Tools
Sleep Insufficiency
Introduction
Insufficient sleep is defined as a shorter duration of sleep than required to maintain daytime wakefulness. The American Academy of Sleep Medicine (AASM) and the Sleep Research Society consensus recommends a minimum of 9 hours for children 6 to 12 years of age, 8 hours for adolescents, and at least 7 hours for adults.[1]
A sleep duration shorter than recommended for age is classified as insufficient sleep duration.[2][1] This article will discuss the etiology, epidemiology, clinical manifestation, evaluation, and prognosis/complications for sleep insufficiency.
Etiology
Register For Free And Read The Full Article
Search engine and full access to all medical articles- 10 free questions in your specialty
- Free CME/CE Activities
- Free daily question in your email
- Save favorite articles to your dashboard
- Emails offering discounts
Learn more about a Subscription to StatPearls Point-of-Care
Etiology
Insufficient sleep is due to an inadequate opportunity for sleep manifested by a reduced time in bed (number of hours) and/or poor sleep quality (depth of sleep or having sufficient restorative deep stages of sleep). Reduced sleep subsequently affects daytime wakefulness, performance, quality of life, accidents, hypertension, and cardiovascular morbidities.[3][4]
The current ICSD-3 definition of insufficient sleep syndrome requires the sleep pattern to be present for at least three months.[5]
Epidemiology
Insufficient sleep is a prevalent condition, with up to a third of the U.S. adult population reporting less than 7 hours of sleep per night.[2] According to the National Health and Nutrition Examination Survey (NHANES) conducted between 2005 and 2008, one-third of adults reported sleeping less than 7 hours per night regularly.
Short sleep duration of fewer than 7 hours was reported to affect 37% of adults aged between 20 to 39 years, 40.3% of adults aged between 40 to 59 years, and 32% of adults 60 years or older in this survey. Differences among races were also noted, with 53% of non-Hispanic blacks, 34.5% of non-Hispanic whites, 35.2% of Mexican Americans, and 41.7% of other ethnicities reporting regular short sleep durations. There were no significant differences in prevalence between men (39.8%) and women (35.8%).[6]
Other studies have reported similar findings of more than one-third of the surveyed population reporting a typical sleep duration of fewer than 7 hours.[7] A Centers for Disease Control and Prevention (CDC) study showed that between 1985 and 2012, the percentage of adults sleeping six or fewer hours a night increased by 31%.[8]
The National Health Interview Survey assessed different occupational groups for the prevalence of short sleep duration, defined as a self-reported sleep duration of 6 or fewer hours a day. According to the survey, in the transportation/warehouse industry category, production, installation, maintenance, and repair jobs had the highest prevalence of short sleep duration. In contrast, the manufacturing category's installation, maintenance, and repair jobs showed the highest prevalence of short sleep duration.[9]
Pathophysiology
Two physiological processes regulate the sleep-wake cycle. A homeostatic process, also called process S, builds a homeostatic pressure to sleep with the amount of time spent awake and diminishes that pressure with the amount of time spent in sleep. The second process is a biological circadian rhythm, also known as process C, and involves the suprachiasmatic nuclei in the hypothalamus. Process C responds to temporal cues such as sunlight, also known as zeitgebers, which synchronize the internal circadian rhythm with external time.[10][11][12] A restriction in sleep results in a sleep debt manifested as daytime sleepiness.
Studies on sleep deprivation demonstrate an impact on neurocognition, such as mood, executive function, and cognitive performance. Experiments on chronic partial sleep deprivation, in particular, show that these neurocognitive impairments accumulate over time. Similar neurocognitive deficits occur when sleep deprivation is associated with sleep fragmentation due to an underlying condition.[13] Sleep deprivation has been shown to disrupt hippocampal function, particularly memory consolidation.[14]
While not completely understood, evidence also suggests that sleep deprivation is linked with changes to the epigenome. These alterations involve DNA methylation, histone protein modification, and non-coding RNA.[15] Sleep loss has also increased immune system biomarkers such as interleukin 6 and interleukin 1 receptor antagonists, suggesting a link between sleep and immunity.[16][17]
History and Physical
Patients with insufficient sleep usually complain of sleep deprivation and excessive daytime sleepiness or fatigue, which may affect their daytime functioning. Other symptoms, such as sleep paralysis and hypnogogic hallucinations, may be noted.[18]
Patients may also report neuropsychological symptoms such as mood changes, irritability, difficulty concentrating, and decreased motivation. A thorough history usually reveals that these patients have a reduced time in bed due to reduced sleep opportunities. In contrast to insomnia, in sleep insufficiency, there is no difficulty in the ability to initiate and maintain sleep naturally. An alarm or a bed partner can disrupt sleep, and in the absence of these disruptions, patients can usually sleep for adequate hours with improvement in daytime symptoms.
