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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
SLEEP DISORDERS AND SLEEP DEPRIVATION
AN UNMET PUBLIC HEALTH PROBLEM
Committee on Sleep Medicine and Research
Board on Health Sciences Policy
Harvey R. Colten and Bruce M. Altevogt, Editors
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by contracts between the National Academy of Sciences and the American Academy of Sleep Medicine, the Department of Health and Human Services (contract No. N01-OD-4-2139), the National Sleep Foundation, and the Sleep Research Society. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Sleep disorders and sleep deprivation : an unmet public health problem / Committee on Sleep Medicine and Research, Board on Health Sciences Policy ; Harvey R. Colten and Bruce M. Altevogt, editors.
p. ; cm.
Includes bibliographical references and index.
Supported by contracts between the National Academy of Sciences and the American Academy of Sleep Medicine, the Department of Health and Human Services, the National Sleep Foundation, and the Sleep Research Society Contract no. N01-OD-4-2139
ISBN 0-309-10111-5 (hardback)
1. Sleep disorders—Social aspects. 2. Sleep deprivation—Social aspects. 3. Sleep—Social aspects. 4. Public health. I. Colten, Harvey R. II. Altevogt, Bruce M. III. Institute of Medicine (U.S.). Committee on Sleep Medicine and Research.
[DNLM: 1. Sleep Disorders—United States. 2. Health Policy—United States. 3. Sleep Deprivation—United States. WM 188 S63178 2006]
RC547.S554 2006
362.196′8498—dc22
2006014107
Additional copies of this report are available from the
National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2006 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.
www.national-academies.org
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
COMMITTEE ON SLEEP MEDICINE AND RESEARCH
HARVEY R. COLTEN (Chair),
Columbia University, Health Sciences and College of Physicians and Surgeons, New York
FRANCOIS M. ABBOUD,
University of Iowa
GENE D. BLOCK,
University of Virginia
THOMAS F. BOAT,
University of Cincinnati, Ohio
IRIS F. LITT,
Stanford University School of Medicine, California
EMMANUEL MIGNOT,
Stanford University, California
ROBERT H. MILLER,
American Board of Otolaryngology, Texas
F. JAVIER NIETO,
University of Wisconsin School of Medicine and Public Health
ALLAN I. PACK,
University of Pennsylvania Medical Center
KATHY P. PARKER,
Emory University, Georgia
SAMUEL J. POTOLICCHIO,
The George Washington University Medical Center, Washington, DC
SUSAN REDLINE,
Case Western Reserve University School of Medicine, Ohio
CHARLES F. REYNOLDS III,
University of Pittsburgh, Pennsylvania
CLIFFORD B. SAPER,
Harvard Medical School, Massachusetts
Study Staff
BRUCE M. ALTEVOGT, Study Director
SARAH L. HANSON, Research Associate
DAVID CODREA, Financial Associate
AMY HAAS, Administrative Assistant
ELEANORE EDSON, Research Fellow
CATHARYN T. LIVERMAN, Senior Program Officer
ANDREW M. POPE, Board Director
LORA K. TAYLOR, Senior Project Assistant
Consultant
MIRIAM DAVIS,
School of Public Health and Health Services, George Washington University, Washington, DC
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
BOARD ON HEALTH SCIENCES POLICY
FRED H. GAGE (Chair),
The Salk Institute for Biological Studies, La Jolla, California
GAIL H. CASSELL,
Eli Lilly and Company, Indianapolis, Indiana
JAMES F. CHILDRESS,
University of Virginia, Charlottesville
ELLEN WRIGHT CLAYTON,
Vanderbilt University Medical School, Nashville, Tennessee
DAVID R. COX,
Perlegen Sciences, Mountain View, California
LYNN R. GOLDMAN,
Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
BERNARD D. GOLDSTEIN,
University of Pittsburgh, Pittsburgh, Pennsylvania
MARTHA N. HILL,
Johns Hopkins University School of Nursing, Baltimore, Maryland
ALAN LESHNER,
American Association for the Advancement of Science, Washington, D.C.
