The Extraordinary Importance of Sleep

The Detrimental Effects of Inadequate Sleep on Health

and Public Safety Drive an Explosion of Sleep Research
Susan L. Worley

In the inaugural issue of the Journal of Clinical Sleep Medicine enforcement, airports and all kinds of transportation, industrial
(2005), a feature article1 traced early milestones in the devel- operations, and hospitals—operates 24/7. People have come to
oping field of sleep medicine, which slowly emerged from value time so much that sleep is often regarded as an annoying
the older field of sleep research during the 1970s and 1980s. interference, a wasteful state that you enter into when you do
Sleep medicine, the article noted, was closely linked with and not have enough willpower to work harder and longer.”
made possible by the discovery of electrical It has become increasingly clear, however,
activity in the brain. The examination of elec- that no matter how hectic our lives may be, we
troencephalogram (EEG) patterns that occur can no longer afford to ignore what research
during sleep led to the classification of stages is telling us about the importance of sleep for
of sleep, which in turn created an important our safety and mental and physical well-being.
foundation for probing human sleep, discern-
ing abnormalities, and discovering significant Impact on Attention, Cognition, and Mood
relationships between sleep and health. By While scientists are still working to iden-
2005, scientists and clinicians had not only tify and clarify all of the functions of sleep,12
identified and clearly defined a large number of decades of studies—many of which have used
sleep disorders but had discovered that many the method of disrupting sleep and examining
of them were highly prevalent. the consequences—have confirmed that sleep
The pace of research and discovery has only is necessary for our healthy functioning and
accelerated since 2005, and the number of peer- even survival.
David F. Dinges, PhD
reviewed sleep journals has more than tripled. “We know for sure that sleep serves mul-
Today, researchers are more deeply probing the cellular and tiple functions,” says Dr. Dinges. “Nature tends to be very
subcellular effects of disrupted sleep, as well as the effects of parsimonious in that it often uses a single system or biology
sleep deprivation on metabolism, hormone regulation, and in multiple ways to optimize the functioning of an organism.
gene expression. Newer studies are strengthening known We know, for example, that sleep is critical for waking cogni-
and suspected relationships between inadequate sleep and a tion––that is, for the ability to think clearly, to be vigilant and
wide range of disorders, including hypertension,2 obesity and alert, and sustain attention. We also know that memories are
type- 2 diabetes,3 impaired immune functioning,4 cardiovascular consolidated during sleep, and that sleep serves a key role in
disease and arrhythmias,5,6 mood disorders,7 neurodegenera- emotional regulation.”
tion and dementia, 8,9 and even loneliness.10 Studies conducted by Dr. Dinges and other scientists have
Research findings continue to underscore early concerns shown that cognitive performance and vigilant attention begin
about public safety that were first raised when major industrial to decline fairly quickly after more than 16 hours of continuous
disasters such as the Exxon Valdez oil spill were linked to inad- wakefulness, and that sleep deficits from partial sleep depriva-
equate sleep.11 Related research sponsored by major organiza- tion can accumulate over time, resulting in a steady deterio-
tions, including the U.S. Department of Transportation, the U.S. ration in alertness. The widely used psychomotor vigilance
Department of Defense, the National Institutes of Health, and test (PVT), a simple neurocognitive test developed by Dr.
the National Aeronautics and Space Administration (NASA), has Dinges and colleagues that assesses an individual’s ability to
helped to inspire national initiatives aimed at improving public sustain attention and respond to signals in a timely manner,
safety and health. However, despite the astounding accelera- has proven to be an exceptionally sensitive tool for capturing
tion in research during the past few decades, inadequate sleep dose–response effects of sleep loss on neurobehavioral func-
due to sleep disorders, work schedules, and chaotic lifestyles tioning.13 The PVT also reliably detects sleep deficits caused
continues to threaten both health and safety. by disrupted or fragmented sleep, and/or poorly timed sleep,
“Pushing against the wave of accelerated growth in the which is important because a growing body of evidence sug-
field has been a shoreline of indifference,” says David F. gests that the continuity and timing (or circadian alignment)
Dinges, PhD, Professor and Chief of the Division of Sleep of sleep may be as important as the total amount of time spent
and Chronobiology in the Department of Psychiatry at the sleeping.