Patients may or may not be aware of the discrepancy between the hours of sleep needed and the hours achieved. A good history is essential to formulate an initial provisional diagnosis and to help differentiate it from other causes of disrupted sleep and excessive daytime sleepiness.
Physical examination in patients with insufficient sleep is generally unremarkable and is not explanatory of the patient's presenting complaints. A thorough clinical analysis, nevertheless, must be performed for signs of other sleep disorders.
Evaluation
The International Classification of Sleep Disorders or ICSD-3 criteria requires that several criteria be met to establish a diagnosis of insufficient sleep syndrome.[5] These include:
- The patient has irrepressible daytime lapses into sleep daily; in prepubertal children, a complaint of behavioral abnormalities due to sleepiness.
- The patient's total sleep time can be provided through clinical history, sleep diaries, or objective methods such as actigraphy and is usually shorter than expected for age.
- Sleep pattern is present on most days for a minimum of three months.
- The patients have decreased total sleep time due to external factors such as an alarm clock or curtailment of sleep by another person and, in the absence of such measures, are generally able to sleep longer.
- Extending the total sleep time causes the resolution of the symptoms.
- The symptoms should not be better explained by other untreated sleep disorders, medication or drug effects, or other underlying physical or mental disorders.
The AASM guidelines suggest using actigraphy to evaluate total sleep time in adults suspected of insufficient sleep syndrome. Compared to patient-reported sleep logs, actigraphy provides objective data that may be valuable in assessing poor sleep.[19]
Treatment / Management
Managing insufficient sleep requires extending total sleep time to the amount needed for age. The underlying etiology involves an inadequate opportunity to sleep; hence increasing total sleep time requires lifestyle changes and cognitive and behavioral interventions to allow an adequate opportunity to sleep. These interventions help promote sleep quality and duration in patients reporting poor sleep without a diagnosed sleep disorder.[20] Exercise, relaxation training, stimulus control, and sleep hygiene are the individual components of behavioral interventions. (A1)
Sleep hygiene education involves avoiding caffeine, nicotine, or alcohol close to bedtime, regular bedtimes, and waketimes, and avoiding daytime naps.[21] Irregular sleep timing is associated with daytime sleepiness, and regular sleep timing increases the synchrony between the underlying homeostatic mechanisms regulating sleep and subsequently increases sleep health. Daytime naps can disrupt the homeostatic sleep drive, and naps longer than 30 minutes are not recommended.[22] Caffeine is a stimulant that blocks adenosine receptors in the basal forebrain and hypothalamus and can disrupt sleep if taken up to 6 hours before bedtime.[23][24] (A1)
Similarly, nicotine stimulates cholinergic neurons in the basal forebrain promoting wakefulness and is associated with sleep disruption and a reduced total sleep time.[23][25] Alcohol use before bedtime results in an increased stage N1 and REM rebound sleep along with frequent arousals and has been consistently shown to disrupt consolidated sleep. Its use before bedtime is discouraged in sleep hygiene education.[22](B3)
Regular exercise is recommended as a part of sleep hygiene education and has increased total sleep time and slow-wave sleep.[26] Relaxation and mindfulness exercises are recommended and have improved sleep quality.[27] These components of sleep hygiene principles may help enhance the quality of sleep in individuals with insufficient sleep syndrome.(A1)
Differential Diagnosis
Establishing a diagnosis of insufficient sleep syndrome requires ruling out other disorders which can result in curtailed sleep and/or symptoms of daytime sleepiness. The differentials include:
- Sleep-related breathing disorders such as obstructive sleep apnea, central sleep apnea syndromes, and sleep-related hypoventilation disorders
- Central disorders of hypersomnolence such as narcolepsy, idiopathic hypersomnia, or hypersomnia due to a medical condition, medication or substance use, or psychiatric disorder
- Chronic insomnia disorder
- Circadian rhythm sleep disorders
- Affective disorder
- Periodic limb movement disorder
Insufficient sleep can also result in abnormal mean sleep latency test (MSLT) findings of short sleep latency and two or more sleep-onset REM periods (SOREMPS). Hence, a thorough clinical assessment, sleep diaries, and polysomnography are vital in establishing an accurate diagnosis.[28]
Prognosis
Chronic sleep deprivation has been associated with comorbidities, including elevated blood pressure, heart disease, and stroke.[29] Insufficient sleep can disrupt metabolism, is associated with altered expression of genes and hormones involved in metabolism, and can predispose to obesity.[30] Sleep restriction at a young age is associated with impulsive behavior, depression symptoms, and poor academic performance.[31]
Daytime sleepiness resulting from insufficient sleep can increase the risk of motor vehicle accidents.[32] Although sleep loss has been associated with harmful physical and psychological complications, it is a modifiable risk factor and is reversible.
