SLEEP DISORDERS AND SLEEP DEPRIVATION
AN UNMET PUBLIC HEALTH PROBLEM
Harvey R. Colten and Bruce M. Altevogt, Editors
THE NATIONAL ACADEMIES PRESS
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 (contract 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]
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THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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The Institute of Medicine was established in 1970 by the National Academy of Sciences 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 congressional 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.
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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
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
Case Western Reserve University School of Medicine, Ohio
CHARLES F. REYNOLDS III,
University of Pittsburgh, Pennsylvania
CLIFFORD B. SAPER,
Harvard Medical School, Massachusetts
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
School of Public Health and Health Services, George Washington University, Washington, DC
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
American Association for the Advancement of Science, Washington, D.C.
Vanderbilt University Medical Center, Nashville, Tennessee
JONATHAN D. MORENO,
University of Virginia, Charlottesville
E. ALBERT REECE,
University of Arkansas, Little Rock
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
Research!America, Alexandria, Virginia
ANDREW M. POPE, Director
AMY HAAS, Board Assistant
DAVID CODREA, Financial Associate
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report 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
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, University of Pittsburgh School of Medicine, and Floyd E. Bloom, Professor Emeritus Department of Neuropharmacology, The Scripps Research Institute. Appointed 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.
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 scientists and physicians attempted a systematic study of the biology and disorders of sleep. Within the past four decades remarkable advances in the neurophysiology 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, otolaryngology, 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 difficulties in coordination and planning of research and clinical services. Recognition of around 90 distinct clinical disorders of sleep has created a platform and need for specialization in the study of sleep (somnology) and sleep pathology. 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 Specialties. 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 address 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-
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 National Sleep Foundation, and the Sleep Research Society requested that the Institute of Medicine (IOM) do the following:
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.
Identify gaps in the public health system relating to the understanding, management, and treatment of sleep loss and sleep disorders and assess the adequacy of the current resources and infrastructure for addressing the gaps.
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.
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 medicine, 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 addition, 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 suffering 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.
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 potential to increase the workforce of health care practitioners and scientists to meet even current demands. In addition, research that will advance our understanding 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: education (public, professional); technology; coordination of research initiatives at the NIH; and organization of research, clinical care, and education in academic health centers.
The lack of public awareness should prompt a multimedia public education campaign that also targets elementary, middle, and high school students 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 curricula 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.
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 monitoring 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 disorders, and it should promote training programs that increase the pipeline of highly qualified investigators. Together with other federal agencies, the
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 relevant 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 implementation 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
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, American Heart Association; Debra J. Brody, National Center for Health Statistics; 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 University 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 Association; Lee Goldman, University of California, San Francisco Medical School; Allan Gordon, American Thoracic Society; Daniel Gottlieb, Boston University 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
Medicine; Michael Martin, Center for Scientific Review, National Institutes 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 California, 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 guidance and Judy Estep for her expertise in formatting the report for production. Finally, we especially thank Cathy Liverman for all of her thoughtful guidance throughout the project.