University of Pennsylvania Perelman School of Medicine. “We know that sleep is much more restorative of waking func-
“Modern industrial pressures to use time 24 hours a day have tions and health when it is consolidated and not fragmented,”
led to shiftwork and a world in which virtually everything––law explains Dr. Dinges. “That is, when sleep goes through the
appropriate physiological sequences of non-REM (rapid eye
Susan L. Worley is a freelance medical writer who resides in Penn- movement) and REM states at night, and occurs when human
sylvania. sleep is temporally programmed by our circadian clock to occur.

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 The Extraordinary Importance of Sleep
Such consolidated sleep is typically of a longer duration and in sleep time that stretches back to about 2003 or 2004,” says
better sleep quality than sleep taken at other times of the day, Dr. Dinges. “We think this increase, which is modest––at most
such as that which occurs with nightshift work, jet lag, and a minute or two more per year––is due in part to the develop-
other conditions of circadian misalignment.” ment of the field of sleep medicine, and public and scientific
Dr. Dinges and his colleagues have found that people whose reports in the media about sleep loss contributing to accidents
daily sleep duration is inadequate, or repeatedly disrupted and catastrophes, and so forth. Ever so slowly, the message that
(e.g., by obstructive sleep apnea, restless legs syndrome, it is important not to get sleep deprived, and to get help if you
pain or stress, or shiftwork or jet lag), often are not aware of have a sleep disorder, has begun to penetrate to the public.”
their accumulating sleep deficits or the toll that these deficits The analysis notes that one sign of greater interest in sleep on
can take on their waking cognitive functions, including their the part of the public has been a significant increase in Google
performance, working memory, cognitive speed, and accuracy. searches containing the word “sleep” since 2004. Data from the
Inadequate sleep also can take a toll on psychological well- ATUS also suggest that over time, people have been willing to
being, significantly affecting our emotional and psychosocial trade some of their daily activities in exchange for more sleep.
interpretation of events and exacerbating our stress levels. It is important to note, says Dr. Dinges, that self-reports of time
Studies have indicated that changes in mood may be due in spent sleeping are not always accurate––they can be off by a
part to the effects of sleep deprivation on the processing of half an hour or more, usually with people tending to estimate
emotional memory––in other words, our tendency to select that they slept more than they did. He also notes that there is
and remember negative memories after inadequate sleep.14 still a fairly large population sleeping 6 hours or less.
In one study conducted by Dr. Dinges and colleagues, “Although there are signs that sleep time is increasing, it is
participants’ mood was observed after they were confronted not happening at nearly the dramatic rate that most experts
with “high” and “low” performance demands, following varying would like to see,” says Dr. Dinges. “This is especially true
degrees of sleep deprivation.15 for vulnerable populations. There is concern about school
“To our surprise, those who were sleep-deprived responded start times and bus times affecting the sleep of children and
to low stressors in much the same way that people without adolescents, and about extracurricular activities at the end of
any sleep deprivation tended to respond to high stressors,” the school day sometimes leading to a delay in bed times for
said Dr. Dinges. “In other words, we tend to become much teenagers. All of this is an ongoing, evolving picture, with more
more sensitive emotionally and socially when we are sleep- research results coming out all the time, and with consequent
deprived. That is what I like to call the ‘who was at my desk changes in recommendations, to make sure that at least our
or who touched my coffee cup?’ phenomenon. I think we all most vulnerable populations are getting adequate sleep.”
