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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem (2006)

Chapter: 8 Bolstering Somnology and Sleep Disorders Research Programs

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Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
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8
Bolstering Somnology and Sleep Disorders Research Programs

CHAPTER SUMMARY The National Center on Sleep Disorders Research (NCSDR) and the Trans-NIH Sleep Research Coordinating Committee were established to coordinate the sleep-related research, training, and education activities at the National Institutes of Health (NIH). At the same time that the science and magnitude of the public health and economic burden requires greater investment, the output from the NCSDR and Trans-NIH Sleep Research Coordinating Committee has not kept pace. As a consequence, NIH funding for sleep-related activities has reached a plateau, and the future outlook for somnology and sleep medicine is unclear. A detailed examination of the past and current investment in sleep-related research demonstrates that there are only 331 funded research projects and 253 independent investigators, far below the requirements of the field. Further, of the 253 principal investigators only 151 researchers are primarily involved in clinical sleep research and 126 primarily focus on basic research projects. The challenge for the field is to develop a collaborative and focused approach with a strong research infrastructure. To bolster clinical and basic research efforts, catalyze collaborative research efforts, and attract the breadth of talented researchers who will be able to move somnology and sleep disorders research and clinical care forward to achieve optimal outcomes requires a coordinated and integrated strategy. The NCSDR, its advisory board, and the Trans-NIH Sleep Research Coordinating Committee need to take a proactive role in providing continued leadership. Further, a research network is of particular importance in the

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

field because of the need for a coordinated interdisciplinary research approach to basic and clinical research, clinical care, public education, and training. Therefore, the NIH should establish Somnology and Sleep Medicine Centers of Excellence within a National Somnology and Sleep Medicine Research and Clinical Network.

The field of somnology and sleep medicine is poised to take great strides in elucidating and addressing the etiology, pathogenesis, and public health burden of chronic sleep loss and sleep disorders. This strong position is the result of the National Institutes of Health (NIH) establishing the Trans-NIH Sleep Research Coordinating Committee and the National Center on Sleep Disorders Research (NCSDR). However, at the same time that the science and magnitude of the problem requires greater investment, NIH funding to sleep-related activities has reached a plateau. Consequently, the future outlook for somnology and sleep medicine is unclear. The next significant advances necessitate leveraging these resources to their utmost potential in conducting research and refining diagnosis and treatment interventions for sleep loss and sleep disorders.

This chapter provides an overview of the current coordination of sleep-related activities at the NIH, including an evaluation of the NCSDR. Included in the evaluation is a detailed a summary of sleep-related research activities sponsored by the NIH between 1995 and 2004. The chapter culminates with a discussion on the next steps required to accelerate progress, including the establishment of a National Somnology and Sleep Medicine Research and Clinical Network.

NIH COORDINATION OF SLEEP-RELATED ACTIVITIES

To a greater extent than many medical and research disciplines, the field of somnology and sleep medicine cuts across many disciplines, including but not limited to cardiology, dentistry, endocrinology, epidemiology, geriatrics, molecular biology, neurology, neurosciences, nursing, nutrition, otolaryngology, pediatrics, pharmacology, psychiatry, and pulmonology. In 2004, there were 331 sleep-related research project grants sponsored by 17 institutes at the NIH (Table 8-1, Appendix G). The NIH has two mechanisms to coordinate its sleep-related activities, the Trans-NIH Sleep Research Coordinating Committee and the NCSDR.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

TABLE 8-1 NIH Institute Support of Somnology and Sleep Disorders Research Project Grants (R01) in 2004

Institute

Number of Grants

National Heart, Lung, and Blood Institute

102

National Institute of Mental Health

88

National Institute of Neurological Disorders and Stroke

49

National Institute on Aging

31

National Institute of General Medical Sciences

22

National Institute of Nursing Research

19

National Eye Institute

15

National Institute on Drug Abuse

13

National Institute on Alcohol Abuse and Alcoholism

12

National Institute of Diabetes and Digestive and Kidney Diseases

11

National Institute of Child Health and Human Development

10

National Cancer Institute

7

National Institute of Arthritis and Musculoskeletal and Skin Diseases

5

National Institute on Deafness and Other Communication Disorders

4

National Center for Complementary and Alternative Medicine

3

National Institute of Allergy and Infectious Diseases

1

Fogarty International Center

1

NOTE: Institutes and centers in bold are not members of the Trans-NIH Sleep Research Coordinating Committee.

Trans-NIH Sleep Research Coordinating Committee

In 1986, the Director of the NIH established the Trans-NIH Sleep Research Coordinating Committee to facilitate an interchange of information about somnology and sleep disorders research. This coordinating committee meets every 2 to 3 months to discuss current sleep-related activities within the NIH and develop new programs. Currently 13 NIH institutes and offices are members of the Trans-NIH Sleep Research Coordinating Committee. The director of the NCSDR chairs the Coordinating Committee, and its members are program staff from the various NIH institutes with an interest in somnology and sleep disorders. Although most institutes that support sleep-related research are members of the coordinating committee, a few are not (Table 8-1), including the National Institute of General Medical Sciences and the National Eye Institute. In 2004 these two institutes each supported more sleep-related grants than 8 of the 13 current members—close to 10 percent of all sleep-related research project grants.

The Trans-NIH Sleep Research Coordinating Committee offers the somnology and sleep medicine field an exceptional resource for increasing and coordinating NIH support of interdisciplinary sleep-related research

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

and career development programs. Over the last 10 years, through requests for applications (RFAs) and program announcements (PAs), members of the coordinating committee have cosponsored 16 out of the 18 research project grant initiatives (Appendix F). This has the advantage of spreading out the costs of an initiative over multiple institutes, thus being able to support greater investment. However, as will be discussed in greater detail later in this chapter, recently the coordinating committee has not taken a proactive role in developing new research programs.

National Center on Sleep Disorders Research

In direct response to the 1993 report of the National Commission on Sleep Disorders Research, Wake Up America: A National Sleep Alert, a provision of the NIH Revitalization Act instructed the Director of the NIH and the National Heart, Lung, and Blood Institute (NHLBI) to establish the NCSDR. As described in the congressional language, the mission of the NCSDR is to “conduct and support of biomedical and related research and research training, the dissemination of health information, and the conduct of other programs with respect to various sleep disorders, the basic understanding of sleep, biological and circadian rhythm research, chronobiology and other sleep related research” (U.S. Congress, Senate, 1993). As mandated by Congress the NCSDR has the authority:

  • for the conduct and support of research, training, health information dissemination, and other activities with respect to sleep disorders, including biological and circadian rhythm research, basic understanding of sleep, chronobiological and other sleep-related research; and

  • to coordinate the activities of the NCSDR with similar activities of other federal agencies, including the other agencies of the NIH, and similar activities of other public entities and nonprofit entities. (See Appendix D for complete congressional language.)

The NCSDR establishment within the NHLBI allowed it to call upon the existing successful programs at the NHLBI in sleep-disordered breathing as well as the NHLBI’s expertise in public education programs. It was realized at the inception of the NCSDR that there was a major need to educate both public and health care professionals about sleep and sleep disorders. Because many NIH institutes have a strong interest in somnology and sleep disorders research and fund portfolios of grants in this area, it was not envisioned that all funding for sleep-related programs would be done through the NCSDR. Rather, the NCSDR would facilitate development of research and training programs in areas of identified need. In addition, it would be a center that facilitated and coordinated research across

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

the many institutes of the NIH with an interest in sleep-related research, as well as across the many federal agencies that have an interest in sleep deprivation and sleep disorders. These agencies include: the Centers for Disease Control and Prevention (CDC) (prevalence and impact of sleep disorders, inadequate sleep); the Department of Defense (impact of sleep deprivation and nighttime activity on human performance); the Department of Transportation (crashes occurring from falling asleep at the wheel); the Occupational Safety and Health Administration (impact of sleep deprivation and sleep disorders on industrial accidents and shift work sleep disorder); and the Department of Veterans Affairs (VA) (impact of sleep disorders on health of veterans, posttraumatic stress disorder). It is of note that although one out of every five Americans perform shift work, the Department of Labor withdrew its membership from the NCSDR advisory board in 2003. Following the departure of the department’s representative the Department of Labor chose not to appoint a replacement member. The committee hopes that the Department of Labor will reconsider this, as it can make an important contribution to the national effort to decrease the burden of sleep loss and sleep disorders.

