Sleeping

Introduction

In the Inaugural issue of the journal of clinical sleep medicine (2005), a

feature article1 traced early milestones in the developing field of sleep medicine,
which slowly emerged from the older fied of sleep research during the 1970s and
1980s. Sleep medicine, the article noted, was closely linked with and made possible
by the discovery of electrical activity in the brain. The examination of
electroencephalogram (eeg) patterns that occur during sleep led to the classification
of stages of sleep, which in turn created an important foundation for probing human
sleep, discerning abnormalities, and discovering significant relationships between
sleep and health. By 2005, scientists and clinicians had not only identified and
clearly defined a large number of sleep disorders but had discovered that many of
them were highly prevalent.

The pace of research and discovery has only accelerated since 2005, and the
number of peer-reviewed sleep journals has more than tripled. Today, researchers
are more deeply probing the cellular and subcellular effects of disrupted sleep, as
well as the effects of sleep deprivation on metabolism, hormone regulation, and
gene expression. Newer studies are strengthening known and suspected
relationships between inadequate sleep and a wide range of disorders, including
hypertension,2 obesity and type-2 diabetes,3 impaired immune
functioning,4 cardiovascular disease and arrhythmias,5,6 mood
disorders,7 neurodegeneration and dementia, 8,9 and even loneliness.10

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 Research findings continue to underscore early concerns about public safety
that were first raised when major industrial disasters such as the exxon valdez oil
spill were linked to inadequate sleep.11 related research sponsored by major
organizations, including the u.s. Department of transportation, the u.s. Department
of defense, the national institutes of health, and the national aeronautics and space
administration (nasa), has helped to inspire national initiatives aimed at improving
public safety and health. However, despite the astounding acceleration in research
during the past few decades, inadequate sleep due to sleep disorders, work
schedules, and chaotic lifestyles continues to threaten both health and safety.

“pushing against the wave of accelerated growth in the field has been a
shoreline of indifference,” says david f. Dinges, phd, professor and chief of the
division of sleep and chronobiology in the department of psychiatry at the
university of pennsylvania perelman school of medicine. “modern industrial
pressures to use time 24 hours a day have led to shiftwork and a world in which
virtually everything—law susan l. Worley is a freelance medical writer who resides
in pennsylvania. Enforcement, airports and all kinds of transportation, industrial
operations, and hospitals—operates 24/7. People have come to value time so much
that sleep is often regarded as an annoying interference, a wasteful state that you
enter into when you do not have enough willpower to work harder and longer.”

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 David f. Dinges, phd

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 It has become increasingly clear, however, that no matter how hectic our lives
may be, we can no longer afford to ignore what research is telling us about the
importance of sleep for our safety and mental and physical well-being.

Impact on attention, cognition, and mood

While scientists are still working to identify and clarify all of the functions of
sleep,12 decades of studies—many of which have used the method of disrupting
sleep and examining the consequences—have confirmed that sleep is necessary for
our healthy functioning and even survival.

“we know for sure that sleep serves multiple functions,” says dr. Dinges.
“nature tends to be very parsimonious in that it often uses a single system or
biology in multiple ways to optimize the functioning of an organism. We know, for
example, that sleep is critical for waking cognition—that is, for the ability to think
clearly, to be vigilant and alert, and sustain attention. We also know that memories
are consolidated during sleep, and that sleep serves a key role in emotional
regulation.”

Studies conducted by dr. Dinges and other scientists have shown that
cognitive performance and vigilant attention begin to decline fairly quickly after
more than 16 hours of continuous wakefulness, and that sleep deficits from partial
sleep deprivation can accumulate over time, resulting in a steady deterioration in
alertness. The widely used psychomotor vigilance test (pvt), a simple
neurocognitive test developed by dr. Dinges and colleagues that assesses an
individual’s ability to sustain attention and respond to signals in a timely manner,
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has proven to be an exceptionally sensitive tool for capturing dose–response effects
of sleep loss on neurobehavioral functioning. 13 the pvt also reliably detects sleep
deficits caused by disrupted or fragmented sleep, and/or poorly timed sleep, which
is important because a growing body of evidence suggests that the continuity and
timing (or circadian alignment) of sleep may be as important as the total amount of
time spent sleeping.

