem / Committee on Sleep Medicine and Research, Board on Health Sciences Policy ; Harvey R. Colten and Bruce M. Altevogt, editors. p. ; cm. Includes bibliographical references and index. Supported by contracts between the National Academy of Sciences and the American Academy of Sleep Medicine, the Department of Health and Human Services, the National Sleep Foundation, and the Sleep Research Society Contract no. N01-OD-4-2139 ISBN 0-309-10111-5 (hardback) 1. Sleep disorders—Social aspects. 2. Sleep deprivation—Social aspects. 3. Sleep—Social aspects. 4. Public health. I. Colten, Harvey R. II. Altevogt, Bruce M. III. Institute of Medicine (U.S.). Committee on Sleep Medicine and Research. [DNLM: 1. Sleep Disorders—United States. 2. Health Policy—United States. 3. Sleep Deprivation—United States. WM 188 S63178 2006] RC547.S554 2006 362.196′8498—dc22 2006014107 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi- neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sci- ences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its con- gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the gov- ernment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON SLEEP MEDICINE AND RESEARCH HARVEY R. COLTEN (Chair), Columbia University, Health Sciences and College of Physicians and Surgeons, New York FRANCOIS M. ABBOUD, University of Iowa GENE D. BLOCK, University of Virginia THOMAS F. BOAT, University of Cincinnati, Ohio IRIS F. LITT, Stanford University School of Medicine, California EMMANUEL MIGNOT, Stanford University, California ROBERT H. MILLER, American Board of Otolaryngology, Texas F. JAVIER NIETO, University of Wisconsin School of Medicine and Public Health ALLAN I. PACK, University of Pennsylvania Medical Center KATHY P. PARKER, Emory University, Georgia SAMUEL J. POTOLICCHIO, The George Washington University Medical Center, Washington, DC SUSAN REDLINE, Case Western Reserve University School of Medicine, Ohio CHARLES F. REYNOLDS III, University of Pittsburgh, Pennsylvania CLIFFORD B. SAPER, Harvard Medical School, Massachusetts Study Staff BRUCE M. ALTEVOGT, Study Director SARAH L. HANSON, Research Associate DAVID CODREA, Financial Associate AMY HAAS, Administrative Assistant ELEANORE EDSON, Research Fellow CATHARYN T. LIVERMAN, Senior Program Officer ANDREW M. POPE, Board Director LORA K. TAYLOR, Senior Project Assistant Consultant MIRIAM DAVIS, School of Public Health and Health Services, George Washington University, Washington, DC

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BOARD ON HEALTH SCIENCES POLICY FRED H. GAGE (Chair), The Salk Institute for Biological Studies, La Jolla, California GAIL H. CASSELL, Eli Lilly and Company, Indianapolis, Indiana JAMES F. CHILDRESS, University of Virginia, Charlottesville ELLEN WRIGHT CLAYTON, Vanderbilt University Medical School, Nashville, Tennessee DAVID R. COX, Perlegen Sciences, Mountain View, California LYNN R. GOLDMAN, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland BERNARD D. GOLDSTEIN, University of Pittsburgh, Pittsburgh, Pennsylvania MARTHA N. HILL, Johns Hopkins University School of Nursing, Baltimore, Maryland ALAN LESHNER, American Association for the Advancement of Science, Washington, D.C. DANIEL MASYS, Vanderbilt University Medical Center, Nashville, Tennessee JONATHAN D. MORENO, University of Virginia, Charlottesville E. ALBERT REECE, University of Arkansas, Little Rock MYRL WEINBERG, National Health Council, Washington, D.C. MICHAEL J. WELCH, Washington University School of Medicine, St. Louis, Missouri OWEN N. WITTE, University of California, Los Angeles MARY WOOLLEY, Research!America, Alexandria, Virginia IOM Staff ANDREW M. POPE, Director AMY HAAS, Board Assistant DAVID CODREA, Financial Associate

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Independent Report Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with proce- dures approved by the National Research Council’s Report Review Com- mittee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published re- port as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Ruth Benca, Department of Psychiatry, University of Wisconsin, Madison Mary A. Carskadon, Sleep Research Laboratory, Brown University Norman H. Edelman, Health Sciences Center, SUNY Stony Brook University Stephen L. Hauser, Department of Neurology, University of California, San Francisco Meir H. Kryger, Sleep Disorders Center, St. Boniface General Hospital Winnipeg, Manitoba, Canada Lawrence S. Lewin, Executive Consultant, Chevy Chase, Maryland Thomas Roth, Sleep Center, Henry Ford Hospital, Detroit, Michigan Joan L. Shaver, College of Nursing, University of Illinois at Chicago Joseph S. Takahashi, Department of Neurobiology & Physiology, Northwestern University vii