Several federal agencies have research and public education programs including the Department of Defense, the Department of Transportation, and the CDC. However, the NCSDR has not made clear or demonstrated far-reaching coordination of these activities, with potential missed opportunities for integrating sleep-related programs among federal agencies and departments. The original mandate to the NCSDR, as envisioned in the authorizing legislation, saw the CDC playing a major role in public education and surveillance. As described in Chapter 5, the CDC is involved in many public education campaigns and national surveys. Apart from the recent addition of sleep-related questions in the National Health and Nutrition Examination Survey (NHANES), this has not occurred. There are insufficient data about the sleep patterns of Americans, and the CDC’s expertise should be sought in conducting surveillance, monitoring sleep disorders and sleep habits, and developing public health campaigns about sleep loss and sleep disorders.

The NCSDR budget is a line item on the NHLBI administrative budget and includes the director, a public health analyst, an executive assistant, and an office assistant. From a separate NHLBI budget source, the NCSDR receives an allocation each year to support the activities of the Sleep Disorders Research Advisory Board and other programmatic activities, including workshops. Thus, the budget available to the director of the NCSDR is limited. The member institutes in the Trans-NIH Sleep Research Coordinating Committee provide support for their representative to the Committee, and NCSDR provides administrative support as needed for the Trans-NIH Sleep Research Coordinating Committee from its fiscal resources

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

already described. The Office of Prevention, Education, and Control support other NHLBI personnel who work on educational programs and two such individuals (personal communication, M. Twery, NIH, January 24, 2006).

The Advisory Board of the National Center on Sleep Disorders Research

The original NCSDR authorizing legislation established an advisory board to the NCSDR, composed of 12 members of the public—8 scientific members and 4 public members who either are advocates for or have a particular sleep disorder. Included in the advisory board are 10 ex officio members who represent relevant federal agencies (Table 8-2). The advisory board meets biannually. As directed in the authorizing congressional language “The advisory board shall advise, assist, consult with, and make recommendations to the Director of the National Institutes of Health and the Director of the Center concerning matters relating to the scientific activities carried out by and through the Center and the policies respecting such activities, including recommendations with respect to the [research] plan” (U.S. Congress, Senate, 1993). As will be discussed in further detail below, throughout the 12 years since its establishment the advisory board has had varying levels of activity in these responsibilities.

Since its inception, the advisory board has had 29 members. It is NIH policy that the appointed members of advisory councils or other mandated boards cannot serve for terms of more than 4 years and that reappointment is not permitted. This presents a strain on a small field such as somnology and sleep medicine, as those most knowledgeable about the field are frequently selected. It is important that the composition of the advisory board consists of members who are credible and who have the respect of the somnology and sleep medicine community, as well as an understanding of large research and educational enterprises, background as a practicing

TABLE 8-2 Ex Officio Members of the NCSDR Advisory Board

Director of the National Institutes of Health (NIH)

Director of the National Center on Sleep Disorders Research (NCSDR)

Director of the National Heart, Lung, and Blood Institute (NHLBI)

Director of the National Institute of Mental Health

Director of the National Institute on Aging

Director of the National Institute of Child Health and Human Development

Director of the National Institute of Neurological Disorders and Stroke

Assistant Secretary for Health

Assistant Secretary of Defense (Health Affairs)

Chief Medical Director of the Veterans Affairs (VA)

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

researcher, and awareness of a wide variety of public policy issues. Individuals who have been involved in the advisory board are provided in Appendix E, together with, where appropriate, their academic honors and area of expertise. As a result of the small numbers of senior members in the field, the tradition of academic leadership has been difficult to maintain on the advisory board. The board would benefit from advice made by senior investigators who have credibility and a sound understanding of both scientific and clinical advances, as well as an appreciation for policy issues. It is the opinion of this committee that after an appropriate interval senior members of the somnology and sleep medicine fields should be permitted to be reappointed to serve an additional term on the advisory board, along with the most promising juniors member of the field. This should be permitted until the field has a large enough cadre of experienced leaders.

NATIONAL SLEEP DISORDERS RESEARCH PLAN

One of the requirements of the advisory board is to periodically develop a comprehensive research plan. The first research plan was published in 1996. Its recommendations were based on analyses of the needs of the field and the investment in sleep-related programs by the federal government. The recommendations reflected the need to support three areas of research: (1) basic research using state-of-the-art approaches to elucidate the functions of sleep and the fundamental molecular and cellular processes underlying sleep; (2) patient-oriented research to understand the cause, evaluate the scope, and improve the prevention, diagnosis, and treatment of sleep disorders; and (3) applied research to evaluate the scope and consequences of sleepiness and to develop new approaches to prevent impaired performance during waking hours (NHLBI, 1996). Sixteen specific recommendations were crafted in such a way that the outcomes of the effort were easily measurable (see grant analysis below).

The second research plan, published in 2003, provided a brief overview of each topic area and an update of the research progress made since the 1996 report. The report contained over 191 individual recommendations. It has yet to be established, but the large number of recommendations may decrease the effectiveness of the document. The report did provide relative weight to some recommendations, but this may limit the implementation of the remaining recommendations. Based on the recommendations the advisory board identified a limited number of research priorities:

  • Understand the neurobiology and function of sleep.

  • Assess the impact of reduced sleep across age.

  • Find the causes of various sleep disorders.

  • Establish normative standards for sleep need and sleep variables.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×
  • Discover/improve treatments for sleep disorders.

  • Study if sleep disorders are associated with, and how they affect, the progression of other diseases.

  • Educate health care professionals and the public about healthy sleep habits and sleep disorders.

  • Apply novel technologies to the study of sleep.

  • Develop data and examine prevention, intervention, treatment, and other sleep-related programs specific to women and minorities.

In the research plan, training was considered the highest priority and a separate category was created to underline its importance.

Although the 2003 plan is more comprehensive than the 1996 plan, it lacks specificity in each recommendation, and no strategy was established to advance the research agenda. The large number of recommendations and the broad focus make it difficult to establish measures to evaluate the research plan’s effectiveness. The 2003 research plan laid out an ambitious set of priorities but did not provide a strategy to implement the recommendations.

Scientific Advances Since the 2003 Sleep Disorders Research Plan

Below is a brief update of the state of science since 2003. However, as only 2 years have passed since the publication of the 2003 plan, this review is not meant to serve as an in-depth evaluation of the plan or an in-depth review of the current state of the field. Rather, its purpose is to demonstrate the potential the field has to continue to make great scientific strides. The outline for this update uses the organization originally used in the executive summary of the 2003 National Sleep Disorders Research Plan. As the following sections will demonstrate, although there has been scientific progress leading to an even greater number of unanswered questions, over the last few years the field has not grown but has reached a plateau.

Circadian Neurobiology

Research in this area is expanding because of advances in basic research. The major molecular and anatomical components associated with the generation of circadian rhythms have been known for about a decade. Genetic variants associated with delayed and advanced sleep phase are increasingly reported in a small minority of patients with familial occurrence (Xu et al., 2005). However, the clinical implications of altered circadian rhythms are yet to be explored. Some examples include the need to better define the causes and consequences of delayed phase in adolescence and to understand advanced phase in the elderly (Carskadon et al., 2004; Monk, 2005).

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

The importance of circadian rhythms extends beyond the brain. It is now recognized that the circadian clock does not solely operate within the suprachiasmatic nucleus but also at multiple levels in peripheral and central organs (Yamazaki et al., 2000; Yoo et al., 2004). Researchers have continued to elucidate with increasing detail the molecular mechanisms regulating these multiple molecular clocks. For example, peripheral clock markers can now be generated and studied in human fibroblasts (Brown et al., 2005). In addition, the genetic disruption of molecular mechanisms regulating circadian rhythms is recognized as deleterious at multiple levels within the organism. For example, the Clock-mutated mouse was found to suffer from metabolic abnormalities and to be prone to obesity (Turek et al., 2005). It is also increasingly likely that Clock genes have effects on the sleep process itself. This research may explain, for example, why shift workers are prone to certain diseases (Harrington, 1994; Boggild and Knutsson, 1999).

Sleep Neurobiology and Basic Sleep Research

The importance of the hypothalamus in sleep regulation, beyond the generation of circadian rhythms and their genesis within the suprachiasmatic nuclei, is increasingly clear (Saper et al., 2005). The recognition of the ventrolateral preoptic area as a sleep generator, together with the identification of the hypocretin (orexin) system as a wake promoting system, has fueled intense research in this area. How these two systems interact neuroanatomically, and how they affect other classical neurobiological systems, such as the monoamine and cholinergic systems, is being elucidated (Saper et al., 2005). Projection sites and novel sleep regulatory nuclei are being identified. The impact of this research is being felt beyond the field; for example, the role of the hypocretin system in regulating dopaminergic systems and addiction potential for drugs of abuse is the subject of intense investigation (Harris et al., 2005).