One study evaluated the effects of three nights of recovery sleep after six nights of sleep restriction and found that inflammatory biomarkers such as IL-6 levels, cortisol levels, subjective and objective sleepiness, and fatigue levels returned to baseline after sleep recovery. However, daytime performance measures by psychomotor vigilance testing declined significantly after sleep restriction and were not shown to improve after sleep recovery.[33]
Long-term studies assessing the effects of sleep extension on variables such as cardiovascular disease and obesity will provide further insight into the outcomes of untreated sleep deprivation.
Complications
Inadequate sleep can have physical and psychological effects that may impact daytime functioning and contribute to comorbidities. The Sleep Heart Health Study reported that insomnia or poor sleep, as evidenced by less than 6 hours of sleep on polysomnography, is associated with an increased risk of cardiovascular disease. Short sleep duration has been associated with a 29 percent higher cardiovascular disease.[34]
A meta-analysis showed that short and long sleep duration is associated with an increased risk of all-cause mortality, cardiovascular disease, coronary heart disease, and stroke, with the lowest risk noted at around 7 hours of sleep. A 1-hour reduction in sleep compared to 7 hours per day was associated with a 6% increase in all-cause mortality.[35]
Fragmented sleep, measured by an increased arousal index, sleep efficiency, and wake after sleep onset (WASO), has been associated with obesity risk.[36] Sleep restriction has been associated with reduced glucose tolerance, increased cortisol levels, increased ghrelin levels, decreased leptin levels, and increased appetite.[37] Evidence points to an association between the duration and architecture of sleep in children and adolescents with type II diabetes mellitus markers.[38]
Increased food intake is an adaptive mechanism to maintain the energy needs for additional wakefulness, and sleep recovery can result in a reduced energy intake [39]; these mechanisms may provide a further understanding of the link between insufficient sleep and metabolism.
Insufficient sleep is associated with poor academic performance.[31] Sleep restriction may also increase impulsive behavior and is related to affective disorders such as depression.[40][41][42] School-aged children with insufficient sleep were observed to have poorer neurobehavioral function, specifically executive and social-emotional function.[43]
Chronic insufficient sleep may also impair neurobehavioral reaction time and increases attention lapses.[44] Sleep restriction can also result in microsleep periods, with evidence of an increase in cumulative microsleep periods with sleep restriction to 4 hours per night for one week.[45] There is emerging evidence that some higher-level cognitive functions remain affected despite an improvement in alertness with countermeasures, which suggests that sleep deprivation may impact specific cognitive systems in addition to a global decline in cognition.[46]
Sleep deprivation may result in a higher risk of impulsive behavior and may subsequently increase the risk of unplanned suicide.[47] Improving sleep has shown a significant effect on mental health, depression, and anxiety symptoms, with a dose-response relationship between sleep quality and mental health improvement.[48]
As evidenced by night shift workers, drowsiness resulting from insufficient sleep is a risk factor for motor vehicle accidents.[32] Sleepiness resulting from inadequate sleep contributes to many road traffic accidents.[49] A study showed that when compared with 7 hours of sleep per night, very short sleepers with five or fewer hours of sleep per night were 3.6 to 3.8 times more likely to report drowsy driving and short sleepers with six or fewer hours of sleep were 1.9-2.0 times more likely to report drowsy driving.[50]