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viii REVIEWERS Terry B. Young, Department of Population Health Sciences, University of Wisconsin Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by David J. Kupfer, Univer- sity of Pittsburgh School of Medicine, and Floyd E. Bloom, Professor Emeri- tus Department of Neuropharmacology, The Scripps Research Institute. Ap- pointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Preface Sleep has been a subject of intense interest to poets and mystics and is found in folklore since antiquity. Only in the last half a century have scien- tists and physicians attempted a systematic study of the biology and disor- ders of sleep. Within the past four decades remarkable advances in the neu- rophysiology of normal sleep and in circadian biology and the discovery of the genes that regulate these biological rhythms have provided a scientific framework for the elucidation of the etiology, pathogenesis, and potential treatment of sleep disorders. These scientific advances and input from many clinical disciplines such as internal medicine, neurology, nursing, oto- laryngology, pediatrics, psychiatry, psychology, and pulmonology have enriched the study and management of sleep pathology. However, the broad intellectual and service requirements for dealing with sleep has created diffi- culties in coordination and planning of research and clinical services. Recog- nition of around 90 distinct clinical disorders of sleep has created a platform and need for specialization in the study of sleep (somnology) and sleep pa- thology. Accordingly, professional societies such as the American Academy of Sleep Medicine, the American Sleep Apnea Association, the National Sleep Foundation, and the Sleep Research Society have been established and the discipline has been recognized by the American Board of Medical Special- ties. Moreover, the National Institutes of Health (NIH) formed the National Center on Sleep Disorders Research (NCSDR) to coordinate research in sleep. Although these developments are positive, they do not yet fully ad- dress the scope and depth of the public and individual health consequences of sleep deprivation and sleep disorders. For example, more than 50 million Americans suffer a chronic sleep disorder and many others experience dis- ix

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x PREFACE ruption of normal daytime activities owing to sleep deprivation. Sadly, the majority of individuals with substantial sleep disorders are not diagnosed and appropriately treated. In recognition of the limited appreciation of the importance of sleep disorders and sleep deprivation for individuals and the public health, the American Academy of Sleep Medicine, the NCSDR at the NIH, the Na- tional Sleep Foundation, and the Sleep Research Society requested that the Institute of Medicine (IOM) do the following: 1. Review and quantify the public health significance of sleep health, sleep loss, and sleep disorders, including assessments of the contribution of sleep disorders to poor health, reduced quality of life, and early mortality, as well as the economic consequences of sleep loss and sleep disorders. 2. Identify gaps in the public health system relating to the understand- ing, management, and treatment of sleep loss and sleep disorders and assess the adequacy of the current resources and infrastructure for addressing the gaps. 3. Identify barriers to and opportunities for improving and stimulating multi- and interdisciplinary research and education in sleep medicine and biology. Delineate organizational models that will promote and facilitate sleep research in the basic sciences, collaborative research between basic scientists, clinicians, and population scientists in relevant specialties, and education of practitioners and scientists in sleep health, sleep disorders, and sleep research. 4. Develop a comprehensive plan for enhancing sleep medicine and sleep research for improving the public’s health. In response, the IOM appointed a 14-member committee with expertise in pulmonology, cardiology, nursing, neurology, pediatrics, adolescent medi- cine, psychiatry, epidemiology, public health, otolaryngology, academic and medical administration, and health sciences research. The committee met five times during the course of its work and held two workshops. In addi- tion, the committee received input from relevant federal, private, and non- profit organizations. Our findings confirmed the enormous public health burden of sleep disorders and sleep deprivation and the strikingly limited capacity of the health care enterprise to identify and treat the majority of individuals suffer- ing sleep problems. The direct effects of sleep disorders as well as the comorbidity with other substantial public health problems such as obesity, diabetes, stroke, and depression have a profound economic and social impact. Only minimal estimates of the economic impact of sleep disorders and their derivative consequences are possible because of underrecognition and underreporting.

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xi PREFACE At a minimum, however, the total direct and indirect cost of sleep disorders and sleep deprivation in the United States is hundreds of billions of dollars. The magnitude of the effect of sleep pathology is shocking even to experts in the field of somnology and sleep medicine. We found that there are too few professionals dedicated to sleep problems to meet the size and importance of the problem and there are too few educational programs that have the po- tential to increase the workforce of health care practitioners and scientists to meet even current demands. In addition, research that will advance our un- derstanding of sleep pathology and its treatment has been underfunded. We therefore have outlined recommendations to address these shortcomings, in the hope that the burden of sleep disorders and sleep deprivation can be minimized. These recommendations fall into four broad categories: educa- tion (public, professional); technology; coordination of research initiatives at the NIH; and organization of research, clinical care, and education in academic health centers. EDUCATION The lack of public awareness should prompt a multimedia public edu- cation campaign that also targets elementary, middle, and high school stu- dents as well as undergraduate college health education programs about the impact of inadequate sleep. Professional education will be enhanced by integrating the teaching of sleep medicine and biology into medical, nursing, and pharmacology cur- ricula and into residency and specialty fellowships. Strategies to facilitate careers in somnology will be needed to meet the demand for sound science and expert clinical capacity to take care of the health problems related to sleep disorders. TECHNOLOGY The cumbersome nature and cost of diagnosis and treatment of sleep disorders and sleep loss will require research to develop and validate the efficacy of advances in diagnostic technologies, including ambulatory moni- toring and imaging as well as the development of new therapeutic options for specific sleep disorders. NATIONAL INSTITUTES OF HEALTH The NCSDR at the NIH should take a more proactive role in promoting integration of research disciplines pertinent to somnology and sleep dis- orders, and it should promote training programs that increase the pipeline of highly qualified investigators. Together with other federal agencies, the