The function of sleep is also increasingly explored through phylogenetic approaches—the study of sleep in various animal species (Rattenborg et al., 2004; Lyamin et al., 2005). Sleep is a vital behavior conserved across evolution, suggesting it serves one or more critical functions. One important function may be the development of the neonatal brain, as many animals sleep a lot just after birth. The necessity of sleep may also be seen in animals that are in constant motion (e.g., swimming aquatic mammals or migrating birds) as they have developed unihemispheric sleep to allow for the generation of sleep under these difficult ecological circumstances. Interestingly, several reports are now suggesting that in specific instances, sleep can be suppressed completely for very long periods (up to months), such as during long-range migration in certain birds (Rattenborg et al., 2004) or even more surprisingly just after birth in some cetaceans (Lyamin et al.,

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

2005). These recent results suggest it may be possible to sustain life without sleep in special circumstances, which challenges existing dogma and suggests an area ripe for further advances.

This field of research is also benefiting from genetic studies in animal models. Knockout mice models (mice that are bred so that they lack certain genes) are now systematically being evaluated for sleep abnormalities. Gene variants, including a number of variants that affect sleep, have been isolated in various mouse strains that have specific electroencephalogram patterns (Tafti et al., 2003). These and other genetic mechanisms should be explored in future studies (Maret et al., 2005).

Sleep Disorders in Neurology

The discovery in 1999 and 2000 that hypocretin/orexin is involved in the pathophysiology of most narcolepsy-cataplexy cases is now being translated into clinical practice. Measuring cerebral spinal fluid (CSF) hypocretin-1 (orexin-A) is used in some cases to diagnose narcolepsy and is listed as a diagnostic tool in the revised International Classification of Sleep Disorders (AASM, 2005; Bader et al., 2003; Mignot et al., 2003). This diagnostic procedure may be especially important considering the recent report of high prevalence of sleep onset during rapid eye movement (REM) sleep instead of during nonrapid eye movement (NREM) sleep in the general population, a finding that may suggest a large number of false positives for this test and/ or a high prevalence of narcolepsy without cataplexy (Singh et al., 2005).

Sleep disturbances are recognized as a major issue in Parkinson’s and Lewy body disease (Rye, 2004), also suggesting a role for dopamine in sleep regulation. Not only can Parkinson’s disease patients have a narcolepsy-like daytime sleepiness, but REM behavior disorder is now recognized as an important component of these disorders, often preceding Parkinson’s disease by several decades. Investigators are also increasingly interested in other disorders where hypocretin abnormalities might explain sleep disturbances (Nishino and Kanbayashi, 2005), most notably Huntington’s chorea, a disorder where mice models show a preferential hypocretin cell loss (Petersen et al., 2005). Similar sleep studies are also occurring with Alzheimer’s dementia and stroke patients, where central and obstructive sleep apnea (OSA) may play an important role in both causing and exacerbating the condition.

Finally, rapid progress is occurring in our understanding of restless legs syndrome (Trenkwalder et al., 2005). Pathophysiology and treatment may be closely linked to the dopaminergic system and iron metabolism. Genetic studies suggest the existence of at least three potential loci, located on chromosomes 12, 14, and 9, and investigators are narrowing down on possible candidate genes. It is likely that those actually causing diseases will soon be identified (Manconi et al., 2004).

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×
Sleep-Disordered Breathing

Genetic epidemiological studies conducted over the prior decade have clearly established that sleep-disordered breathing, although a complex trait, has a strong genetic basis with evidence of oligogenic inheritance (Buxbaum et al., 2002). Areas of linkage for the apnea-hypopnea index (AHI) appear to differ by ethnicity (Palmer et al., 2003, 2004). Association and fine mapping studies have quantified the potential role of several candidate genes in the pathogenesis of sleep apnea (Gottlieb et al., 2004b; Larkin et al., 2005a), with results implicating a gene near the APOe4 locus (Larkin et al., 2005a). There is also evidence that sleep-disordered breathing and obesity, a major public health problem, are partly linked by pleiotropic genetic mechanisms (Palmer et al., 2003, 2004). Thus, future studies of the genetics of sleep-disordered breathing also likely will illuminate the genetic basis of obesity. Applying advances in genome association methods to population studies of sleep apnea will be important in discovering genes for this and related diseases.

Large scale epidemiological studies in the 1990s quantified the prevalence of OSA in middle aged and elderly populations (Ancoli-Israel et al., 1991, 1995; Young et al., 1993). More recently, population-based studies also identified sleep-disordered breathing to be common in American school-aged children, with an especially high prevalence in African American children (Rosen et al., 2003). Other studies have identified the predilection of other groups to sleep apnea. These include commercial drivers (Howard et al., 2004), whose occupations place them at particular risk for sleepiness-associated injuries (Gurubhagavatula et al., 2004). Further work is needed to develop and apply screening approaches for identifying individuals at high risk for sleep apnea (see technology section). However, in the case of commercial drivers, a two-stage screening strategy using questionnaires and simplified tests was shown to be effective (Gurubhagavatula et al., 2004). Given that commercial drivers with sleep apnea are likely to be at an increased risk for crashes, occupational screening of this group may provide an important opportunity to test the model for occupational screening for sleep disorders.

There is developing evidence that sleep apnea leads to oxidative stress (Lavie, 2003). This likely results from the cyclical doxygenation-reoxygenation, akin to ischemia reperfusion, that occurs with apneic events, causing free radial production and increased levels of inflammatory molecules. C-reactive protein, a biomarker for cardiovascular disease, may be elevated in OSA. C-reactive protein declines with treatment with continuous positive airway pressure (CPAP) (Yokoe et al., 2003). Increasing oxidative stress is not only relevant to the cardiovascular risk of sleep apnea but also to its effects on neurocognition. Cyclical intermittent hypoxia leads to oxidative damage of various groups of

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

neurons: hippocampal neurons with resulting learning deficits (Row et al., 2003); hypoglossal motoneurons, a mechanism that may accelerate disease progression (Veasey et al., 2004b), as well as wake active neurons (Veasey et al., 2004a). The latter may be the mechanism by which residual sleepiness occurs in patients with OSA even when they are well treated with nasal CPAP.

There is ongoing evidence from prospective studies that OSA is a risk factor for cardiovascular events and mortality, and this evidence is becoming more compelling based on large prospective cohort studies. Such studies show that patients with sleep apnea, in particular severe sleep apnea (i.e., AHI greater than 30 episodes per hour), have increased rates of cardiovascular events, strokes, mortality independent of other risk factors, and hypertension (Yaggi et al., 2005; Marin et al., 2005). Patients with severe sleep apnea who were not treated have an increased rate of cardiovascular events and deaths compared to controls with similar degrees of obesity who do not have sleep apnea (Marin et al., 2005). When patients with severe sleep apnea are treated with CPAP, both the rate of cardiovascular events and cardiac deaths drop to control rates (Marin et al., 2005). Although this provides strong support for a role of OSA in atherogenesis, the critical proof for a causal association, and further defining a need for early treatment, requires randomized trials designed to assess the impact of OSA on cardiovascular events.

The Sleep Heart Health Study has added further support for sleep apnea being a risk factor for insulin resistance independent of the effects of obesity (Punjabi et al., 2004). In this large study the presence of sleep apnea (i.e., AHI greater than 15 events per hour) was independently associated with insulin resistance even after controlling for body mass index and waist-to-hip ratio, a measure of visceral obesity (Punjabi et al., 2004). Moreover, data suggest that treating patients with OSA by nasal CPAP significantly increases insulin sensitivity as measured by the euglycemic clamp method (Harsch et al., 2004). This effect was, however, most evident in relatively nonobese subjects, with questions regarding the extent to which sleep apnea treatment improves glucose tolerance in obese individuals with sleep apnea and may help prevent diabetes. A small study suggests that this is so; improvement is particularly found in those with high levels of a specific type of hemoglobin that is a marker for poor glucose control (Babu et al., 2005).

Although much of the focus of research continues to be on OSA, progress is also being made in other aspects of sleep-disordered breathing. Obesity-hypoventilation syndrome, a condition in which individuals hypoventilate during sleep (due to an increased respiratory load from the increased weight) and have elevated daytime arterial PCO2 levels, has been shown to be common yet frequently unrecognized in obese hospitalized

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

patients. Obese patients with this problem have poorer medical outcomes (Nowbar et al., 2004).