have experienced having an extreme reaction or a very nega-
tive emotional response to a mild stressor when we have not Interindividual Differences in Vulnerability to Sleep Loss
had enough sleep.” While it is well established that the effects of sleep loss
accumulate over time, with repeated exposure to inadequate,
Aiming for the Sweet Spot fragmented, or disrupted sleep, the degree to which individu-
How much sleep is enough? After decades of investigation, als demonstrate adverse effects of inadequate sleep can vary
it appears that scientists have gathered enough evidence to considerably.18
begin to answer that question.16 “We have learned that there are astonishingly mysterious
“When duration of sleep drops below seven hours, and phenotypes, or trait-like differences, in how vulnerable people
especially when it starts to move toward six and half hours are to sleep loss,” says Dr. Dinges. “This is still a relatively
or less, a number of different disorders begin to increase in new area of research, and it has only been in the past few
prevalence,” says Dr. Dinges. “Most experts would agree that years that scientists have begun to replicate early findings
there is a kind of sweet spot that most people should aim for, regarding these phenotypic differences in vulnerability to the
and for the average healthy adult that zone is ideally somewhere negative neurobehavioral effects of sleep loss. The interindi-
between 7 and 7 and a half hours. That is what the consensus vidual differences that have been observed so far raise some
evaluations of more than a thousand scientific articles have extremely provocative scientific questions. We may find that
yielded––the consensus of evaluations conducted by the AASM there is something in waking biology that can substitute for, or
(American Academy of Sleep Medicine) and Sleep Research somehow reduce, the impact of sleep loss on waking function-
Society jointly.” ing, but thus far there is no evidence as to what that might be.”
Numerous large U.S. surveys––beginning with a 1982 survey Differences among individuals exist with regard to both the
by the American Cancer Society—have been used to estimate effects of sleep loss and the ability to recover from the effects of
the number of hours that most people spend sleeping. Many sleep loss. Differences in performance also have been shown to
surveys have identified a worrisome prevalence of “short” be task-dependent, suggesting that people who are vulnerable
sleepers (people who sleep 6 hours or less) among respon- to the effects of sleep loss in one or more cognitive or neu-
dents, and a general trend toward decreasing sleep duration robehavioral domains may be resistant to the effects of sleep
between 1975 and 2006. More recently, however, an analysis loss in others. To better understand interindividual variability,
of the American Time Use Survey (ATUS), spearheaded by scientists are investigating possible genetic mechanisms that
Mathias Basner, MD, PhD, at the University of Pennsylvania17, may underlie complex interactions between circadian and sleep
has suggested that there may be cause for optimism. homeostatic systems—the systems that affect our drive for
“The analysis shows that there is a slight but steady increase sleep as well as our alertness and performance during waking

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Table 1 ICSD-3 Major Diagnostic Sections *

Insomnia Difficulty getting to sleep or staying asleep, with associated daytime consequences.
Sleep-related breathing disorders Obstructive sleep apnea (cessation of breathing due to upper airway obstruction), central sleep apnea
(cessation of breathing due to absent respiratory effort), and hypoventilation disorders (shallow breathing
due to a variety of medical conditions).
Central disorders of hypersomno- Excessive daytime sleepiness not due to other sleep disorders. These include narcolepsy, idiopathic hyper-
lence somnolence, and insufficient sleep syndrome.
Circadian rhythm sleep–wake Abnormalities of sleep–wake cycles due to misalignment between the biological clock and customary or
disorders required sleep–wake times. These include delayed or advanced sleep phase, shift work disorder, and jet
lag.
Parasomnias Abnormal behaviors or events arising from sleep. These include sleepwalking, sleep terrors, and rapid
eye-movement sleep behavior disorder.
Sleep-related movement disorders Abnormal, usually stereotyped, recurring movements in sleep. Restless legs syndrome, although a waking
sensory disorder, is included, as well as periodic limb movement in sleep and leg cramps.
Other sleep disorders Those sleep–wake disorders not classified elsewhere, most notably environmental sleep disorder.
*Table courtesy of Michael J. Sateia, MD

hours. A current goal is to discover biomarkers that may help more personalized approach to assessment and treatment.
predict individual performance after varying degrees of sleep A chief goal is to improve the diagnosis of sleep disorders.
loss.19 And one hope is that biomarkers––ideally in the form of Although approximately 70 million people in the U.S. have at
a simple “roadside” test such as a breathalyzer––may eventually least one sleep disorder, experts estimate that up to 80% of
be used to detect sleep loss-related impairment in drivers or in sleep disorders may go undetected or undiagnosed. One major
individuals responsible for operating sophisticated equipment challenge that clinicians face during the initial assessment of
or machinery. To date, no viable candidates have been found. people with sleep disorders is the process of identifying and
Investigators also are shedding light on the role that age sorting out comorbidities. Untangling the causes and effects
may play in resilience to sleep loss. The results of one recent in bidirectional comorbidities can be particularly difficult. For
study indicate that younger adults are more vulnerable to the example, insomnia––by far the most common sleep disorder––
adverse effects of chronic sleep loss and recurring circadian often is complicated by the presence of another sleep disorder,
disruption than older adults.20 Although the neurobiological such as sleep apnea or restless legs syndrome.