DANIEL MASYS,
Vanderbilt University Medical Center, Nashville, Tennessee
JONATHAN D. MORENO,
University of Virginia, Charlottesville
E. ALBERT REECE,
University of Arkansas, Little Rock
MYRL WEINBERG,
National Health Council, Washington, D.C.
MICHAEL J. WELCH,
Washington University School of Medicine, St. Louis, Missouri
OWEN N. WITTE,
University of California, Los Angeles
MARY WOOLLEY,
Research!America, Alexandria, Virginia
IOM Staff
ANDREW M. POPE, Director
AMY HAAS, Board Assistant
DAVID CODREA, Financial Associate
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Independent Report Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Ruth Benca, Department of Psychiatry, University of Wisconsin, Madison
Mary A. Carskadon, Sleep Research Laboratory, Brown University
Norman H. Edelman, Health Sciences Center, SUNY Stony Brook University
Stephen L. Hauser, Department of Neurology, University of California, San Francisco
Meir H. Kryger, Sleep Disorders Center, St. Boniface General Hospital Winnipeg, Manitoba, Canada
Lawrence S. Lewin, Executive Consultant, Chevy Chase, Maryland
Thomas Roth, Sleep Center, Henry Ford Hospital, Detroit, Michigan
Joan L. Shaver, College of Nursing, University of Illinois at Chicago
Joseph S. Takahashi, Department of Neurobiology & Physiology, Northwestern University
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Terry B. Young, Department of Population Health Sciences, University of Wisconsin
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by David J. Kupfer, University of Pittsburgh School of Medicine, and Floyd E. Bloom, Professor Emeritus Department of Neuropharmacology, The Scripps Research Institute. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Preface
Sleep has been a subject of intense interest to poets and mystics and is found in folklore since antiquity. Only in the last half a century have scientists and physicians attempted a systematic study of the biology and disorders of sleep. Within the past four decades remarkable advances in the neurophysiology of normal sleep and in circadian biology and the discovery of the genes that regulate these biological rhythms have provided a scientific framework for the elucidation of the etiology, pathogenesis, and potential treatment of sleep disorders. These scientific advances and input from many clinical disciplines such as internal medicine, neurology, nursing, otolaryngology, pediatrics, psychiatry, psychology, and pulmonology have enriched the study and management of sleep pathology. However, the broad intellectual and service requirements for dealing with sleep has created difficulties in coordination and planning of research and clinical services. Recognition of around 90 distinct clinical disorders of sleep has created a platform and need for specialization in the study of sleep (somnology) and sleep pathology. Accordingly, professional societies such as the American Academy of Sleep Medicine, the American Sleep Apnea Association, the National Sleep Foundation, and the Sleep Research Society have been established and the discipline has been recognized by the American Board of Medical Specialties. Moreover, the National Institutes of Health (NIH) formed the National Center on Sleep Disorders Research (NCSDR) to coordinate research in sleep. Although these developments are positive, they do not yet fully address the scope and depth of the public and individual health consequences of sleep deprivation and sleep disorders. For example, more than 50 million Americans suffer a chronic sleep disorder and many others experience dis-
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
ruption of normal daytime activities owing to sleep deprivation. Sadly, the majority of individuals with substantial sleep disorders are not diagnosed and appropriately treated.
In recognition of the limited appreciation of the importance of sleep disorders and sleep deprivation for individuals and the public health, the American Academy of Sleep Medicine, the NCSDR at the NIH, the National Sleep Foundation, and the Sleep Research Society requested that the Institute of Medicine (IOM) do the following:
Review and quantify the public health significance of sleep health, sleep loss, and sleep disorders, including assessments of the contribution of sleep disorders to poor health, reduced quality of life, and early mortality, as well as the economic consequences of sleep loss and sleep disorders.