Thus, this research in sleep and sleep disorders is vibrant and has great potential to improve public health problems related to sleep-disordered breathing.

Insomnia

A turning point in this area may have been the recent NIH-sponsored State-of-the Science Conference on chronic insomnia (Dolan-Sewell et al., 2005). In this conference, a decision was made to abandon the concept of secondary insomnia. The rationale for this change was that it is difficult in most cases to distinguish causes and consequences for insomnia. The possibility that insomnia is associated with abnormalities of sleep microarchitecture and brain metabolism, as measured by imaging studies, is also increasingly recognized. This, together with the concept of hyperarousal in patients with insomnia (Nofzinger et al., 2004), is leading to the discovery of objective markers and a pathophysiological model for insomnia. It was also recognized that insomnia is not only frequently associated with depression but may be an independent predictor of it (Roth and Roehrs, 2003).

Treatment modalities for insomnia are changing. Prescribed hypnotic use is reported in children and adolescents, a pattern that raises concern as there are limited data in this area (Owens et al., 2003). An increasing number of well-designed studies are showing efficacy and safety for cognitive-behavioral therapies (Morin, 2004). This, together with the introduction and development of a large number of new hypnotics of various modes of action, is changing clinical practice in insomnia.

Pediatric Sleep Sciences

There have been several advances in the field of pediatric sleep medicine in the last two years: the discovery of the gene for congenital central hypoventilation syndrome, improved understanding of the pathogenesis and epidemiology of sleep apnea, and better understanding of the complications associating OSA in children. However, pediatric sleep remains relatively understudied, and there are still many gaps in the knowledge base. For example, although the Back to Sleep Campaign has been very successful there is still very little information concerning the etiology of sudden infant death syndrome (SIDS).

In 2003, Amiel and colleagues described a mutation of the PHOX2B gene in 62 percent of their patients with congenital central hypoventilation syndrome (Amiel et al., 2003). Following refinement of the technique, 97

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

percent of patients have been shown to have a mutation of the gene (Weese-Mayer et al., 2003), which is dominant and usually a de novo mutation. This finding has already become useful in clinical practice, with clinical testing and amniocentesis now available.

There has been increasing research in the area of pediatric sleep-disordered breathing. Several studies have provided a better understanding of the pathophysiology of OSA in children, including the role of upper airway reflexes in this disease (Gozal and Burnside, 2004; Marcus et al., 2005). Major advances have been made in understanding the complications of childhood OSA. In particular, work from a number of different labs has shown that very mild obstructive apnea, and perhaps even primary snoring, is associated with changes in neurocognitive and behavioral function in children (Fregosi et al., 2003; Rosen et al., 2004; Gottlieb et al., 2004a). Other studies have shown that childhood OSA is associated with cardiac hypertrophy (Amin et al., 2005), inflammation (Tauman et al., 2004; Larkin et al., 2005b), and the metabolic syndrome (de la Eva et al., 2002), potentially putting children at risk for cardiovascular complications later in life. Of great interest is the observation of adverse outcomes in individuals with a very mild sleep apnea (including habitual snoring without appreciable levels of overnight hypoxemia). Given that almost all of the work to date has been descriptive, it is imperative that interventional studies assess whether early diagnosis and treatment would modify short- or long-term health outcomes. In this regard, there is also a need to identify the efficacy of sleep apnea treatment in children, including tonsillectomy and adenoidectomy, for which there has not yet been a single randomized controlled study of treatment for sleep apnea.

Sleep Deprivation

The impact of sleep deprivation and shift work on driving and industrial accidents has been known for more than a decade. Unfortunately, change, especially in the area of commercial driving, has been difficult to implement. Modafinil, a wake-promoting agent, may be effective for the treatment of shift work disorder and prove to be useful in this setting (Czeisler et al., 2005). Sleep deprivation is also increasingly recognized as being associated with poor school performance, especially when school restarts after an extended number of days off. This may be mediated by delayed sleep phase, early school start time, and increased sleep need during adolescence (Carskadon et al., 2004).

Recent studies have shown that sleep deprivation causes medical errors among physicians (Lockley et al., 2004; Landrigan et al., 2004; Barger et al., 2005). Attentional lapses and errors can be improved by reducing work hours and increasing sleep (Lockley et al., 2004; Landrigan et al., 2004).

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

These findings are leading to rapid changes in the on-call requirements for physicians in training (Cavallo et al., 2004).

The impact of chronic sleep restriction on human health and endocrinological status is also increasingly recognized. Associations among short sleep, obesity, diabetes, and mortality have been reported (Alvarez and Ayas, 2004; Gottlieb et al., 2005). A large number of studies have shown cross-sectional association between short sleep and obesity (Cizza et al., 2005). A trend for a longitudinal association between shortening sleep and gaining weight is also typically found. The biological mediation of these changes may be through alterations in leptin and ghrelin, two major appetite regulatory hormones (Taheri et al., 2004; Spiegel et al., 2004). The levels of these hormones are altered in health subjects if sleep is restricted for a few nights.

Sleep Education and Training

Although a top priority of the 2003 research plan, the NIH has not established any new large-scale programs in training or career development. In fact, as has been described in Chapter 7, there has been a decrease in the number of career development grants pertaining to sleep. Further, although a few private foundations and professional societies have invested some in professional development, as discussed in Chapter 5, increased efforts are required to fully embrace the need to increase education and training programs. Thus, progress in this critical area has been quite limited.

ANALYSIS OF NIH-SPONSORED RESEARCH PROJECT GRANTS

Currently, assessment of the success of the sleep research effort at NIH seems to be based largely on the total dollars being committed by various institutes to the field (for more information see the 2001 to 2004 annual reports of the Trans-NIH Sleep Research Coordinating Committee). NIH funding for somnology research has increased by more than 150 percent since the NCSDR became fully operational in 1996, reaching a total of $196.2 million (0.07 percent of the NIH budget) in fiscal year 2004 (NHLBI, 2003). However, this growth occurred during the same period that the overall budget to the NIH doubled.

At the same time that the science and magnitude of the problem requires greater investment, over the last few years NIH funding to sleep-related activities has plateaued. This has partially overlapped the period when the overall NIH budget has plateaued. Consequently, the future outlook for somnology and sleep medicine is unclear. In 2004, for the first time since the NCSDR was established, there was a decrease of $846,000 in annual expenditures for sleep-related projects. This decrease raises even greater concern because it occurred in the same year that the NCSDR in-

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

cluded the expenditures of three additional institutes not included in previous fiscal reports. A comparison of research funding for the institutes in 2003 fiscal year analysis reveals a decrease of $1.142 million. Further, between 2003 and 2004 there were fewer research project grants funded, and this trend may continue as the number of new research project grants funded in 2004 also decreased (Appendix G). There must be incremental growth in this field to meet the public health and economic burden caused by sleep loss and sleep disorders.

It is difficult to accurately track the commitment of different NIH institutes to somnology and sleep disorders, in part because there is no uniform accounting system. Some NIH institutes count only a proportion of a grant when only a component of the grant is related to sleep research, but others count the entire grant, even though sleep-related research is only a minor part of the grant. This is particularly problematic for large program project or center grants. More important, however, these financial data do not allow the advisory board or leadership of the NCSDR to track the type of research being conducted and hence help identify areas of need. Originally the NCSDR Advisory Board took an active role in assessing the then current portfolio of sleep research grants, such as the analysis that was published in the journal Sleep in 1999 (Gillette et al., 1999). The committee presents its analysis below and urges the advisory board to continue to take an active role in this and perform a similar analysis on an annual basis.

Somnology and Sleep Disorders RFAs and PAs

The 1996 research plan was based on analyses of currently funded grants and led to a number of specific RFAs and PAs. Recently, there has been a marked reduction in the number of sleep-related RFAs that provide an important mechanism to develop research programs in specific areas of need. They identify a narrowly defined area for which one or more NIH institutes have set aside funds for awarding grants. This is different from PAs, which identify areas of increased priority or emphasis but typically do not have specific funds set aside (except for PAS announcements).

Over the last 3 years, the NCSDR has only sponsored two programs, one PA and one RFA—Research on Sleep and Sleep Disorders: PA-05-046 (in 2004) (NIH, 2004) and Mechanisms Linking Short Sleep Duration and Risk of Obesity or Overweight: RFA-HL-06-003 (in 2005) (NIH, 2005). The marked reduction over recent years in efforts identifying and developing RFAs and PAs is seen by examining the list of RFAs and PAs in sleep disorders research since the inception of the NCSDR (Appendix F).