Daylight saving time utilizes turning clocks forward by one hour in spring and backward by one hour in autumn. More than 1.5 billion people undergo the transitions involved twice each year, reducing sleep duration by 60.14 minutes and a 10% reduced sleep efficiency.[51][52]
A meta-analysis of 6 studies showed a 4 to 29% higher incidence of acute myocardial infarction in the spring daylight saving shift.[53] An increase in ischemic heart disease in males and females older than 60 years, as well as in road traffic accidents, has been reported in association with daylight saving time.[54][55] The American Academy of Sleep Medicine (AASM) published a position statement in 2020 supporting a year-round standard time based on current evidence.[56]
Medical trainees are exposed to extended duration work hours. A systemic review by Levine et al. showed evidence that eliminating shift hours exceeding 16 hours improved patient safety and the residents' quality of life.[57] Interns performing extended overnight shifts are shown to have moderate chronic sleep restriction and significantly reduced alertness levels after on-call night shifts.[58]
Studies have also shown an association between reduced speed and accuracy with simulated laparoscopic surgery performance and taking night calls.[59] These studies suggest that acute and chronic sleep deprivation due to extended work hours can impact daytime alertness. When comparing a 16-hour work limit to flexible duty hours with extended work hours, no significant difference was found in the mortality of medical patients.[60]
More recent studies also confirm that resident physicians performing extended shifts of 24 to 28 hours slept significantly less compared with a rapid cycling work roster where continuous shift hours were limited to 16 hours. When adjusted for workload, the residents on rapid cycling work rosters had significantly lower rates of attentional failures and reduced risk of serious medical errors compared to extended duration work rosters.[61]
Deterrence and Patient Education
Patients should be counseled on the behavioral and lifestyle factors likely resulting in insufficient sleep. The fundamental physiological processes involved in sleep, including circadian rhythm and the homeostatic build-up of sleep pressure, should be explained to patients during the clinic visit. This information can provide patients insight into the need for adequate quality and duration of sleep. Educational handouts about good sleep habits may be provided in the clinic or electronically. These educational measures may help patients prevent and treat insufficient sleep syndrome.
Insufficient sleep is common in school-aged children, and counseling at an early age may assist the patients and their families in establishing good sleep habits.
Enhancing Healthcare Team Outcomes
The diagnosis and management of insufficient sleep benefits from a multidisciplinary approach. Primary care clinicians may play an essential role in screening patients with insufficient sleep and providing these patients with adequate resources to follow sleep hygiene principles.
Since insufficient sleep may present symptoms such as fatigue and mood changes, psychiatrists and neurologists are integral to the multidisciplinary approach. They may help in screening and triaging these patients when indicated. Sleep medicine clinicians are pivotal in ensuring other underlying conditions are appropriately ruled out. Psychologists with expertise in behavioral sleep can educate these patients on the importance of adequate sleep and hygiene principles.
AN interprofessional healthcare team can also enhance the management of sleep insufficiency. Nursing can provide patient counsel, assist in performing exams, take an accurate patient history, and coordinate activities between various clinical participants. Pharmacists can provide valuable counsel if pharmaceutical agents may be affecting the patient's condition. All members of the interprofessional/multidisciplinary team must document their patient interventions and interactions in the patient's medical record so that all team members operate from the same accurate, up-to-date information base.