“we know that sleep is much more restorative of waking functions and health
when it is consolidated and not fragmented,” explains dr. Dinges. “that is, when
sleep goes through the appropriate physiological sequences of non-rem (rapid eye
movement) and rem states at night, and occurs when human sleep is temporally
programmed by our circadian clock to occur. Such consolidated sleep is typically of
a longer duration and better sleep quality than sleep taken at other times of the day,
such as that which occurs with nightshift work, jet lag, and other conditions of
circadian misalignment.”

Dr. Dinges and his colleagues have found that people whose daily sleep
duration is inadequate, or repeatedly disrupted (e.g., by obstructive sleep apnea,
restless legs syndrome, pain or stress, or shiftwork or jet lag), often are not aware of
their accumulating sleep deficits or the toll that these deficits can take on their
waking cognitive functions, including their performance, working memory,
cognitive speed, and accuracy. Inadequate sleep also can take a toll on
psychological well-being, significantly affecting our emotional and psychosocial
interpretation of events and exacerbating our stress levels. Studies have indicated
that changes in mood may be due in part to the effects of sleep deprivation on the

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processing of emotional memory—in other words, our tendency to select and
remember negative memories after inadequate sleep.14

In one study conducted by dr. Dinges and colleagues, participants’ mood was
observed after they were confronted with “high” and “low” performance demands,
following varying degrees of sleep deprivation.15

“to our surprise, those who were sleep-deprived responded to low stressors in
much the same way that people without any sleep deprivation tended to respond to
high stressors,” said dr. Dinges. “in other words, we tend to become much more
sensitive emotionally and socially when we are sleep-deprived. That is what i like
to call the ‘who was at my desk or who touched my coffee cup?’ phenomenon. I
think we all have experienced having an extreme reaction or a very negative
emotional response to a mild stressor when we have not had enough sleep.”

Aiming for the sweet spot

How much sleep is enough? After decades of investigation, it appears that
scientists have gathered enough evidence to begin to answer that question.16

“when duration of sleep drops below seven hours, and especially when it
starts to move toward six and half hours or less, a number of different disorders
begin to increase in prevalence,” says dr. Dinges. “most experts would agree that
there is a kind of sweet spot that most people should aim for, and for the average
healthy adult that zone is ideally somewhere between 7 and 7 and a half hours. That
is what the consensus evaluations of more than a thousand scientific articles have

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yielded—the consensus of evaluations conducted by the aasm (american academy
of sleep medicine) and sleep research society jointly.”

Numerous large u.s. Surveys—beginning with a 1982 survey by the american

cancer society—have been used to estimate the number of hours that most people
spend sleeping. Many surveys have identified a worrisome prevalence of “short”
sleepers (people who sleep 6 hours or less) among respondents, and a general trend
toward decreasing sleep duration between 1975 and 2006. More recently, however,
an analysis of the american time use survey (atus), spearheaded by mathias basner,
md, phd, at the university of pennsylvania17, has suggested that there may be cause
for optimism.

“the analysis shows that there is a slight but steady increase in sleep time that
stretches back to about 2003 or 2004,” says dr. Dinges. “we think this increase,
which is modest—at most a minute or two more per year—is due in part to the
development of the field of sleep medicine, and public and scientific reports in the
media about sleep loss contributing to accidents and catastrophes, and so forth. Ever
so slowly, the message that it is important not to get sleep deprived, and to get help
if you have a sleep disorder, has begun to penetrate to the public.”

The analysis notes that one sign of greater interest in sleep on the part of the
public has been a significant increase in google searches containing the word
“sleep” since 2004. Data from the atus also suggest that over time, people have
been willing to trade some of their daily activities in exchange for more sleep. It is
important to note, says dr. Dinges, that self-reports of time spent sleeping are not
always accurate—they can be off by a half an hour or more, usually with people

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tending to estimate that they slept more than they did. He also notes that there is
still a fairly large population sleeping 6 hours or less.

“although there are signs that sleep time is increasing, it is not happening at
nearly the dramatic rate that most experts would like to see,” says dr. Dinges. “this
is especially true for vulnerable populations. There is concern about school start
times and bus times affecting the sleep of children and adolescents, and about
extracurricular activities at the end of the school day sometimes leading to a delay
in bed times for teenagers. All of this is an ongoing, evolving picture, with more
research results coming out all the time, and with consequent changes in
recommendations, to make sure that at least our most vulnerable populations are
getting adequate sleep.”