basis for these age-related differences is not yet understood, “Some experts have even suggested that all cases of insomnia
such findings may help to inform new approaches to the pre- coexist with, or are caused by, another sleep disorder, most
vention of drowsy driving and related motor-vehicle accidents commonly sleep apnea,” says Clete A. Kushida, MD, PhD,
among young drivers. Professor of Psychiatry and Behavioral Sciences at Stanford,
Dr. Dinges emphasizes that findings regarding interindi- and Division Chief and Medical Director of Stanford Sleep
vidual differences in response to sleep loss and in recovery Medicine. “I’m not sure I would go quite that far, but certainly
from sleep loss should not diminish the message that adequate bidirectional comorbidities among individuals who experience
sleep is critical for everyone. sleep disorders are common. For example, pain syndromes––
“Research has shown us that sleep is not an optional activity,” including back pain and limb pain, especially among older
says Dr. Dinges. “There is no question that sleep is fundamen- patients––are common comorbidities in patients with insomnia.
tally conserved across species and across lifespans, and that Mood disorders also frequently occur in patients who experi-
any effort to eliminate it has been unsuccessful. We must plan ence insomnia.”
our lives in the time domain with a serious consideration for Comorbidities can complicate treatment and often require
sleep––planning when to sleep, ensuring that we get adequate sleep specialists to collaborate with not only primary care
sleep, and making sure that our sleep is not disturbed by physicians but also specialists in other therapeutic areas.
disorders or diseases, whether or not they are sleep-related.” “If, for example, a person with insomnia also has been diag-
nosed with depression by a psychiatrist,” says Dr. Kushida,
Addressing Sleep Disorders “our goal is to work hand in hand with the psychiatrist to find
As connections between sleep disruption and both disease the right medication. There are both sedating and alerting
and mortality have become more firmly established, accurate antidepressants, and a patient may need to try one medication
and efficient diagnosis and management of sleep disorders (see for a couple of weeks to months, slowly increasing the dose to
Table 1) have become increasingly critical. Recent directions a therapeutic level, until the effect on both the depression and
in the field of sleep medicine include a move toward patient- the patient’s sleep can be determined. For some individuals,
centered care, greater collaboration between specialists and an alerting antidepressant can cause poor sleep, which in turn
primary care physicians, and the incorporation of new tools–– can exacerbate the depression. The process of achieving the
including home-based diagnostic tests and novel electronic right dose of the right medication can be complex, and benefits
questionnaires––in the effort to create a comprehensive yet from a collaboration between specialists.”

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Undetected obstructive sleep apnea (OSA) in patients with then suddenly experience a traumatic event, such as the loss
chronic pain, or other serious illnesses, can result in potentially
of a job, a divorce, or the death of a loved one, resulting in very
dangerous comorbidities. Opioids, for example, are known to poor sleep,” says Dr. Kushida. “Down the road, that person
have adverse effects on respiration, and can lead to central might obtain a better job, overcome grief, or find a new relation-
sleep apnea (CSA)––shallow and irregular or interrupted ship, but continue to experience insomnia. We think in some
breathing and sustained hypoventilation––a potentially lethal cases the transition from acute insomnia to chronic insomnia
condition that can intensify the consequences of OSA. These occurs because the behavioral event triggers something in
risks underscore the need to improve methods for identifying the person’s physiology that may lead to long-term changes.
and properly diagnosing the estimated 23.5 million U.S. adults Once they are in a chronic insomnia phase, we tell patients
with OSA. Public education and advocacy efforts are already that CBT is the only truly effective intervention.”
helping to improve detection––in part by helping to address If a patient is already taking hypnotics, Dr. Kushida says
misconceptions about OSA. that he will gradually wean the patient off medications while
“One of the biggest misconceptions is that only people who introducing CBT. He notes that often it is necessary for sleep
are significantly overweight experience sleep specialists to manage the expectations of
apnea,” says Dr. Kushida. “In fact, only up to chronic sufferers.