The recent efforts of the NCSDR can be compared to those of the National Center for Medical Rehabilitation Research (NCMRR), which is a similarly structured center in the National Institute of Child Health and

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

Human Development. The NCMRR supports research on enhancing the functioning of people with disabilities in daily life. Compared to the 1 RFA established by the NCSDR in fiscal year 2004, the NCMRR established 6 RFAs and 4 PAs. Further, between 2001 and 2004 the NCMRR established 20 RFAs, while the NCSDR established only 4 RFAs. It is unclear why there is such a dramatic difference in the activity of these two centers.

Protocol for Research Project Grant Analysis

This committee performed a detailed analysis of the 1995 and 2004 portfolios of NIH somnology and sleep disorders research project grants (R01) to determine the current investment in the field and to examine how the grant portfolio has changed over the last 10 years. To do so, abstracts of all sleep-related R01s in the Computer Retrieval of Information on Scientific Projects (CRISP) database were analyzed. This database collects information on the number of federally funded biomedical research projects. Sleep-related R01s were collected by searching the CRISP database for all abstracts that were classified under the following thesaurus terms: insomnia, periodic limb movement disorder, restless legs syndrome, circadian rhythm, SIDS, sleep disorder, narcolepsy, sleep apnea, sleep, hibernation, and dream. To limit the number of grants that were not relevant to somnology or sleep disorders, the committee only included grants in which the key words appeared in both the thesaurus terms and abstract and not the abstract alone. It should be noted that the following conclusions are based on the number of grants awarded in each area. The committee did not have access to the applications that were submitted and not funded; therefore, it is not possible to conclusively determine if changes in investment are the result of NIH policy, the number and/or quality of submissions in each area, composition of grant review committees, or a combination of these factors.

General Findings

The CRISP search identified 156 sleep-related grants for 1995 and 397 for 2004. Upon review of their abstracts a number of these were determined to be unrelated to sleep. This resulted in 116 total sleep-related grants in 1995 and 331 sleep-related grants in 2004, a 2.85 fold increase (Table 8-3). The number of the grants deemed not relevant to sleep-related research—34 out of 156 in 1995, and 59 out of 397 in 2004—represents a relatively constant percentage (i.e., 21 percent and 15 percent, respectively; supplemental grants and grants with no abstract were also not classified). Thus, use of this methodology to track temporal trends in number of grants seems appropriate. Of the relevant sleep R01 grants there were 253 principal

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

TABLE 8-3 Analysis of Somnology and Sleep Disorders Research Project Grants (R01): 1995 and 2004

 

1995

2004

Number in 2004 / Number in 1995

Number of Sleep Grants

Percentage of Sleep Grants

Number of Sleep Grants

Percentage of Sleep Grants

Grants Analyzed

 

Number of grants analyzed

156

 

397

 

2.54

Number of grants relevant to sleep

116

 

331

 

2.85

Number of principal investigators

100

 

253

 

2.53

Clinical or Basic Research

 

Clinical research projects

71

61

179

54

2.52

Basic research projects (not circadian rhythm)

28

24

61

18

2.18

Circadian rhythm projects

19

16

97

29

5.11

Type of Sleep Disorder

 

Restless legs syndrome and periodic limb movements

0

0

5

2

N/A

Insomnia

10

9

22

7

2.20

Narcolepsy/hypersomnia

5

4

6

2

1.20

Circadian rhythm

7

6

22

7

3.14

Parasomnia

1

1

0

0

N/A

Sleep deprivation

3

3

18

5

6.00

Sleep apnea

19

16

65

20

3.42

Sleep neurological, other

3

3

6

2

2.00

Drug abuse

2

2

11

3

5.50

Sleep medical, other

15

13

23

7

1.53

Sleep psychiatric disorder

13

11

10

3

–0.23

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

Research Strategy

Systems neuroscience

32

28

62

19

1.94

Electrophysiology

26

22

70

21

2.69

Pharmacology

13

11

36

11

2.77

Cell biology

27

23

57

17

2.11

Molecular

10

9

70

21

7.00

Genetic

5

4

53

16

10.60

Observational study

36

31

84

25

2.33

Intervention study

22

19

54

16

2.45

Epidemiology

10

9

24

7

2.40

Hormone/biomarker

13

11

71

22

5.46

Clinical trial

12

10

27

8

2.25

Assessment of devices

4

3

5

2

1.25

Species

Human, no age specified

26

22

68

21

2.62

Human, child and adolescent

12

10

23

7

1.92

Human, adult

18

16

51

15

2.83

Human, elderly

17

15

30

9

1.76

Rat

21

18

77

23

3.67

Mouse

2

2

32

10

16.00

Drosophila

2

2

15

5

7.50

Other or not specified

32

28

60

18

1.88

NOTE: Percentages were rounded. N/A = Not applicable.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

investigators in 2004, a 2.53 fold increase from 1995 (100 principal investigators). Given that an estimated 50 to 70 million Americans have sleep-related health challenges, the current investment of 0.07 percent of the NIH budget and presumably a lesser proportion across other agencies, we believe, is not sufficient.

Clinical, Basic, and Circadian Rhythm Research Projects

Each grant was categorized to determine if the research was primarily basic or clinical in nature. Fifty-four percent of the grants in 2004 focused on clinical sleep disorders. Seventeen percent of 2004 grants were focused on basic sleep research projects, and 29 percent were devoted to the study of circadian rhythms. The total percentage of nonclinical research projects devoted to circadian rhythms rose from 40 percent of nonclinical research projects in 1995 to 61 percent in 2004. There has been over the last 10 years a disparate growth in these areas. Investment in circadian rhythms research projects increased by 5.11-fold; however, basic research unrelated to circadian rhythms only increased by 2.53-fold, well below the need. Not surprisingly, this largely reflects where much scientific advance has occurred.

Sleep Disorders

Since 1995, there has also been growth in the number of grants focused on sleep disorders. The current analysis suggests that research funding is disproportional to the public health burden and the known prevalence and consequences of the disorders. In a few cases, research has actually decreased or barely grown. These areas include parasomnia research (from one grant in 1995 to none in 2004), sleep in psychiatric disorders (0.23-fold decrease), and narcolepsy (1.20-fold increase). The lack of research regarding parasomnias is troublesome, considering the prevalence of these conditions. Similarly, the decrease in research grants in the area of sleep disturbances in psychiatric diseases is disturbing, considering the growing recognition that insomnia is a major risk factor for depression (see the Scientific Advances Since the 2003 Sleep Disorders Research Plan). This last observation should be mitigated by the relatively hefty increase in insomnia research.

Research in the area of narcolepsy and hypersomnia sleep disorder research also stayed flat. This last finding was disappointing, considering the recent discovery of hypocretin deficiency as the main cause of narcolepsy with cataplexy and the growing recognition that a large number of patients have milder forms of centrally mediated hypersomnolence, narcolepsy without cataplexy, and idiopathic hypersomnia. Research in this area may be uniquely poised to make progress, but funding has not increased. Not a

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

single grant was identified on the study of idiopathic hypersomnia or Kleine-Levin syndrome. The latter is admittedly a rare condition.

Over the 10-year span between 1995 and 2004 there has been no growth in research examining the etiology and pathophysiology of SIDS. In 1995 seven R01s were identified as focusing, at least partially, on SIDS, but in 2004 there were only six grants. Although the prevalence of SIDS has decreased since the Back to Sleep public education campaign began, this is still an area of research that warrants attention.

Selected areas grew more rapidly. There has been increasing interest in restless legs syndrome/periodic leg movements research; but the current investment is still low. There were no grants with a primary focus in these areas in 1995 and six in 2004. Given the high prevalence of restless legs syndrome and its negative impact (Chapter 3), the small number of grants is, however, still surprising. Further, although the number of insomnia research project grants has also grown from 10 grants in 1995 to 22 grants in 2004 (2.20-fold growth), this growth is modest given the high prevalence of insomnia. Clinical research project grants focused on the elucidation of sleep apnea demonstrated an increase in support that is reflected in the increased appreciation of its public health burden that occurred over the same period—19 grants in 1995 (15 percent of total grants) and 65 in 2004 (22 percent of total grants), a growth of 3.42-fold.

Assessment of Devices

The committee also noted that research assessing new devices barely grew from 1995 to 2004 (1.25-fold increase). This was also a troubling trend, as the study group identified the need to validate and increase the use of ambulatory monitoring devices in the diagnosis and assessment of sleep disorders, most notably sleep-disordered breathing (see Chapter 6).