Interindividual differences in vulnerability to sleep loss

While it is well established that the effects of sleep loss accumulate over time,
with repeated exposure to inadequate, fragmented, or disrupted sleep, the degree to
which individuals demonstrate adverse effects of inadequate sleep can vary
considerably.18

“we have learned that there are astonishingly mysterious phenotypes, or trait-
like differences, in how vulnerable people are to sleep loss,” says dr. Dinges. “this
is still a relatively new area of research, and it has only been in the past few years
that scientists have begun to replicate early findings regarding these phenotypic
differences in vulnerability to the negative neurobehavioral effects of sleep loss.
The interindividual differences that have been observed so far raise some extremely
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provocative scientific questions. We may find that there is something in waking
biology that can substitute for, or somehow reduce, the impact of sleep loss on
waking functioning, but thus far there is no evidence as to what that might be.”

Differences among individuals exist with regard to both the effects of sleep
loss and the ability to recover from the effects of sleep loss. Differences in
performance also have been shown to be task-dependent, suggesting that people
who are vulnerable to the effects of sleep loss in one or more cognitive or
neurobehavioral domains may be resistant to the effects of sleep loss in others. To
better understand interindividual variability, scientists are investigating possible
genetic mechanisms that may underlie complex interactions between circadian and
sleep homeostatic systems—the systems that affect our drive for sleep as well as
our alertness and performance during waking hours. A current goal is to discover
biomarkers that may help predict individual performance after varying degrees of
sleep loss.19 and one hope is that biomarkers—ideally in the form of a simple
“roadside” test such as a breathalyzer—may eventually be used to detect sleep loss-
related impairment in drivers or in individuals responsible for operating
sophisticated equipment or machinery. To date, no viable candidates have been
found.

Investigators also are shedding light on the role that age may play in resilience
to sleep loss. The results of one recent study indicate that younger adults are more
vulnerable to the adverse effects of chronic sleep loss and recurring circadian
disruption than older adults.20 although the neurobiological basis for these age-
related differences is not yet understood, such findings may help to inform new

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approaches to the prevention of drowsy driving and related motor-vehicle accidents
among young drivers.

Dr. Dinges emphasizes that findings regarding interindividual differences in

response to sleep loss and in recovery from sleep loss should not diminish the
message that adequate sleep is critical for everyone.

“research has shown us that sleep is not an optional activity,” says dr. Dinges.
“there is no question that sleep is fundamentally conserved across species and
across lifespans, and that any effort to eliminate it has been unsuccessful. We must
plan our lives in the time domain with a serious consideration for sleep—planning
when to sleep, ensuring that we get adequate sleep, and making sure that our sleep
is not disturbed by disorders or diseases, whether or not they are sleep-related.”

Addressing sleep disorders

As connections between sleep disruption and both disease and mortality have
become more firmly established, accurate and efficient diagnosis and management
of sleep disorders (see table 1) have become increasingly critical. Recent directions
in the field of sleep medicine include a move toward patient-centered care, greater
collaboration between specialists and primary care physicians, and the
incorporation of new tools—including home-based diagnostic tests and novel
electronic questionnaires—in the effort to create a comprehensive yet more
personalized approach to assessment and treatment.

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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 Obstructive sleep apnea (cessation of breathing due

breathing disorders 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 Excessive daytime sleepiness not due to other sleep

of hypersomnolence disorders. These include narcolepsy, idiopathic
hypersomnolence, and insufficient sleep syndrome.

Circadian Abnormalities of sleep–wake cycles due to

rhythm sleep–wake misalignment between the biological clock and customary
disorders or 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 Abnormal, usually stereotyped, recurring

movement disorders movements in sleep. Restless legs syndrome, although a
waking sensory disorder, is included, as well as periodic
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 limb movement in sleep and leg cramps.

Other sleep Those sleep–wake disorders not classified

disorders elsewhere, most notably environmental sleep disorder.