67% of people who have OSA are overweight, “We sometimes have to let patients with
the rest are of normal weight. OSA also can be chronic insomnia know that we may never
caused by craniofacial dysmorphism, or a defect get them back to where they were when they
of the airway that occurs during development. had optimal sleep,” Dr. Kushida explains. “The
A narrow airway caused by deficient growth behavioral methods we use work well, and
of the craniofacial skeleton, particularly the usually we can get patients to the point where
jaws, can become narrower and more prone the insomnia is having less of an impact on their
to collapse with age, leading to sleep apnea.” quality of life. Our inability to completely restore
the patient’s ability to sleep well may partly
Treating Insomnia: The Value of Cognitive be explained by as yet unidentified changes
Behavioral Therapy in his or her neurophysiology or neurochem-
Insomnia, the most prevalent sleep disorder, istry. Some patients with chronic insomnia
Clete A. Kushida, MD, PhD
affects approximately one third of all adults and can begin to sleep normally again, but for the
is the most common condition that family and primary-care phy- vast majority, we aim to make insomnia less of a burden on a
sicians encounter. According to the International Classification patient’s daily life.”
of Sleep Disorders (ICSD-3), chronic insomnia is the inability
to attain sufficient sleep (despite adequate opportunity) for at Improving Clinical Research
least three nights per week for three months or longer, with In the field of sleep medicine, as in many other therapeutic
negative daytime consequences. For most people, the disorder areas, future directions in clinical trial research will place
is transient, but for approximately 10% to 15% of those who an emphasis on patient engagement and patient-centered
experience insomnia (around 30 million people) it becomes outcomes.
chronic. Although pharmacologic treatments for insomnia “Perhaps the most important aim these days when develop-
(Table 2) can be effective, most experts now recommend ing and implementing any type of large-scale clinical research
against the long-term use of pharmacotherapy. study is to incorporate the patient’s perspective,” says Dr.
“If a person has been diagnosed with chronic insomnia, Kushida, who is currently analyzing the results of a comparative
the only treatment that has been shown to have long-term effectiveness sleep study sponsored by the Patient-Centered
benefit is cognitive behavioral therapy, “says Dr. Kushida. Outcomes Research Institute (PCORI).22 The study, designed
“Medications really should be considered short-term treat- and conducted by a team at Stanford, introduced a new model
ments, because patients tend to develop dependence on, or of patient-centered, coordinated care and tested it against
tolerance to, hypnotic drugs. In our clinic, we commonly see conventional outpatient treatment for sleep disorders.
that, over time, medications stop having an effect, and that “The patient’s perspective is so invaluable in guiding the
means that patients may try higher doses of a medication, or success of a study that ideally it should be incorporated right at
keep switching to different medications. So, medications are a the inception of a research question or idea,” says Dr. Kushida.
temporary solution––they just put a Band-Aid on the problem “When you are designing an especially complicated trial, for
of insomnia, whereas cognitive behavioral therapy targets one example, it is easy to incorporate a lot of tests and measures
of the pathways toward success.” without being aware of the burden these can place on the
Cognitive behavioral therapy (CBT), which involves tech- participants. It’s critical to learn from patients whether they
niques that work in part by reducing cognitive and somatic are overwhelmed by the number of tests, or whether travel
arousal, is estimated to be effective in approximately 70% to time or the amount of time they need to take off from work
80% of people who experience chronic insomnia. Dr. Kushida may be impractical.”