Research Strategy

The committee also examined the primary research strategy proposed in each project. The striking trends in this area have been the dramatic growth in studies employing molecular (7.00-fold growth) and genetic (10.60-fold growth) strategies. Although this partially reflects the trends in modern biomedical research, the NHLBI, the National Institute of Mental Health, and the National Institute of Child Health and Human Development sponsored an RFA in 1996 to advance the understanding of the molecular and genetic basis of sleep and sleep disorders (RFA-HL-96-015). This RFA provided researchers funding for research projects that had molecular and genetic strategies.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×
Species

In this area there are also key trends. The growth in studies using mice is staggering, 16-fold from 1995 to 2004. There were only two grants using mice in 1995 and 32 in 2004. This is likely to be in direct response to the NHLBI, the National Institute of Mental Health, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke sponsoring an RFA in 1998 to develop improved molecular, cellular, and systems approaches to investigate sleep and circadian phenotypes in mice (RFA-HL-99-001).

There has also been a major increase in studies utilizing Drosophila as a model organism (7.50 fold increase). The use of Drosophila to study sleep was originally recommended at a workshop held by the NCSDR in 1995 and was included in the previously mentioned 1996 RFA to advance the understanding of the molecular and genetic basis of sleep and sleep disorders (RFA-HL-96-015). There are also a large number of grants that are in the “Other” category for species.

There are, as expected, a large number of studies on humans. The total number of grants in humans in 1995 was 73, but in 2004 it was 172, a 3.35-fold increase. It is concerning, however, that there are still only 23 grants studying sleep and its disorders in children and adolescents. This represents only 13 percent of total grants in humans, and the increase in pediatric sleep grants (1.92-fold) is lower than that for all grants (2.35-fold) and for all grants in humans (3.35-fold increase). The number of grants studying sleep and its disorders in the elderly, a population with a particularly high prevalence of sleep disorders, is also only 30. The growth in this area (1.77-fold) is also less than in other categories. Finally, although there has been growth in human subjects research, there has been a limited number of long-term clinical outcomes intervention studies that have examined strategies to improve the scientific base and treatments.

Composition of Grant Review Panels

An analysis of relevant NIH review panel expertise was also performed. To do so, the composition of review panels that received applications with sleep was analyzed. A total of 24 review panels, including special emphasis panels and standing integrated review groups (IRG), were included. Reviewers were subjected to Medline searches with the keywords sleep and circadian. Names were also visually inspected by multiple members of the committee who had expertise in various aspects of somnology and sleep medicine. Membership to sleep or circadian rhythms societies was noted, together with area of expertise. Only reviewers with a major sleep or circa-

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

dian research focus, as judged by their publication record or professional society, were considered.

Twenty-eight reviewers with knowledge in sleep or circadian biology were identified in the 24 review panels. It is important to note that although some review panels may not have experts in the field, often the Center of Scientific Review will appoint ad hoc reviewers when specific expertise is absent on the review panel. One third of the reviewers (12 out of 36 reviewers) were concentrated in a single study section, the Biological Rhythms and Sleep Study Section. Another third (9 reviewers) were in NHLBI special emphasis panels. Eleven of the total 28 (39 percent) reviewers were primarily interested in circadian rhythm research, rather than basic sleep research or clinical sleep disorders. Four other NHLBI review panels had more than 2 reviewers with sleep and circadian expertise; these included the mentored patient-oriented carrier development (K23) grant review panel (2 reviewers); a NHLBI special emphasis panel on T32 grants (2 reviewers); a small business activities special emphasis panel (4 reviewers) and the Respiratory Integrative Biology and Translational Research panel (2 reviewers). It was notable that two study sections with sleep in their title (and mandate) had one or no reviewers with a sleep expertise: the Neural Basis of Psychopathology panel, addictions and sleep disorders (1 reviewer); and the cardiovascular and sleep epidemiology study section (no reviewers with sleep expertise).

As expected, there was an association between reviewer expertise and types of grants funded. A notable finding was the low percentage of reviewers with clinical research expertise (36 percent) covering all of the different sleep disorders outlined in earlier chapters. This finding may be one potential reason why clinical research was the area with the least growth. However, because the committee was unable to examine and categorize all the grants that were submitted and not funded, it is difficult to interpret this finding. Further, the limited number of sleep reviewers, as well as the small number of funded grants, may also be a direct reflection of the limited number of scientists (especially senior investigators) in specific areas of this field.

Value of Grant Analysis Protocol

Categorizing each research project grant offers researchers and policy makers the opportunity to examine the current investment in particular areas, identify areas in need of greater investment, and provide a quantifiable metric to examine the success of specific RFA and PA programs. This committee strongly encourages the NCSDR Advisory Board to perform a similar annual analysis of all somnology and sleep disorders grants, including research (R), training (T), fellowship (F), career development (K), pro-

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

gram (P), and cooperative (U) activities sponsored by the NIH, the CDC, and Department of Defense, Department of Transportation, Department of Labor, and other relevant federal agencies. This committee also believes that the Center for Scientific Review should gather basic keyword information on submitted grants and reviewers to address adequacy of review expertise on review panels. This information would be helpful to the NIH at large and to the NCSDR as it develops a more proactive research plan.

Although the success of an RFA is dependent on the number and quality of grant applications, this analysis demonstrates the value an RFA may have in expanding interest and awareness in specific areas of a field. Therefore, this committee recommends that the NCSDR Advisory Board use their annual analysis to identify priority research and training areas and annually recommend an RFA to appropriate advisory councils of the Trans-NIH Sleep Coordinating Committee and other federal agencies including the CDC.

NEXT STEPS IN ACCELERATING PROGRESS

Given the multiple and varied sources of federal and private funding and support for the field and the numerous disciplines involved in research and clinical care, the challenge for the field of sleep medicine is to develop a collaborative and focused approach with a strong research infrastructure. To bolster clinical and basic research efforts, catalyze collaborative research efforts, and attract the breadth of talented researchers who will be able to move somnology and sleep disorders research and clinical care forward to achieve the therapeutic solutions requires a coordinated and integrated strategy.

Strengthen the NCSDR and Its Advisory Board

It is an opportune time for coordination of sleep-related activities throughout the federal government. The NCSDR and its advisory board should take the lead in reinvigorating a coordinated strategy. To assist in this coordination, annually the directors of the NCSDR and the NCSDR Advisory Board should meet with all institute directors who are members of the Trans-NIH Sleep Coordinating Committee and directors of other relevant federal agencies. Further, institutes at the NIH that manage a large sleep-related portfolio should be encouraged to appoint appropriate representatives of the field of Somnology and Sleep Medicine to their advisory councils and program project review committees.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

Recommendation 8.1: The National Center on Sleep Disorders Research and its advisory board should play a more proactive role in stimulating and coordinating the field.


The National Center on Sleep Disorders and Research (NCSDR) should have adequate staff and resources to ensure its ability to fulfill its mission of coordinating and stimulating training, research, and health information dissemination relevant to somnology and sleep disorders. All relevant institutes with significant sleep portfolios should become members of the Trans-NIH Sleep Research Coordinating Committee. Further, the NCSDR Advisory Board should take a more proactive role in advising the director of the NCSDR. On an annual basis, the NCSDR and its advisory board should:

  • Identify specific objectives that address each of the three NCSDR missions and evaluate specific actions taken to accomplish each objective. This assessment should be reported in an annual meeting to the Trans-NIH Sleep Coordinating Committee, the institute directors of its members, and to the director of the NIH.

  • Directors of the other federal agencies that fund significant sleep-related activities, such as Department of Defense, Department of Commerce, Department of Education, Department of Labor, and Department of Transportation should report annually on their activities to the NCSDR Advisory Board.

  • The NCSDR Advisory Board should annually review the current NIH portfolio of sleep-related grants, as well as requests for applications, and program announcements, assess them for responsiveness to the program plan and identify gaps in research and training.

  • The NCSDR Advisory Board should annually recommend new, or modify existing, requests for applications that can be presented to appropriate NIH institutes and other federal agencies including the Centers for Disease Control and Prevention and Department of Defense. Multiple members of the Trans-NIH Sleep Coordinating Committee are encouraged to continue to cosponsor sleep-related grants.

Enhance Research Collaborations

Clinical advances in treatments for chronic sleep loss and sleep disorders depends on the quality and integration of fundamental knowledge from multiple laboratory and clinical disciplines; including but not limited to: cardiology, dentistry, endocrinology, epidemiology, molecular biology,

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

neurology, neurosciences, nursing, nutrition, otolaryngology, pediatrics, pharmacology, psychiatry, and pulmonology. Historically the field has been clinically focused and has not integrated the efforts of its clinical and basic research scientists. For the field to make its next set of advances it will require a strengthened research infrastructure that will feature the development of combined clinical and research centers of excellence focused on somnology and sleep medicine and a structured network to facilitate and ensure collaborative interdisciplinary approaches.