A chief goal is to improve the diagnosis of sleep disorders. Although

approximately 70 million people in the u.s. Have at least one sleep disorder, experts
estimate that up to 80% of sleep disorders may go undetected or undiagnosed. One
major challenge that clinicians face during the initial assessment of people with
sleep disorders is the process of identifying and sorting out comorbidities.
Untangling the causes and effects in bidirectional comorbidities can be particularly
difficult. For example, insomnia—by far the most common sleep disorder—often is
complicated by the presence of another sleep disorder, such as sleep apnea or
restless legs syndrome.

“some experts have even suggested that all cases of insomnia coexist with, or
are caused by, another sleep disorder, most commonly sleep apnea,” says clete a.
Kushida, md, phd, professor of psychiatry and behavioral sciences at stanford, and
division chief and medical director of stanford sleep medicine. “i’m not sure i
would go quite that far, but certainly bidirectional comorbidities among individuals
who experience sleep disorders are common. For example, pain syndromes—
including back pain and limb pain, especially among older patients—are common
comorbidities in patients with insomnia. Mood disorders also frequently occur in
patients who experience insomnia.”

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 Comorbidities can complicate treatment and often require sleep specialists to
collaborate with not only primary care physicians but also specialists in other
therapeutic areas.

“if, for example, a person with insomnia also has been diagnosed with
depression by a psychiatrist,” says dr. Kushida, “our goal is to work hand in hand
with the psychiatrist to find the right medication. There are both sedating and
alerting antidepressants, and a patient may need to try one medication for a couple
of weeks to months, slowly increasing the dose to a therapeutic level, until the
effect on both the depression and the patient’s sleep can be determined. For some
individuals, an alerting antidepressant can cause poor sleep, which in turn can
exacerbate the depression. The process of achieving the right dose of the right
medication can be complex, and benefits from a collaboration between specialists.”

Undetected obstructive sleep apnea (osa) in patients with chronic pain, or

other serious illnesses, can result in potentially dangerous comorbidities. Opioids,
for example, are known to have adverse effects on respiration, and can lead to
central sleep apnea (csa)—shallow and irregular or interrupted breathing and
sustained hypoventilation—a potentially lethal condition that can intensify the
consequences of osa. These risks underscore the need to improve methods for
identifying and properly diagnosing the estimated 23.5 million u.s. Adults with osa.
Public education and advocacy efforts are already helping to improve detection—in
part by helping to address misconceptions about osa.

“one of the biggest misconceptions is that only people who are significantly
overweight experience sleep apnea,” says dr. Kushida. “in fact, only up to 67% of
people who have osa are overweight, the rest are of normal weight. Osa also can be
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caused by craniofacial dysmorphism, or a defect of the airway that occurs during
development. A narrow airway caused by deficient growth of the craniofacial
skeleton, particularly the jaws, can become narrower and more prone to collapse
with age, leading to sleep apnea.”

Treating insomnia: the value of cognitive behavioral therapy

Insomnia, the most prevalent sleep disorder, affects approximately one third
of all adults and is the most common condition that family and primary-care
physicians encounter. According to the international classification of sleep
disorders (icsd-3), chronic insomnia is the inability to attain sufficient sleep (despite
adequate opportunity) for at least three nights per week for three months or longer,
with negative daytime consequences. For most people, the disorder is transient, but
for approximately 10% to 15% of those who experience insomnia (around 30
million people) it becomes chronic. Although pharmacologic treatments for
insomnia (table 2) can be effective, most experts now recommend against the long-
term use of pharmacotherapy

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 Table 2

Selected pharmaceutical treatments for insomnia21,27

Agent Dosage Indications/comments

(generic name) forms

Non-benzodiazepines

Eszopiclone 1-mg, 2- Primarily used for sleep-onset and

mg, and 3-mg maintenance insomnia; intermediate-acting;
tablets no short-term usage restriction

Zolpidem 5-mg, 10- Primarily used for sleep-onset

mg tablets insomnia; short-to intermediate-acting;
primarily used for sleep-onset and
maintenance insomnia; controlled-release

Zaleplon 5-mg, 10- Primarily used for sleep-onset

mg capsules insomnia; maintenance insomnia as long as
a 4-hour period is available for further
sleep; short-acting

Benzodiazepines

Estazolam 1-mg, 2- Short-to intermediate-acting

mg tablets

Temazepam 7.5-mg, Short-to intermediate-acting

15-mg, and 30-
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 Agent Dosage Indications/comments
(generic name) forms

mg capsules

Triazolam 0.125-mg, Short-acting

0.25-mg tablets

Flurazepam 15-mg, 30- Long-acting; risk of residual daytime

mg capsules drowsiness

Melatonin receptor agonists (non-scheduled)