notes that while drugs can sometimes be useful in the treat- Other efforts to improve clinical research include those
ment of acute insomnia, they become problematic after acute focused on correcting for and/or eliminating several confound-
insomnia transitions to chronic insomnia. ing variables that tend to plague sleep research. The surprising
“A person might be an OK sleeper for several years, and power of the placebo effect,23 the related disconnect between

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 The Extraordinary Importance of Sleep
assessment of sleep is polysomnography
Table 2 Selected Pharmaceutical Treatments for Insomnia21, 27
(PSG), which includes electrophysiologi-
Agent (Generic Name) Dosage Forms Indications/Comments cal recordings of brain activity (EEG),
Non-benzodiazepines muscle activity (EMG), and eye move-
ments (EOG). A valuable, non-invasive
Eszopiclone 1-mg, 2-mg, and 3-mg Primarily used for sleep-onset and
method for determining sleep continuity
tablets maintenance insomnia; intermediate-
and sleep architecture, PSG has been an
acting; no short-term usage restriction
indispensable objective endpoint in clinical
Zolpidem 5-mg, 10-mg tablets Primarily used for sleep-onset insomnia; trials, but it is expensive and not always
short- to intermediate-acting; primarily practical. Novel approaches to objective
used for sleep-onset and maintenance measurement, including actigraphy, which
insomnia; controlled-release may be used to help minimize recall bias
Zaleplon 5-mg, 10-mg capsules Primarily used for sleep-onset insomnia; and complement subjective measures of
maintenance insomnia as long as a sleep (e.g., sleep logs or diaries), still have
4-hour period is available for further drawbacks.24
sleep; short-acting “The problem with wearable devices
right now,” says Dr. Kushida, “is that they
Benzodiazepines tend to overestimate sleep, sometimes by
Estazolam 1-mg, 2-mg tablets Short- to intermediate-acting as much as an hour. They also are not yet
capable of accurately detecting different
Temazepam 7.5-mg, 15-mg, and Short- to intermediate-acting
stages of sleep, such as non-REM and REM
30-mg capsules
sleep. Because of our proximity to Silicon
Triazolam 0.125-mg, 0.25-mg Short-acting Valley, our laboratory tests a lot of these
tablets new devices, and often by the time we
Flurazepam 15-mg, 30-mg capsules Long-acting; risk of residual daytime have finished testing one prototype, new
drowsiness ones have emerged. The product cycles
are rapid, and the companies keep incor-
Melatonin Receptor Agonists (Non-Scheduled)
porating newer and newer technology.
Ramelteon 8-mg tablet Primarily used for sleep-onset insomnia; So, down the road, within about five to
short-acting; no short-term usage ten years, I think these devices will likely
restriction estimate sleep and detect sleep stages with
Orexin Receptor Antagonist precision.”
Also, objective tools are needed for
Suvorexant 5-mg, 10-mg, 15-mg, and Indicated for the treatment of insomnia addressing problems with adherence to
20-mg tablets characterized by difficulties with sleep treatment. One important current aim is to
onset and/or sleep maintenance. detect and correct for non-obvious factors
Lowest effective dose should be used. that result in failure to adhere to treat-
ment, whether unintended or deliberate,
objective and subjective evaluations of sleep loss and recovery to ensure that trial outcomes accurately reflect the efficacy of
from sleep loss, variable adherence to treatments, and, more a drug, medical device, or behavioral intervention.25 A related
recently, deceptive practices among clinical trial participants, problem is deliberate deception by trial participants. As part of
are a few examples. a National Heart, Lung, and Blood Institute (NHLBI)-supported
The placebo effect, which refers to any outcome that may study focused on detecting and correcting for adherence prob-
be attributable to the expectations of clinical trial participants lems, Dr. Kushida and colleagues began to explore the preva-
rather than to the drug or device being tested, can be especially lence of deceptive practices among clinical trial participants.26
problematic in experimental protocols that involve self-reports “We found that deception among clinical trial participants
of sleep quality. is pretty common and that there is quite a range of deceptive
“Clinical trials involving patients with disorders such as practices, “says Dr. Kushida. “They include underreported drug
insomnia or RLS that rely solely on subjective measures, or holidays, fabrication or withholding of medical histories, pill
ratings of severity based on patient report, are particularly dumping, exaggerated symptoms, and falsification of current
vulnerable to the placebo effect,” says Dr. Kushida. “It has health status. It’s important that we find a way to address these
been demonstrated that when these patients believe that deceptive practices because both the integrity of research data
they are receiving the study drug or device the likelihood of and the safety of participants are at risk.”
their experiencing a positive effect can increase significantly. Dr. Kushida adds that newer tools, such as electronic moni-
There have been efforts to develop or introduce new objective toring of pill dispensing and statistical predictive adherence
endpoints in these studies, which may help with this problem.” models, may uncover and remedy pressing problems related
Achieving the right balance of subjective and objective to adherence and deceptive practices. “It already takes about
measures of sleep is an important goal in both research and 12 years for a new drug to be approved, and about three to
clinical practice. The current gold standard for objective five years for a new device to be approved. When deceptive

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practices are discovered too late, it can lead to the invalidation 11. Dinges, DF. An overview of sleepiness and accidents. J Sleep Res
of research findings and further delays in approving much- 1995; 4(S2):4–14. doi: 10.1111/j.1365-2869.1995.tb00220.x.