Identify gaps in the public health system relating to the understanding, management, and treatment of sleep loss and sleep disorders and assess the adequacy of the current resources and infrastructure for addressing the gaps.
Identify barriers to and opportunities for improving and stimulating multi- and interdisciplinary research and education in sleep medicine and biology. Delineate organizational models that will promote and facilitate sleep research in the basic sciences, collaborative research between basic scientists, clinicians, and population scientists in relevant specialties, and education of practitioners and scientists in sleep health, sleep disorders, and sleep research.
Develop a comprehensive plan for enhancing sleep medicine and sleep research for improving the public’s health.
In response, the IOM appointed a 14-member committee with expertise in pulmonology, cardiology, nursing, neurology, pediatrics, adolescent medicine, psychiatry, epidemiology, public health, otolaryngology, academic and medical administration, and health sciences research. The committee met five times during the course of its work and held two workshops. In addition, the committee received input from relevant federal, private, and non-profit organizations.
Our findings confirmed the enormous public health burden of sleep disorders and sleep deprivation and the strikingly limited capacity of the health care enterprise to identify and treat the majority of individuals suffering sleep problems.
The direct effects of sleep disorders as well as the comorbidity with other substantial public health problems such as obesity, diabetes, stroke, and depression have a profound economic and social impact. Only minimal estimates of the economic impact of sleep disorders and their derivative consequences are possible because of underrecognition and underreporting.
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
At a minimum, however, the total direct and indirect cost of sleep disorders and sleep deprivation in the United States is hundreds of billions of dollars. The magnitude of the effect of sleep pathology is shocking even to experts in the field of somnology and sleep medicine. We found that there are too few professionals dedicated to sleep problems to meet the size and importance of the problem and there are too few educational programs that have the potential to increase the workforce of health care practitioners and scientists to meet even current demands. In addition, research that will advance our understanding of sleep pathology and its treatment has been underfunded. We therefore have outlined recommendations to address these shortcomings, in the hope that the burden of sleep disorders and sleep deprivation can be minimized. These recommendations fall into four broad categories: education (public, professional); technology; coordination of research initiatives at the NIH; and organization of research, clinical care, and education in academic health centers.
EDUCATION
The lack of public awareness should prompt a multimedia public education campaign that also targets elementary, middle, and high school students as well as undergraduate college health education programs about the impact of inadequate sleep.
Professional education will be enhanced by integrating the teaching of sleep medicine and biology into medical, nursing, and pharmacology curricula and into residency and specialty fellowships. Strategies to facilitate careers in somnology will be needed to meet the demand for sound science and expert clinical capacity to take care of the health problems related to sleep disorders.
TECHNOLOGY
The cumbersome nature and cost of diagnosis and treatment of sleep disorders and sleep loss will require research to develop and validate the efficacy of advances in diagnostic technologies, including ambulatory monitoring and imaging as well as the development of new therapeutic options for specific sleep disorders.
NATIONAL INSTITUTES OF HEALTH
The NCSDR at the NIH should take a more proactive role in promoting integration of research disciplines pertinent to somnology and sleep disorders, and it should promote training programs that increase the pipeline of highly qualified investigators. Together with other federal agencies, the
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
NCSDR can support increased public awareness and generation of more reliable prevalence data.
ORGANIZATION OF ACADEMIC HEALTH CENTERS
Within academic health centers new and existing sleep programs should be organized as Interdisciplinary Sleep Programs that encompass the relevant basic and clinical disciplines. The complexity of these programs will vary in accord with the capacity and goals of each center; therefore, we have proposed several different models. Networking among the most complex of these programs will facilitate research progress and accelerate implementation of new clinical strategies with help from the NCSDR.
The committee has been fortunate in having superb support from IOM staff and willing consultants in related fields. Without their help this report could not have been completed. We are most grateful.