Centers of excellence are required to establish and enhance somnology and sleep disorders research. A critical feature of these centers will be their ability to foster collaborations among the many research and clinical disciplines through a coordinated and integrated effort. They should promote interdisciplinary research, which is needed to explore the interrelationship between sleep and an individual’s health (e.g., common medical illnesses). The proposed research network described below will integrate the efforts of the broad array of researchers (both investigators at centers of excellence and from other institutions) who study or are involved in somnology and sleep medicine and other relevant avenues of therapeutic intervention for chronic sleep loss and sleep disorders.

Establish Centers of Excellence

The committee urges a strong continued commitment by the NIH to designate and support Somnology and Sleep Medicine Centers of Excellence. These centers would provide the interdisciplinary environment that is essential to accelerate the development of future advances in treating chronic sleep loss and sleep disorders. They would facilitate interactions between laboratory, clinical, and population scientists. Further, the centers would create an environment to support cross-cutting research that requires collaboration among scientists who work in different intellectual contexts. These would not only be “research centers,” but they would be sites for collaborations focused on the close association between research, clinical care, education, and dissemination of information.

Modeled after the National Cancer Institute’s Cancer Center Program (NCI, 2004), these comprehensive centers of excellence would offer expanded laboratory facilities; focused interactions among preclinical researchers, clinical researchers, and patients; and central sites for clinical trial design. They would serve as the centerpiece of the nation’s effort to reduce morbidity and mortality from chronic sleep loss and sleep disorders. This investment would likely draw new senior-level researchers into the somnology and sleep medicine field and would heighten the interest of young investigators in devoting their research interests to chronic sleep loss

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

and sleep disorders treatment. Further, structuring these centers to include strong integrated and coordinated clinical and basic research programs will help facilitate translational research. The centers would deliver medical advances to patients, educate health care professionals and the public, and reach out to underserved populations.

As described in detail in Chapters 5 and 7, enhancing career opportunities for researchers at all points in their careers is vital to accelerating progress in somnology and sleep medicine research. The committee believes that strengthening the research infrastructure through the development of new comprehensive centers will be the impetus needed to attract and retain early career, mid-career, and senior researchers. At these centers they will have the opportunity to fully engage in their own research initiatives, in addition to having the resources to develop and nurture trainees and sustain a full research effort.

These centers should be supported with the infrastructure needed to promote and enhance the institutional development of somnology and sleep medicine and treatment capabilities. This includes core research laboratory equipment, tools, and facilities; an emphasis on training programs; strong basic and clinical research components; and a structured plan for research priorities. However, the committee does not call on any specific organizational model, recognizing the diversity of academic settings that include well organized, freestanding centers; a center matrix within an academic institution; or a formal consortium under centralized leadership. The centers should also have the capacity to facilitate clinical trials; develop best practices and clinical guidelines; educate the community; screen and counsel individuals with chronic sleep loss and sleep disorders; and educate health professionals about state-of-the-art diagnostic, preventive, and treatment techniques. These centers of excellence should serve as the cornerstone of a National Somnology and Sleep Medicine Research and Clinical Network designed to coordinate and support somnology and sleep medicine research efforts.

Similar to the organization of the cancer centers, this committee envisions both Somnology and Sleep Medicine Centers and Comprehensive Somnology and Sleep Medicine Centers (NCI, 2004). Somnology and Sleep Medicine Centers should have a scientific agenda primarily focused on basic, population science, or clinical research, or any two of these three components. Similar to comprehensive cancer centers with a clinical component, the centers with clinical components are expected to conduct early phase clinical trials (NCI, 2004). A comprehensive somnology and sleep medicine center is expected to have reasonable depths and breadths of research in each of these areas. As with the National Cancer Institute designated comprehensive centers, Comprehensive Somnology and Sleep Medicine Centers are expected to disseminate information to the public and

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

health care professionals about medical advances developed within the center. They should also establish formal programs for teaching, screening, therapy, and/or preventative interventions.

As identified by the National Cancer Institute, there are six essential characteristics of a designated cancer center: facilities, organizational capabilities, interdisciplinary and transdisciplinary collaboration and coordination, cancer focus, institutional commitment, and center director (Box 8-1). Each of these attributes—substituting somnology and sleep medicine focus for cancer—is also likely to be critical for establishing and sustaining efficient and productive somnology and sleep medicine centers of excellence.

BOX 8-1

The Six Essential Characteristics of a National Cancer Institute-Designated Cancer Center

Facilities: Dedicated resources to the conduct of cancer-focused research and to the center’s shared resources, administration, and research dissemination should be appropriate and adequate to the task.


Organizational capabilities: Adequate capacity for the conduct of research and the evaluation and planning of center activities should take maximum advantage of the parent institution’s capabilities in cancer research.


Interdisciplinary and transdisciplinary collaboration and coordination: Substantial coordination, interaction, and collaboration among center members from a variety of disciplines should enhance and add value to the productivity and quality of research in the center.


Cancer focus: A defined scientific focus on cancer research should be clear from the center members’ grants and contracts, and from the structure and objectives of its programs.


Institutional commitment: The center should be recognized as a formal organizational component with sufficient space, positions, and resources to ensure organizational stability and fulfill the center’s objectives.


Center director: The director should be a highly qualified scientist and administrator with the leadership experience and institutional authority appropriate to manage the center.

SOURCE: National Cancer Institute (2004).

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×
Develop Comprehensive Somnology and Sleep Medicine Centers of Excellence

The establishment of Somnology and Sleep Medicine Centers of Excellence requires large programs that can support and foster excellence in research, clinical care, and population science. This committee recognizes that there are few academic programs that currently have this capacity. However, to facilitate other academic centers achieving this goal, the NIH Exploratory Center award (P20) may be used for this endeavor. These awards are intended to facilitate the development of collaborative research teams of established investigators by providing support for collaborative research projects and core services for investigating leading-edge research questions not currently being addressed in optimal ways (NIMH, 2006). Further, the mechanism supports planning for new programs, expansion or modification of existing resources, and feasibility studies to explore various approaches to the development of interdisciplinary programs that offer potential solutions to problems of special significance (NIH, 2006a). Support is typically limited to 5 years and is not renewable.

The Silvio O. Conte Centers to Develop Collaborative Neuroscience Research provide a good example. These centers, supported through a P20 mechanism, support early-stage development of collaborative teams of high-caliber investigators from diverse disciplines to study basic and/or clinical neuroscience issues. They are characterized by the following:

  • the capacity to bring together a team of collaborative investigators with different scientific perspectives.

  • an organization that supports innovative creativity, and potentially high-risk/high-import research questions that require collaborative research.

  • interactive research projects and core facilities to support projects.

  • a program director with a demonstrated ability to organize, administer, and direct the center.

  • opportunities for young investigators and close coordination between the center and relevant predoctoral and/or postdoctoral research training programs.

  • outreach that makes the public aware of the importance and implications of the center’s research.

A developing center must have a clearly articulated plan to develop a set of scientific core functions that will enhance and expand the capacity to move somnology and/or sleep disorders research and treatment into community settings.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×
NIH Institutional Clinical and Translational Science Award

The NIH has established the Institutional Clinical and Translational Science Award, which has the purpose of developing programs to overcome the growing barriers between clinical and basic research, facilitate the sharing of knowledge to the clinic and back again to the basic research laboratory, and aid academic institutes in developing efficient capabilities to perform clinical and translational science. Through these programs, the NIH aims to: (1) attract and develop a cadre of well-trained multi- and interdisciplinary investigators and research teams; (2) develop programs that spawn innovative research tools and information technologies; and (3) synergize multi- and interdisciplinary clinical and translational research and researchers to catalyze the application of new knowledge and techniques to clinical practice at the front lines of patient care (NIH, 2006b). As supported by all the same arguments already presented throughout this report, somnology and sleep medicine programs are ideal recipients.

As the NIH highlights, to ensure the successful establishment and long-term sustenance of these groundbreaking programs, it is important that the developed program accrue significant institutional support, be granted status as a major administrative entity within the applicant institution, and that the program director have authority, perhaps shared with other high-level institutional officials, over requisite space, resources, faculty appointments, protected time, and promotion (NIH, 2006b).