12. Cirelli C, Tononi G. The sleeping brain [published online May 1,
needed treatments.” 2017]. Cerebrum 2017: cer-07-17. Available at: https://www.ncbi.
Enhancing clinical research in the field will require a coop- nlm.nih.gov/pmc/articles/PMC5501041/.
erative, international effort focused on advancing knowledge 13. Basner M, Dinges, DF. Maximizing sensitivity of the psychomo-
about sleep, circadian rhythms, and sleep disorders worldwide. tor vigilance test (PVT) to sleep loss. Sleep 2011;34(5):581–591.
Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/
During Dr. Kushida’s tenure as inaugural president of the World
PMC3079937/.
Sleep Society (WSS), he led an initiative to create international 14. Stickgold R, Walker MP. Sleep-dependent memory triage: evolv-
sleep fellowships to prepare physicians and scientists from ing generalization through selective processing [published online
various countries for future leadership roles in basic and/or January 28, 2013]. Nat Neurosci 2013;16(2):139–145. doi: 10.1038/
clinical sleep research. He also oversaw the development of nn.3303.
15. Minkel JD, Banks S, Htaik O, et al. Sleep deprivation and stressors:
an International Sleep Research Network, designed to help evidence for elevated negative affect in response to mild stressors
sleep scientists and clinicians find collaborators with similar when sleep deprived [published online February 6, 2012]. Emotion
clinical/research interests. As the WSS continues to offer new 12(5):1015-1020. doi: 10.1037/a0026871.
services and expand its programs, it will be with an awareness 16. Watson NF, Badr MS, Belenky G, et al. Recommended amount
of sleep for a healthy adult: a joint consensus statement of the
of the needs of disadvantaged populations and the importance
American Academy of Sleep Medicine and Sleep Research Society.
of access to appropriate treatment. Sleep 2015;38(6):843–844. doi: 10.5665/sleep.4716.
“One initiative of the WSS involves reviewing current pub- 17. Basner M, Dinges DF. Sleep duration in the United States 2003-
lished guidelines in various countries, to determine whether 2016: first signs of success in the fight against sleep deficiency?
they meet international standards,” says Dr. Kushida. “Many Sleep 2018;41(4). doi: 10.1093/sleep/zsy012.
18. Tkachenko O, Dinges D. Interindividual variability in neurobehav-
guidelines are region-specific and list only medications approved ioral response to sleep loss: a comprehensive review [published
in specific countries or regions. As we review the guidelines, online March 18, 2018]. Neurosci Biobehav Rev 2018;89:29–48. doi:
we endorse them with caveats; we may note that particular 10.1016/j.neubiorev.2018.03.017.
treatments for insomnia are recommended, and when these 19. Goel N. Neurobehavioral effects and biomarkers of sleep loss in
healthy adults [published online September 25, 2017]. Curr Neurol
are not available we recommend acceptable substitutes. The
Neurosci Rep 2017;17(11):89. doi: 10.1007/s11910-017-0799-x.
goal is to ensure that specialists can use practice guidelines 20. Zitting KM, Münch MY, Cain SW, et al. Young adults are more
in whichever country they practice sleep medicine, and that vulnerable to chronic sleep deficiency and recurrent circadian
patients are receiving the best possible treatment available.” disruption than older adults [published online July 23, 2018]. Sci
Rep 2018;8(1):11052. doi:10.1038/s41598-018-29358-x.
21. Sateia MJ,Buysse DJ, Krystal AD, et al. Clinical practice guideline
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Vol. 43 No. 12  •  December 2018 • P&T 763 ®