References
Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C, Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E. Recommended Amount of Sleep for a Healthy Adult: A Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society. Sleep. 2015 Jun 1:38(6):843-4. doi: 10.5665/sleep.4716. Epub 2015 Jun 1 [PubMed PMID: 26039963]
Level 3 (low-level) evidenceParuthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2016 Jun 15:12(6):785-6. doi: 10.5664/jcsm.5866. Epub 2016 Jun 15 [PubMed PMID: 27250809]
Level 3 (low-level) evidenceKim CW, Chang Y, Kang JG, Ryu S. Changes in sleep duration and subsequent risk of hypertension in healthy adults. Sleep. 2018 Nov 1:41(11):. doi: 10.1093/sleep/zsy159. Epub [PubMed PMID: 30137630]
Ai S, Zhang J, Zhao G, Wang N, Li G, So HC, Liu Y, Chau SW, Chen J, Tan X, Jia F, Tang X, Shi J, Lu L, Wing YK. Causal associations of short and long sleep durations with 12 cardiovascular diseases: linear and nonlinear Mendelian randomization analyses in UK Biobank. European heart journal. 2021 Sep 7:42(34):3349-3357. doi: 10.1093/eurheartj/ehab170. Epub [PubMed PMID: 33822910]
Sateia MJ. International classification of sleep disorders-third edition: highlights and modifications. Chest. 2014 Nov:146(5):1387-1394. doi: 10.1378/chest.14-0970. Epub [PubMed PMID: 25367475]
Centers for Disease Control and Prevention (CDC). Effect of short sleep duration on daily activities--United States, 2005-2008. MMWR. Morbidity and mortality weekly report. 2011 Mar 4:60(8):239-42 [PubMed PMID: 21368739]
Liu Y, Wheaton AG, Chapman DP, Cunningham TJ, Lu H, Croft JB. Prevalence of Healthy Sleep Duration among Adults--United States, 2014. MMWR. Morbidity and mortality weekly report. 2016 Feb 19:65(6):137-41. doi: 10.15585/mmwr.mm6506a1. Epub 2016 Feb 19 [PubMed PMID: 26890214]
Ford ES, Cunningham TJ, Croft JB. Trends in Self-Reported Sleep Duration among US Adults from 1985 to 2012. Sleep. 2015 May 1:38(5):829-32. doi: 10.5665/sleep.4684. Epub 2015 May 1 [PubMed PMID: 25669182]
Level 2 (mid-level) evidenceLuckhaupt SE, Tak S, Calvert GM. The prevalence of short sleep duration by industry and occupation in the National Health Interview Survey. Sleep. 2010 Feb:33(2):149-59 [PubMed PMID: 20175398]
Level 2 (mid-level) evidenceHudson AN, Van Dongen HPA, Honn KA. Sleep deprivation, vigilant attention, and brain function: a review. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. 2020 Jan:45(1):21-30. doi: 10.1038/s41386-019-0432-6. Epub 2019 Jun 8 [PubMed PMID: 31176308]
Jagannath A, Taylor L, Wakaf Z, Vasudevan SR, Foster RG. The genetics of circadian rhythms, sleep and health. Human molecular genetics. 2017 Oct 1:26(R2):R128-R138. doi: 10.1093/hmg/ddx240. Epub [PubMed PMID: 28977444]
Heyde I, Oster H. Differentiating external zeitgeber impact on peripheral circadian clock resetting. Scientific reports. 2019 Dec 27:9(1):20114. doi: 10.1038/s41598-019-56323-z. Epub 2019 Dec 27 [PubMed PMID: 31882641]
Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Seminars in neurology. 2005 Mar:25(1):117-29 [PubMed PMID: 15798944]
Prince TM, Wimmer M, Choi J, Havekes R, Aton S, Abel T. Sleep deprivation during a specific 3-hour time window post-training impairs hippocampal synaptic plasticity and memory. Neurobiology of learning and memory. 2014 Mar:109():122-30. doi: 10.1016/j.nlm.2013.11.021. Epub 2013 Dec 28 [PubMed PMID: 24380868]
Level 3 (low-level) evidenceGaine ME, Chatterjee S, Abel T. Sleep Deprivation and the Epigenome. Frontiers in neural circuits. 2018:12():14. doi: 10.3389/fncir.2018.00014. Epub 2018 Feb 27 [PubMed PMID: 29535611]
Shearer WT, Reuben JM, Mullington JM, Price NJ, Lee BN, Smith EO, Szuba MP, Van Dongen HP, Dinges DF. Soluble TNF-alpha receptor 1 and IL-6 plasma levels in humans subjected to the sleep deprivation model of spaceflight. The Journal of allergy and clinical immunology. 2001 Jan:107(1):165-70 [PubMed PMID: 11150007]