Harvey R. Colten, M.D., Chair
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Acknowledgments
The committee acknowledges with appreciation the individuals who provided information to the committee. These individuals include Richard Allen, Johns Hopkins University School of Medicine; Sonia Ancoli-Israel, University of California, San Diego School of Medicine; Bonnie Austin, AcademyHealth; Donald Bliwise, Emory University; Martha Brewer, American Heart Association; Debra J. Brody, National Center for Health Statistics; Kathleen C. Buckwalter, University of Iowa Center on Aging; Roger Bulger, Association of Academic Health Centers; Daniel Buysse, University of Pittsburgh School of Medicine; Andrea Califano, Columbia University; Sue Ciezadlo, American College of Chest Physicians; Charles A. Czeisler, Harvard University School of Medicine; William Dement, Stanford University School of Medicine; David Dinges, University of Pennsylvania School of Medicine; Darrel Drobnich, National Sleep Foundation; Paul Eggers, National Institute of Diabetes and Digestive and Kidney Diseases; Lawrence Epstein, Sleep HealthCenters; Gary Ewart, American Thoracic Society; David Lewis, SleepMed, Inc; Magda Galindo, American Diabetes Association; Lee Goldman, University of California, San Francisco Medical School; Allan Gordon, American Thoracic Society; Daniel Gottlieb, Boston University School of Medicine; David Gozal, University of Louisville; Meir Kryger, University of Manitoba; James Kiley, National Heart, Lung, and Blood Institute; David J. Kupfer, University of Pittsburgh School of Medicine; Story Landis, National Institute of Neurological Disorders and Stroke; Kathy Lee, University of California, San Francisco; Eugene J. Lengerich, Pennsylvania Cancer Control Consortium; Carole Marcus, The Children’s Hospital of Pennsylvania; Jennifer Markkanen, American Academy of Sleep
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Medicine; Michael Martin, Center for Scientific Review, National Institutes of Health; William McLeod, Institute of Medicine; John McGrath, National Institute of Child Health & Human Development; Merrill Mitler, National Institute of Neurological Disorders and Stroke; Rosanne Money, American Academy of Sleep Medicine; Hal Moses, Vanderbilt-Ingram Cancer Center; Judith Owens, Brown University Medical School; Barbara Phillips, University of Kentucky College of Medicine; Stuart Quan, University of Arizona; Roger Rosa, National Institute for Occupational Safety and Health; Thomas Roth, Henry Ford Health System of Detroit; Michael Sateia, Dartmouth University; Jerome Siegel, University of California, Los Angeles; John Slater, American Academy of Sleep Medicine; Margaret Snyder, National Institutes of Health; Ed Sondik, The National Center for Health Statistics; Ray Vento, American Lung Association; James Walsh, St. Luke’s Hospital; David White, Brigham and Women’s Hospital; Steven Wolinsky, Northwestern University; Terry Young, University of Wisconsin.
This study was sponsored by the American Academy of Sleep Medicine, the National Center on Sleep Disorders Research of the National Institutes of Health, the National Sleep Foundation, and the Sleep Research Society. We appreciate their support and especially thank Jerry Barrett, Richard Gelula, Al Golden, Carl Hunt, and Michael Twery for their efforts on behalf of this study.
We appreciate the work of John Fontanesi, University of California, San Diego for his commissioned paper. We also thank Andrew Pope for his guidance and Judy Estep for her expertise in formatting the report for production. Finally, we especially thank Cathy Liverman for all of her thoughtful guidance throughout the project.