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xii PREFACE NCSDR can support increased public awareness and generation of more reliable prevalence data. ORGANIZATION OF ACADEMIC HEALTH CENTERS Within academic health centers new and existing sleep programs should be organized as Interdisciplinary Sleep Programs that encompass the rel- evant basic and clinical disciplines. The complexity of these programs will vary in accord with the capacity and goals of each center; therefore, we have proposed several different models. Networking among the most complex of these programs will facilitate research progress and accelerate implementa- tion of new clinical strategies with help from the NCSDR. The committee has been fortunate in having superb support from IOM staff and willing consultants in related fields. Without their help this report could not have been completed. We are most grateful. Harvey R. Colten, M.D., Chair

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Acknowledgments The committee acknowledges with appreciation the individuals who provided information to the committee. These individuals include Richard Allen, Johns Hopkins University School of Medicine; Sonia Ancoli-Israel, University of California, San Diego School of Medicine; Bonnie Austin, AcademyHealth; Donald Bliwise, Emory University; Martha Brewer, Ameri- can Heart Association; Debra J. Brody, National Center for Health Statis- tics; Kathleen C. Buckwalter, University of Iowa Center on Aging; Roger Bulger, Association of Academic Health Centers; Daniel Buysse, University of Pittsburgh School of Medicine; Andrea Califano, Columbia University; Sue Ciezadlo, American College of Chest Physicians; Charles A. Czeisler, Harvard University School of Medicine; William Dement, Stanford Univer- sity School of Medicine; David Dinges, University of Pennsylvania School of Medicine; Darrel Drobnich, National Sleep Foundation; Paul Eggers, National Institute of Diabetes and Digestive and Kidney Diseases; Lawrence Epstein, Sleep HealthCenters; Gary Ewart, American Thoracic Society; David Lewis, SleepMed, Inc; Magda Galindo, American Diabetes Associa- tion; Lee Goldman, University of California, San Francisco Medical School; Allan Gordon, American Thoracic Society; Daniel Gottlieb, Boston Univer- sity School of Medicine; David Gozal, University of Louisville; Meir Kryger, University of Manitoba; James Kiley, National Heart, Lung, and Blood Institute; David J. Kupfer, University of Pittsburgh School of Medicine; Story Landis, National Institute of Neurological Disorders and Stroke; Kathy Lee, University of California, San Francisco; Eugene J. Lengerich, Pennsylvania Cancer Control Consortium; Carole Marcus, The Children’s Hospital of Pennsylvania; Jennifer Markkanen, American Academy of Sleep xiii

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xiv ACKNOWLEDGMENTS Medicine; Michael Martin, Center for Scientific Review, National Insti- tutes of Health; William McLeod, Institute of Medicine; John McGrath, National Institute of Child Health & Human Development; Merrill Mitler, National Institute of Neurological Disorders and Stroke; Rosanne Money, American Academy of Sleep Medicine; Hal Moses, Vanderbilt- Ingram Cancer Center; Judith Owens, Brown University Medical School; Barbara Phillips, University of Kentucky College of Medicine; Stuart Quan, University of Arizona; Roger Rosa, National Institute for Occupational Safety and Health; Thomas Roth, Henry Ford Health System of Detroit; Michael Sateia, Dartmouth University; Jerome Siegel, University of Califor- nia, Los Angeles; John Slater, American Academy of Sleep Medicine; Margaret Snyder, National Institutes of Health; Ed Sondik, The National Center for Health Statistics; Ray Vento, American Lung Association; James Walsh, St. Luke’s Hospital; David White, Brigham and Women’s Hospital; Steven Wolinsky, Northwestern University; Terry Young, University of Wisconsin. This study was sponsored by the American Academy of Sleep Medicine, the National Center on Sleep Disorders Research of the National Institutes of Health, the National Sleep Foundation, and the Sleep Research Society. We appreciate their support and especially thank Jerry Barrett, Richard Gelula, Al Golden, Carl Hunt, and Michael Twery for their efforts on behalf of this study. We appreciate the work of John Fontanesi, University of California, San Diego for his commissioned paper. We also thank Andrew Pope for his guid- ance and Judy Estep for her expertise in formatting the report for produc- tion. Finally, we especially thank Cathy Liverman for all of her thoughtful guidance throughout the project.