Level 1 (high-level) evidenceDinges DF, Douglas SD, Hamarman S, Zaugg L, Kapoor S. Sleep deprivation and human immune function. Advances in neuroimmunology. 1995:5(2):97-110 [PubMed PMID: 7496616]
Level 3 (low-level) evidenceStefani A, Högl B. Nightmare Disorder and Isolated Sleep Paralysis. Neurotherapeutics : the journal of the American Society for Experimental NeuroTherapeutics. 2021 Jan:18(1):100-106. doi: 10.1007/s13311-020-00966-8. Epub 2020 Nov 23 [PubMed PMID: 33230689]
Smith MT, McCrae CS, Cheung J, Martin JL, Harrod CG, Heald JL, Carden KA. Use of Actigraphy for the Evaluation of Sleep Disorders and Circadian Rhythm Sleep-Wake Disorders: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2018 Jul 15:14(7):1231-1237. doi: 10.5664/jcsm.7230. Epub 2018 Jul 15 [PubMed PMID: 29991437]
Level 1 (high-level) evidenceMurawski B, Wade L, Plotnikoff RC, Lubans DR, Duncan MJ. A systematic review and meta-analysis of cognitive and behavioral interventions to improve sleep health in adults without sleep disorders. Sleep medicine reviews. 2018 Aug:40():160-169. doi: 10.1016/j.smrv.2017.12.003. Epub 2017 Dec 29 [PubMed PMID: 29397329]
Level 1 (high-level) evidenceBilliard M, Alperovitch A, Perot C, Jammes A. Excessive daytime somnolence in young men: prevalence and contributing factors. Sleep. 1987 Aug:10(4):297-305 [PubMed PMID: 3659728]
Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews. 2015 Aug:22():23-36. doi: 10.1016/j.smrv.2014.10.001. Epub 2014 Oct 16 [PubMed PMID: 25454674]
Boutrel B, Koob GF. What keeps us awake: the neuropharmacology of stimulants and wakefulness-promoting medications. Sleep. 2004 Sep 15:27(6):1181-94 [PubMed PMID: 15532213]
Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2013 Nov 15:9(11):1195-200. doi: 10.5664/jcsm.3170. Epub 2013 Nov 15 [PubMed PMID: 24235903]
Level 1 (high-level) evidenceJaehne A, Loessl B, Bárkai Z, Riemann D, Hornyak M. Effects of nicotine on sleep during consumption, withdrawal and replacement therapy. Sleep medicine reviews. 2009 Oct:13(5):363-77. doi: 10.1016/j.smrv.2008.12.003. Epub 2009 Apr 2 [PubMed PMID: 19345124]
Level 3 (low-level) evidenceKubitz KA, Landers DM, Petruzzello SJ, Han M. The effects of acute and chronic exercise on sleep. A meta-analytic review. Sports medicine (Auckland, N.Z.). 1996 Apr:21(4):277-91 [PubMed PMID: 8726346]
Level 1 (high-level) evidenceCaldwell K, Emery L, Harrison M, Greeson J. Changes in mindfulness, well-being, and sleep quality in college students through taijiquan courses: a cohort control study. Journal of alternative and complementary medicine (New York, N.Y.). 2011 Oct:17(10):931-8. doi: 10.1089/acm.2010.0645. Epub 2011 Oct 14 [PubMed PMID: 21999153]
Level 2 (mid-level) evidenceMarti I, Valko PO, Khatami R, Bassetti CL, Baumann CR. Multiple sleep latency measures in narcolepsy and behaviourally induced insufficient sleep syndrome. Sleep medicine. 2009 Dec:10(10):1146-50. doi: 10.1016/j.sleep.2009.03.008. Epub 2009 May 21 [PubMed PMID: 19464232]
Level 2 (mid-level) evidenceJavaheri S, Zhao YY, Punjabi NM, Quan SF, Gottlieb DJ, Redline S. Slow-Wave Sleep Is Associated With Incident Hypertension: The Sleep Heart Health Study. Sleep. 2018 Jan 1:41(1):. doi: 10.1093/sleep/zsx179. Epub [PubMed PMID: 29087522]
Skuladottir GV, Nilsson EK, Mwinyi J, Schiöth HB. One-night sleep deprivation induces changes in the DNA methylation and serum activity indices of stearoyl-CoA desaturase in young healthy men. Lipids in health and disease. 2016 Aug 26:15(1):137. doi: 10.1186/s12944-016-0309-1. Epub 2016 Aug 26 [PubMed PMID: 27562731]
Lee YJ, Park J, Kim S, Cho SJ, Kim SJ. Academic performance among adolescents with behaviorally induced insufficient sleep syndrome. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2015 Jan 15:11(1):61-8. doi: 10.5664/jcsm.4368. Epub 2015 Jan 15 [PubMed PMID: 25515277]