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Contents
SUMMARY
1
1
INTRODUCTION
19
Magnitude and Cost of the Problem,
20
Historical Background,
21
Growth of Somnology and Sleep Medicine,
22
Challenges in Advancing the Study of Sleep Disorders,
22
Somnology and Sleep Medicine Research in Academic Institutions,
26
Scope and Organization of This Report,
29
References,
31
2
SLEEP PHYSIOLOGY
33
Sleep Architecture,
34
Sleep-Wake Regulation,
39
Circadian Rhythms, the 24-Hour Clock,
41
Sleep Patterns Change with Age,
43
References,
49
3
EXTENT AND HEALTH CONSEQUENCES OF CHRONIC SLEEP LOSS AND SLEEP DISORDERS
55
Sleep Loss,
57
Sleep-Disordered Breathing,
65
Insomnia,
75
Sleep and Psychiatric Disorders,
78
Narcolepsy and Hypersomnia,
82
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
Parasomnias,
88
Sleep and Neurological Disorders,
91
Sudden Infant Death Syndrome,
96
Sleep and Movement Disorders,
97
Sleep and Medical Disorders,
101
Circadian Rhythm Sleep Disorders,
107
References,
111
4
FUNCTIONAL AND ECONOMIC IMPACT OF SLEEP LOSS AND SLEEP-RELATED DISORDERS
137
Performance and Cognition Deficits,
138
Motor Vehicle Crashes and Other Injuries,
147
Impact on Functioning and Quality of Life,
151
Economic Impact of Sleep Loss and Sleep Disorders,
155
References,
163
5
IMPROVING AWARENESS, DIAGNOSIS, AND TREATMENT OF SLEEP DISORDERS
173
Challenges Facing Individuals with Sleep Disorders,
174
Public Education,
178
Professional Training and Awareness Is Required,
182
Graduate Research Training in Somnology and Sleep Disorders,
187
Overview of Medical School Somnology Education,
187
Overview of Somnology in Medical Residency Training Curricula,
191
Overview of Sleep Medicine Fellowship Training,
192
Demonstration of Knowledge: Board Certification,
197
Next Steps,
201
Data Systems for Surveying Sleep and Sleep Disorders,
203
References,
212
6
ENSURING ADEQUATE DIAGNOSIS AND TREATMENT: ACCESS, CAPACITY, AND TECHNOLOGY DEVELOPMENT
217
Developing Portable Diagnostic Tools,
218
Challenges to Developing Ambulatory Technologies,
222
Future Directions,
228
References,
229
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
7
OPPORTUNITIES TO IMPROVE CAREER DEVELOPMENT IN SOMNOLOGY
233
Growth of the Somnology and Sleep Medicine Field,
234
NIH Training and Career Development Programs,
238
Opportunities to Accelerate Somnology and Sleep Medicine Career Development,
247
References,
251
8
BOLSTERING SOMNOLOGY AND SLEEP DISORDERS RESEARCH PROGRAMS
253
NIH Coordination of Sleep-Related Activities,
254
National Sleep Disorders Research Plan,
259
Analysis of NIH-Sponsored Research Project Grants,
267
Next Steps in Accelerating Progress,
276
References,
286
9
BUILDING SLEEP PROGRAMS IN ACADEMIC HEALTH CENTERS
293
Rationale for Sleep Programs in Academic Health Centers,
294
Constraints Facing Interdisciplinary Sleep Programs,
300
Key Components and Guiding Principles for Building Sleep Programs,
303
Organizational and Fiscal Structures for Sustaining or Expanding a Sleep Program,
306
Accreditation and Certification Are Essential to Quality Care,
312
Next Steps,
315
References,
321
APPENDIXES
A
Study Process
325
B
Acronyms
332
C
Glossary of Major Terms
335
D
Congressional Language Establishing the National Center on Sleep Disorders Research, § 285b–7
345
E
Sleep Disorders Research Advisory Board Membership
348
F
National Institutes of Health Sleep-Related Initiatives: 1994–2004
351
G
National Institutes of Health Support of Sleep-Related R01 Grants
356
H
Summary of NIH Support of Sleep-Related Career Development Awards
360
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Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
I
Summary of NIH Support of Sleep-Related R13, R25, P, F, T, and U Grants
368
J
Summary of Investment in Sleep-Related Projects at the Top 30 NIH-Funded Institutions
375
K
Biographical Sketches of Committee Members and Staff
378
INDEX
387
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SLEEP DISORDERS AND SLEEP DEPRIVATION
AN UNMET PUBLIC HEALTH PROBLEM
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