Ramelteon 8-mg Primarily used for sleep-onset

tablet insomnia; short-acting; no short-term usage
restriction

“if a person has been diagnosed with chronic insomnia, the only treatment that
has been shown to have long-term benefit is cognitive behavioral therapy, “says dr.
Kushida. “medications really should be considered short-term treatments, because
patients tend to develop dependence on, or tolerance to, hypnotic drugs. In our
clinic, we commonly see that, over time, medications stop having an effect, and that
means that patients may try higher doses of a medication, or keep switching to
different medications. So, medications are a temporary solution—they just put a

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band-aid on the problem of insomnia, whereas cognitive behavioral therapy targets
one of the pathways toward success.”

Cognitive behavioral therapy (cbt), which involves techniques that work in

part by reducing cognitive and somatic arousal, is estimated to be effective in
approximately 70% to 80% of people who experience chronic insomnia. Dr.
Kushida notes that while drugs can sometimes be useful in the treatment of acute
insomnia, they become problematic after acute insomnia transitions to chronic
insomnia.

“a person might be an ok sleeper for several years, and then suddenly

experience a traumatic event, such as the loss of a job, a divorce, or the death of a
loved one, resulting in very poor sleep,” says dr. Kushida. “down the road, that
person might obtain a better job, overcome grief, or find a new relationship, but
continue to experience insomnia. We think in some cases the transition from acute
insomnia to chronic insomnia occurs because the behavioral event triggers
something in the person’s physiology that may lead to long-term changes. Once
they are in a chronic insomnia phase, we tell patients that cbt is the only truly
effective intervention.”

If a patient is already taking hypnotics, dr. Kushida says that he will gradually
wean the patient off medications while introducing cbt. He notes that often it is
necessary for sleep specialists to manage the expectations of chronic sufferers.

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 Clete a. Kushida, md, phd

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 “we sometimes have to let patients with chronic insomnia know that we may
never get them back to where they were when they had optimal sleep,” dr. Kushida
explains. “the behavioral methods we use work well, and usually we can get
patients to the point where the insomnia is having less of an impact on their quality
of life. Our inability to completely restore the patient’s ability to sleep well may
partly be explained by as yet unidentified changes in his or her neurophysiology or
neurochemistry. Some patients with chronic insomnia can begin to sleep normally
again, but for the vast majority, we aim to make insomnia less of a burden on a
patient’s daily life.”

Improving clinical research

In the field of sleep medicine, as in many other therapeutic areas, future
directions in clinical trial research will place an emphasis on patient engagement
and patient-centered outcomes.

“perhaps the most important aim these days when developing and
implementing any type of large-scale clinical research study is to incorporate the
patient’s perspective,” says dr. Kushida, who is currently analyzing the results of a
comparative effectiveness sleep study sponsored by the patient-centered outcomes
research institute (pcori).22 the study, designed and conducted by a team at
stanford, introduced a new model of patient-centered, coordinated care and tested it
against conventional outpatient treatment for sleep disorders.

“the patient’s perspective is so invaluable in guiding the success of a study

that ideally it should be incorporated right at the inception of a research question or
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idea,” says dr. Kushida. “when you are designing an especially complicated trial,
for example, it is easy to incorporate a lot of tests and measures without being
aware of the burden these can place on the participants. It’s critical to learn from
patients whether they are overwhelmed by the number of tests, or whether travel
time or the amount of time they need to take off from work may be impractical.”

Other efforts to improve clinical research include those focused on correcting

for and/or eliminating several confounding variables that tend to plague sleep
research. The surprising power of the placebo effect,23 the related disconnect
between objective and subjective evaluations of sleep loss and recovery from sleep
loss, variable adherence to treatments, and, more recently, deceptive practices
among clinical trial participants, are a few examples.

The placebo effect, which refers to any outcome that may be attributable to
the expectations of clinical trial participants rather than to the drug or device being
tested, can be especially problematic in experimental protocols that involve self-
reports of sleep quality.