Lee ML, Howard ME, Horrey WJ, Liang Y, Anderson C, Shreeve MS, O'Brien CS, Czeisler CA. High risk of near-crash driving events following night-shift work. Proceedings of the National Academy of Sciences of the United States of America. 2016 Jan 5:113(1):176-81. doi: 10.1073/pnas.1510383112. Epub 2015 Dec 22 [PubMed PMID: 26699470]
Pejovic S, Basta M, Vgontzas AN, Kritikou I, Shaffer ML, Tsaoussoglou M, Stiffler D, Stefanakis Z, Bixler EO, Chrousos GP. Effects of recovery sleep after one work week of mild sleep restriction on interleukin-6 and cortisol secretion and daytime sleepiness and performance. American journal of physiology. Endocrinology and metabolism. 2013 Oct 1:305(7):E890-6. doi: 10.1152/ajpendo.00301.2013. Epub 2013 Aug 13 [PubMed PMID: 23941878]
Bertisch SM, Pollock BD, Mittleman MA, Buysse DJ, Bazzano LA, Gottlieb DJ, Redline S. Insomnia with objective short sleep duration and risk of incident cardiovascular disease and all-cause mortality: Sleep Heart Health Study. Sleep. 2018 Jun 1:41(6):. doi: 10.1093/sleep/zsy047. Epub [PubMed PMID: 29522193]
Yin J, Jin X, Shan Z, Li S, Huang H, Li P, Peng X, Peng Z, Yu K, Bao W, Yang W, Chen X, Liu L. Relationship of Sleep Duration With All-Cause Mortality and Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies. Journal of the American Heart Association. 2017 Sep 9:6(9):. doi: 10.1161/JAHA.117.005947. Epub 2017 Sep 9 [PubMed PMID: 28889101]
Level 1 (high-level) evidenceZhao B, Sun S, He X, Yang J, Ma X, Yan B. Sleep fragmentation and the risk of obesity: The Sleep Heart Health Study. Obesity (Silver Spring, Md.). 2021 Aug:29(8):1387-1393. doi: 10.1002/oby.23193. Epub 2021 Jul 1 [PubMed PMID: 34196121]
Leproult R, Van Cauter E. Role of sleep and sleep loss in hormonal release and metabolism. Endocrine development. 2010:17():11-21. doi: 10.1159/000262524. Epub 2009 Nov 24 [PubMed PMID: 19955752]
Level 3 (low-level) evidenceDutil C, Chaput JP. Inadequate sleep as a contributor to type 2 diabetes in children and adolescents. Nutrition & diabetes. 2017 May 8:7(5):e266. doi: 10.1038/nutd.2017.19. Epub 2017 May 8 [PubMed PMID: 28481337]
Markwald RR, Melanson EL, Smith MR, Higgins J, Perreault L, Eckel RH, Wright KP Jr. Impact of insufficient sleep on total daily energy expenditure, food intake, and weight gain. Proceedings of the National Academy of Sciences of the United States of America. 2013 Apr 2:110(14):5695-700. doi: 10.1073/pnas.1216951110. Epub 2013 Mar 11 [PubMed PMID: 23479616]
Maric A, Montvai E, Werth E, Storz M, Leemann J, Weissengruber S, Ruff CC, Huber R, Poryazova R, Baumann CR. Insufficient sleep: Enhanced risk-seeking relates to low local sleep intensity. Annals of neurology. 2017 Sep:82(3):409-418. doi: 10.1002/ana.25023. Epub [PubMed PMID: 28833531]
Lee YJ, Cho SJ, Cho IH, Kim SJ. Insufficient sleep and suicidality in adolescents. Sleep. 2012 Apr 1:35(4):455-60. doi: 10.5665/sleep.1722. Epub 2012 Apr 1 [PubMed PMID: 22467982]
Level 2 (mid-level) evidenceKamphuis J, Meerlo P, Koolhaas JM, Lancel M. Poor sleep as a potential causal factor in aggression and violence. Sleep medicine. 2012 Apr:13(4):327-34. doi: 10.1016/j.sleep.2011.12.006. Epub 2012 Feb 1 [PubMed PMID: 22305407]
Taveras EM, Rifas-Shiman SL, Bub KL, Gillman MW, Oken E. Prospective Study of Insufficient Sleep and Neurobehavioral Functioning Among School-Age Children. Academic pediatrics. 2017 Aug:17(6):625-632. doi: 10.1016/j.acap.2017.02.001. Epub 2017 Feb 9 [PubMed PMID: 28189692]
McHill AW, Hull JT, Wang W, Czeisler CA, Klerman EB. Chronic sleep curtailment, even without extended (}16-h) wakefulness, degrades human vigilance performance. Proceedings of the National Academy of Sciences of the United States of America. 2018 Jun 5:115(23):6070-6075. doi: 10.1073/pnas.1706694115. Epub 2018 May 21 [PubMed PMID: 29784810]