National Somnology and Sleep Medicine Research Network

A research network is of particular importance in the field because of the need for a coordinated interdisciplinary research approach to basic and clinical research, clinical care, public education, and training. The proposed National Somnology and Sleep Medicine Research Network would improve the efficiency and capacity to research on rare sleep disorders. The Somnology and Sleep Medicine Centers of Excellence discussed above would spearhead this dedicated focus on basic, clinical, and translational research and would promote collaborations among all sites conducting research relevant to somnology and sleep medicine. Similar to cancer centers, the Somnology and Sleep Medicine Centers of Excellence would act as local, regional, and national resources for the scientific community and the community at large. This will require coordination among all participating centers. Although online technologies greatly enhance the nearly instantaneous sharing of ideas across the nation and globally, the research network envisioned by the committee would involve not only a strong virtual component but also a structured plan for periodic and regular meetings and workshops to set priorities and strengthen interactions.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

The committee strongly believes that the somnology and sleep medicine field is now sufficiently mature for the development of a National Somnology and Sleep Medicine Research Network and could successfully compete for network funding from the NHLBI and other members of the Trans-NIH Sleep Research Coordinating Committee that have substantial commitments to somnology and sleep disorders research. Individual Somnology and Sleep Medicine Centers of Excellence could compose the cornerstone of this network, and institutions that do not have sufficient scope and size to successfully compete for a Somnology and Sleep Medicine Center of Excellence would be active affiliate members of this network. The committee envisions a sustained network for somnology and sleep medicine in the United States that would facilitate public education, career development opportunities, translational research, and implementation of multi-center clinical trials.

The process of developing components of the National Somnology and Sleep Medicine Research Network can draw on the experiences of several such networks that already exist, but with more focused objectives, such as the aforementioned National Cancer Institute centers. The NHLBI currently sponsors 12 networks. The National Institute of Child Health and Human Development sponsors the National Center for Medical Rehabilitation Research regional research networks. Each network is coordinated and administered out of one academic institution, which coordinates the efforts of institutions that are affiliated with the network. The leading coordinating institutions are structured to facilitate major collaborations among affiliated institutions, with the potential to connect with researchers from other facilities within the region. They support multidisciplinary research cores, information transfer, and pilot projects with the goal of facilitating ongoing projects and stimulating the development of future research activities in medical rehabilitation (NCMRR, 2005).

Another example of a regional network is the Muscular Dystrophy Cooperative Research Centers. Cosponsored by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute of Neurological Disorders and Stroke, the National Institute of Child Health and Human Development, as well as the Muscular Dystrophy Association, these centers work collaboratively on both basic and clinical research projects. Each center has one or more core facility to support them and must also make core resources or services available to the national muscular dystrophy research community.

The National Somnology and Sleep Medicine Research Network envisioned by the committee would be structured to facilitate and require active involvement of the participants and substantive interactions between basic and clinical researchers. As will be described in detail in Chapter 9, the committee calls on new and existing academic programs in somnology and sleep medicine to be organized to meet the criteria of three types of interdis-

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

ciplinary sleep programs—Type I, Type II, or Type III. A Type I clinical interdisciplinary sleep program is designed to provide optimal interdisciplinary clinical care for individuals who suffer sleep loss or sleep disorders. Although not consisting of large research components, a Type I program should have a data collection and management system that provides clinical data to a coordinating center within the network. A Type II training and research interdisciplinary sleep program includes the characteristics of a Type I program, but in addition is designed to provide optimal education, training, and research in somnology and sleep medicine. A Type III regional interdisciplinary sleep program coordinator includes the characteristics of Type I and II programs; however, a Type III program is designed to serve as a regional comprehensive center and coordinator for education, training, basic research, and clinical research in somnology and sleep medicine within the National Somnology and Sleep Medicine Research Network. The Committee also envisions that all Type I and II programs would be affiliate members of the National Somnology and Sleep Medicine Network.

Although there are only a limited number of academic institutions that currently have the capacity to be a Type III regional interdisciplinary sleep program, this should not delay the establishment of the research network. Initially the network could consist of a limited number of programs. The network would benefit greatly from cultural, ethnic, and environmental diversity. Therefore, a long-range goal should be to have 8 to 10 geographically distributed regional coordinating centers.

In summary, the National Somnology and Sleep Medicine Research Network should do the following:

  • Coordinate and support the current cadre of basic and clinical researchers.

  • Train new investigators and fellows through local and remote mentoring programs.

  • Provide core facilities for basic research.

  • Support multisite clinical research in children, adolescents, adults, and elderly people.

  • Create and support virtual networking centers to facilitate the sharing of data and resources online and enhance collaborations with researchers not working in research centers.

  • Create a data coordinating center that includes an Internet-based clearing house for the publication of all data produced in cooperation with the research and clinical network.

  • Work with the CDC to integrate and support surveillance and population-based research.

  • Create and coordinate public health education campaigns.

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

Efforts to develop a National Somnology and Sleep Medicine Research and Clinical Network are consistent with many of the goals of the NIH Roadmap (NIH, 2006b), including an emphasis on translational research that results in clinically useful therapies and a need for multidisciplinary efforts to be used to address this complex medical condition.

Recommendation 8.2: The National Institutes of Health should establish a National Somnology and Sleep Medicine Research Network.


The National Center on Sleep Disorders Research, in collaboration with the Trans-NIH Sleep Research Coordination Committee, should establish a National Somnology and Sleep Medicine Research Network. Type III regional interdisciplinary sleep programs designated by the National Institutes of Health would act as regional centers working with basic research laboratories and sleep cores at NIH-designated clinical translational research centers. It is envisioned that the networks would do the following:

  • Coordinate and support the current and future cadre of basic and clinical researchers.

  • Train new investigators and fellows.

  • Provide core capabilities for basic, clinical, and translational research.

  • Support multisite clinical research in children, adolescents, adults, and elderly.

  • Create and support virtual networking centers to facilitate the standardization and sharing of data and resources online and enhance collaborations with researchers not working in research centers.

  • Create a data coordinating center that includes an Internet-based clearing house for the publication of all data produced in cooperation with the research and clinical network.

  • Together with the Agency for Healthcare Research and Quality develop standards for research, outcomes, and clinical practice.

  • Work with the Centers for Disease Control and Prevention to integrate and support surveillance and population-based research.

Establish Sleep Laboratories in the NIH Clinical Research Program

As described in the 2003 research plan, “[t]he role of sleep disturbances and sleep disorders in the morbidity of most chronic conditions is understudied … [and] poorly understood” (NHLBI, 2003). The report further went on to call for greater study of the “bidirectional relationship between

Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
×

sleep processes and disease development, progression, and morbidity.” Given these priorities, it is of note that the intramural clinical research program at the NIH does not have a sleep laboratory. Consequently, many experimental sleep therapies and the relationship between sleep processes and disease development are not being examined. If there is adequate investment in extramural sleep-related programs, the field can continue to make great strides; therefore, the committee does not support use of limited resources to invest in an intramural somnology and sleep disorders research program. However, because appropriate sleep patterns constitute one of the basic tenets of health, the committee strongly urges the NIH intramural clinical research program to ascertain the need for potentially establishing a sleep study laboratory so that evaluation of sleep may be integrated into ongoing relevant clinical research protocols at NIH.

Recommendation 8.3: The National Institutes of Health should ascertain the need for a transdisciplinary sleep laboratory that would serve as a core resource in its intramural clinical research program.


The director of the National Institutes of Health Intramural Research Program should ascertain the need for a transdisciplinary sleep laboratory within the intramural clinical research program that would serve as a core resource for the community of intramural clinical investigators across all institutes.

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Suggested Citation:"8 Bolstering Somnology and Sleep Disorders Research Programs." Institute of Medicine. 2006. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press. doi: 10.17226/11617.
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Clinical practice related to sleep problems and sleep disorders has been expanding rapidly in the last few years, but scientific research is not keeping pace. Sleep apnea, insomnia, and restless legs syndrome are three examples of very common disorders for which we have little biological information. This new book cuts across a variety of medical disciplines such as neurology, pulmonology, pediatrics, internal medicine, psychiatry, psychology, otolaryngology, and nursing, as well as other medical practices with an interest in the management of sleep pathology. This area of research is not limited to very young and old patients—sleep disorders reach across all ages and ethnicities. Sleep Disorders and Sleep Deprivation presents a structured analysis that explores the following:

  • Improving awareness among the general public and health care professionals.
  • Increasing investment in interdisciplinary somnology and sleep medicine research training and mentoring activities.
  • Validating and developing new and existing technologies for diagnosis and treatment. This book will be of interest to those looking to learn more about 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 from sleep problems.
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