“clinical trials involving patients with disorders such as insomnia or rls that
rely solely on subjective measures, or ratings of severity based on patient report, are
particularly vulnerable to the placebo effect,” says dr. Kushida. “it has been
demonstrated that when these patients believe that they are receiving the study drug
or device the likelihood of their experiencing a positive effect can increase
significantly. There have been efforts to develop or introduce new objective
endpoints in these studies, which may help with this problem.”

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 Achieving the right balance of subjective and objective measures of sleep is
an important goal in both research and clinical practice. The current gold standard
for objective assessment of sleep is polysomnography (psg), which includes
electrophysiological recordings of brain activity (eeg), muscle activity (emg), and
eye movements (eog). A valuable, non-invasive method for determining sleep
continuity and sleep architecture, psg has been an indispensable objective endpoint
in clinical trials, but it is expensive and not always practical. Novel approaches to
objective measurement, including actigraphy, which may be used to help minimize
recall bias and complement subjective measures of sleep (e.g., sleep logs or diaries),
still have drawbacks.24

“the problem with wearable devices right now,” says dr. Kushida, “is that they
tend to overestimate sleep, sometimes by as much as an hour. They also are not yet
capable of accurately detecting different stages of sleep, such as non-rem and rem
sleep. Because of our proximity to silicon valley, our laboratory tests a lot of these
new devices, and often by the time we have finished testing one prototype, new
ones have emerged. The product cycles are rapid, and the companies keep
incorporating newer and newer technology. So, down the road, within about five to
ten years, i think these devices will likely estimate sleep and detect sleep stages
with precision.”

Also, objective tools are needed for addressing problems with adherence to
treatment. One important current aim is to detect and correct for non-obvious
factors that result in failure to adhere to treatment, whether unintended or
deliberate, to ensure that trial outcomes accurately reflect the efficacy of a drug,
medical device, or behavioral intervention.25 a related problem is deliberate
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deception by trial participants. As part of a national heart, lung, and blood institute
(nhlbi)-supported study focused on detecting and correcting for adherence
problems, dr. Kushida and colleagues began to explore the prevalence of deceptive
practices among clinical trial participants.26

“we found that deception among clinical trial participants is pretty common
and that there is quite a range of deceptive practices, “says dr. Kushida. “they
include underreported drug holidays, fabrication or withholding of medical
histories, pill dumping, exaggerated symptoms, and falsification of current health
status. It’s important that we find a way to address these deceptive practices
because both the integrity of research data and the safety of participants are at risk.”

Dr. Kushida adds that newer tools, such as electronic monitoring of pill
dispensing and statistical predictive adherence models, may uncover and remedy
pressing problems related to adherence and deceptive practices. “it already takes
about 12 years for a new drug to be approved, and about three to five years for a
new device to be approved. When deceptive practices are discovered too late, it can
lead to the invalidation of research findings and further delays in approving much-
needed treatments.”

Enhancing clinical research in the field will require a cooperative,

international effort focused on advancing knowledge about sleep, circadian
rhythms, and sleep disorders worldwide. During dr. Kushida’s tenure as inaugural
president of the world sleep society (wss), he led an initiative to create international
sleep fellowships to prepare physicians and scientists from various countries for
future leadership roles in basic and/or clinical sleep research. He also oversaw the
development of an international sleep research network, designed to help sleep
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scientists and clinicians find collaborators with similar clinical/research interests.
As the wss continues to offer new services and expand its programs, it will be with
an awareness of the needs of disadvantaged populations and the importance of
access to appropriate treatment.

“one initiative of the wss involves reviewing current published guidelines in

various countries, to determine whether they meet international standards,” says dr.
Kushida. “many guidelines are region-specific and list only medications approved
in specific countries or regions. As we review the guidelines, we endorse them with
caveats; we may note that particular treatments for insomnia are recommended, and
when these are not available we recommend acceptable substitutes. The goal is to
ensure that specialists can use practice guidelines in whichever country they
practice sleep medicine, and that patients are receiving the best possible treatment
available.”

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 Contents

Introduction 1

Impact on attention, cognition, and mood 4

Aiming for the sweet spot 6

Interindividual differences in vulnerability to sleep loss 8

Addressing sleep disorders 10

Table 1 11

Treating insomnia: the value of cognitive behavioral therapy 13

Table 2 14

Improving clinical research 18

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