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Contents SUMMARY 1 1 INTRODUCTION 19 Magnitude and Cost of the Problem, 20 Historical Background, 21 Growth of Somnology and Sleep Medicine, 22 Challenges in Advancing the Study of Sleep Disorders, 22 Somnology and Sleep Medicine Research in Academic Institutions, 26 Scope and Organization of This Report, 29 References, 31 2 SLEEP PHYSIOLOGY 33 Sleep Architecture, 34 Sleep-Wake Regulation, 39 Circadian Rhythms, the 24-Hour Clock, 41 Sleep Patterns Change with Age, 43 References, 49 3 EXTENT AND HEALTH CONSEQUENCES OF CHRONIC SLEEP LOSS AND SLEEP DISORDERS 55 Sleep Loss, 57 Sleep-Disordered Breathing, 65 Insomnia, 75 Sleep and Psychiatric Disorders, 78 Narcolepsy and Hypersomnia, 82 xv

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xvi CONTENTS Parasomnias, 88 Sleep and Neurological Disorders, 91 Sudden Infant Death Syndrome, 96 Sleep and Movement Disorders, 97 Sleep and Medical Disorders, 101 Circadian Rhythm Sleep Disorders, 107 References, 111 4 FUNCTIONAL AND ECONOMIC IMPACT OF SLEEP LOSS AND SLEEP-RELATED DISORDERS 137 Performance and Cognition Deficits, 138 Motor Vehicle Crashes and Other Injuries, 147 Impact on Functioning and Quality of Life, 151 Economic Impact of Sleep Loss and Sleep Disorders, 155 References, 163 5 IMPROVING AWARENESS, DIAGNOSIS, AND TREATMENT OF SLEEP DISORDERS 173 Challenges Facing Individuals with Sleep Disorders, 174 Public Education, 178 Professional Training and Awareness Is Required, 182 Graduate Research Training in Somnology and Sleep Disorders, 187 Overview of Medical School Somnology Education, 187 Overview of Somnology in Medical Residency Training Curricula, 191 Overview of Sleep Medicine Fellowship Training, 192 Demonstration of Knowledge: Board Certification, 197 Next Steps, 201 Data Systems for Surveying Sleep and Sleep Disorders, 203 References, 212 6 ENSURING ADEQUATE DIAGNOSIS AND TREATMENT: ACCESS, CAPACITY, AND TECHNOLOGY DEVELOPMENT 217 Developing Portable Diagnostic Tools, 218 Challenges to Developing Ambulatory Technologies, 222 Future Directions, 228 References, 229

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xvii CONTENTS 7 OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT IN SOMNOLOGY 233 Growth of the Somnology and Sleep Medicine Field, 234 NIH Training and Career Development Programs, 238 Opportunities to Accelerate Somnology and Sleep Medicine Career Development, 247 References, 251 8 BOLSTERING SOMNOLOGY AND SLEEP DISORDERS RESEARCH PROGRAMS 253 NIH Coordination of Sleep-Related Activities, 254 National Sleep Disorders Research Plan, 259 Analysis of NIH-Sponsored Research Project Grants, 267 Next Steps in Accelerating Progress, 276 References, 286 9 BUILDING SLEEP PROGRAMS IN ACADEMIC HEALTH CENTERS 293 Rationale for Sleep Programs in Academic Health Centers, 294 Constraints Facing Interdisciplinary Sleep Programs, 300 Key Components and Guiding Principles for Building Sleep Programs, 303 Organizational and Fiscal Structures for Sustaining or Expanding a Sleep Program, 306 Accreditation and Certification Are Essential to Quality Care, 312 Next Steps, 315 References, 321 APPENDIXES A Study Process 325 B Acronyms 332 C Glossary of Major Terms 335 D Congressional Language Establishing the National Center on Sleep Disorders Research, § 285b–7 345 E Sleep Disorders Research Advisory Board Membership 348 F National Institutes of Health Sleep-Related Initiatives: 1994–2004 351 G National Institutes of Health Support of Sleep-Related R01 Grants 356 H Summary of NIH Support of Sleep-Related Career Development Awards 360

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xviii CONTENTS I Summary of NIH Support of Sleep-Related R13, R25, P, F, T, and U Grants 368 J Summary of Investment in Sleep-Related Projects at the Top 30 NIH-Funded Institutions 375 K Biographical Sketches of Committee Members and Staff 378 INDEX 387

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SLEEP DISORDERS AND SLEEP DEPRIVATION AN UNMET PUBLIC HEALTH PROBLEM

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