The majority of the 50-70 million Americans with one or more of 81 discrete
disorders of sleep remain undiagnosed and untreated, according to a report
from the Institute of Medicine (IOM), an arm of the National Academies in
The United States has too few clinicians knowledgeable about sleep
disorders and too few scientists engaged in basic sleep research, the IOM's
Committee on Sleep Medicine and Research concluded after a two-year
Sleep disorders raise an individual's risk of depression, hypertension,
diabetes, obesity, heart attack, and stroke, according to the committee's
500-page report, "Sleep Disorders and Sleep Deprivation: An Unmet Public
Health Problem," released in April.
Sleep loss impairs school and work performance and has contributed to major
industrial catastrophes such as the 1986 explosion of the space shuttle
Challenger. About 20 percent of serious car-crash injuries are attributed to
driver sleepiness, independent of alcohol effects.
In the past 25 years, American adults have decreased their average nightly
sleep by one to two hours, according to the IOM report. Nearly 1 in 3 adults
aged 30 to 64 reports averaging six hours or less sleep a night.
The report identifies gaps in sleep research, treatment, and education of
both health professionals and the public. It also offers a blueprint for
"Above all, the IOM report emphasizes the importance and advantages
of considering sleep and sleep disorders from a multidisciplinary
perspective," IOM study panel member Charles Reynolds III, M.D., told
Psychiatric News. Reynolds is a professor of geriatric psychiatry and
the senior associate dean at the University of Pittsburgh School of
"Patients with sleep disorders need to be assessed and treated by
experts from many domains," said Reynolds. "Like chronic pain, a
sleep problem often is multiply determined. The understanding and management
of a given patient need a team approach."
The IOM report urges the National Institutes of Health (NIH) to develop a
nationwide network to foster basic and clinical sleep research by creating
about eight to 10 centers of excellence. It envisions these centers would
function much like existing comprehensive cancer centers, acting at local,
regional, and national levels to benefit scientists and the community at
"The report places an emphasis on such centers, rather than on
traditional departments," Reynolds explained, "because the needs
of the field and those whom it seeks to serve demand that we move beyond
traditional departmental `silos' to embrace a new type of infrastructure that
encourages and rewards transdisciplinary research and practice."
The sleep field "desperately needs" input from psychiatrists
and other mental health specialists, said Lawrence Epstein, M.D., president of
the American Academy of Sleep Medicine and regional medical director for Sleep
HealthCenters in Boston.
Sleep disturbances figure prominently in many psychiatric disorders,
Epstein noted. An estimated 30 million Americans, about 10 percent of adults,
have chronic insomnia, the most commonly reported sleep problem. About 40
percent of these individuals have a psychiatric disorder, most often
depression or anxiety.
In people with obstructive sleep apnea, breathing stops dozens, even
hundreds, of times a night, causing daytime sleepiness, difficulty
concentrating, irritability, and dulled interest in usual activities,
mimicking depression and even dementia. About half of people with chronic
schizophrenia have this disorder. The restless legs syndrome—a nearly
irresistible urge to move the legs or walk around—may produce agitated
behavior suggestive of attention-deficit/hyperactivity disorder.
Circadian-rhythm sleep disorders cause people to go to sleep or awaken at
times much earlier or later than family and peers. These disorders interfere
with traditional school and work schedules, disrupt social and family life,
and depress mood. People with insomnia, narcolepsy, and other sleep disorders
sometimes self-medicate with alcohol, stimulants, and other drugs of abuse,
trying to foster sleep or wakefulness.
Sleep-deprived adolescents have more emotional and behavioral problems than
peers who are better rested, the IOM committee reported (see
Mistaking a sleep disorder for a psychiatric disorder may delay appropriate
treatment, according to the IOM report. One study of 77 patients diagnosed
with narcolepsy at a sleep center found that only 11 percent of psychiatrists
who had seen the patients in the previous year had recognized the problem. By
comparison, neurologists had identified the narcolepsy in 55 percent of their
patients, internists in about 23 percent, and general practitioners in 22
People with narcolepsy were much more likely to be diagnosed with mental
disorders than were people without narcolepsy, according to Meir Kryger, M.D.,
a professor of medicine at the University of Manitoba, who directed this
study. He and colleagues reported their findings in Sleep in February
"Psychiatrists—indeed all physicians— should ask every
patient about sleep," asserted Kryger, the chief editor of
Principles and Practice of Sleep Medicine, the sleep field's primary
He suggests asking patients a few key questions: "Do you snore? Has
anyone told you that you stopped breathing? Do you fall asleep at the wrong
time or wrong place? What was your sleep like last night?"
The IOM committee included experts in pulmonology, cardiology, nursing,
neurology, pediatrics, adolescent medicine, psychiatry, epidemiology, public
health, otolaryngology, academic and medical administration, and health
sciences research. In conducting its two-year review, the committee met five
times and held two workshops. It also studied scientific literature and other
materials supplied by federal, private, and nonprofit organizations.
The committee's work, which cost $810,000, was underwritten by the
American Academy of Sleep Medicine, NIH, National Sleep Foundation, and Sleep
The NIH sleep disorders research advisory board is scheduled to
discuss the IOM report's recommendations at its next meeting, June 14, to be
Webcast live at<www.videocast.nih.gov>.▪