Bougard C, Gomez-Merino D, Rabat A, Arnal P, Van Beers P, Guillard M, Léger D, Sauvet F, Chennaoui M. Daytime microsleeps during 7 days of sleep restriction followed by 13 days of sleep recovery in healthy young adults. Consciousness and cognition. 2018 May:61():1-12. doi: 10.1016/j.concog.2018.03.008. Epub 2018 Apr 6 [PubMed PMID: 29631192]
Killgore WD. Effects of sleep deprivation on cognition. Progress in brain research. 2010:185():105-29. doi: 10.1016/B978-0-444-53702-7.00007-5. Epub [PubMed PMID: 21075236]
Gottlieb JF, Goel N, Chen S, Young MA. Meta-analysis of sleep deprivation in the acute treatment of bipolar depression. Acta psychiatrica Scandinavica. 2021 Apr:143(4):319-327. doi: 10.1111/acps.13255. Epub 2020 Dec 26 [PubMed PMID: 33190220]
Level 1 (high-level) evidenceScott AJ, Webb TL, Martyn-St James M, Rowse G, Weich S. Improving sleep quality leads to better mental health: A meta-analysis of randomised controlled trials. Sleep medicine reviews. 2021 Dec:60():101556. doi: 10.1016/j.smrv.2021.101556. Epub 2021 Sep 23 [PubMed PMID: 34607184]
Level 2 (mid-level) evidencePapadelis C, Lithari C, Kourtidou-Papadeli C, Bamidis PD, Portouli E, Bekiaris E. Monitoring driver's sleepiness on-board for preventing road accidents. Studies in health technology and informatics. 2009:150():485-9 [PubMed PMID: 19745359]
Maia Q, Grandner MA, Findley J, Gurubhagavatula I. Short and long sleep duration and risk of drowsy driving and the role of subjective sleep insufficiency. Accident; analysis and prevention. 2013 Oct:59():618-22. doi: 10.1016/j.aap.2013.07.028. Epub 2013 Jul 31 [PubMed PMID: 23973762]
Janszky I, Ljung R. Shifts to and from daylight saving time and incidence of myocardial infarction. The New England journal of medicine. 2008 Oct 30:359(18):1966-8. doi: 10.1056/NEJMc0807104. Epub [PubMed PMID: 18971502]
Level 3 (low-level) evidenceLahti TA, Leppämäki S, Lönnqvist J, Partonen T. Transition to daylight saving time reduces sleep duration plus sleep efficiency of the deprived sleep. Neuroscience letters. 2006 Oct 9:406(3):174-7 [PubMed PMID: 16930838]
Level 2 (mid-level) evidenceManfredini R, Fabbian F, De Giorgi A, Zucchi B, Cappadona R, Signani F, Katsiki N, Mikhailidis DP. Daylight saving time and myocardial infarction: should we be worried? A review of the evidence. European review for medical and pharmacological sciences. 2018 Feb:22(3):750-755. doi: 10.26355/eurrev_201802_14306. Epub [PubMed PMID: 29461606]
Zhang H, Dahlén T, Khan A, Edgren G, Rzhetsky A. Measurable health effects associated with the daylight saving time shift. PLoS computational biology. 2020 Jun:16(6):e1007927. doi: 10.1371/journal.pcbi.1007927. Epub 2020 Jun 8 [PubMed PMID: 32511231]
Robb D, Barnes T. Accident rates and the impact of daylight saving time transitions. Accident; analysis and prevention. 2018 Feb:111():193-201. doi: 10.1016/j.aap.2017.11.029. Epub 2017 Dec 7 [PubMed PMID: 29223028]
Rishi MA, Ahmed O, Barrantes Perez JH, Berneking M, Dombrowsky J, Flynn-Evans EE, Santiago V, Sullivan SS, Upender R, Yuen K, Abbasi-Feinberg F, Aurora RN, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Martin JL, Olson EJ, Ramar K, Rosen CL, Rowley JA, Shelgikar AV, Gurubhagavatula I. Daylight saving time: an American Academy of Sleep Medicine position statement. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 2020 Oct 15:16(10):1781-1784. doi: 10.5664/jcsm.8780. Epub [PubMed PMID: 32844740]
Levine AC, Adusumilli J, Landrigan CP. Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review. Sleep. 2010 Aug:33(8):1043-53. doi: 10.1093/sleep/33.8.1043. Epub [PubMed PMID: 20815185]
Level 1 (high-level) evidenceBasner M, Dinges DF, Shea JA, Small DS, Zhu J, Norton L, Ecker AJ, Novak C, Bellini LM, Volpp KG. Sleep and Alertness in Medical Interns and Residents: An Observational Study on the Role of Extended Shifts. Sleep. 2017 Apr 1:40(4):. doi: 10.1093/sleep/zsx027. Epub [PubMed PMID: 28329124]
Level 2 (mid-level) evidenceGrantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Laparoscopic performance after one night on call in a surgical department: prospective study. BMJ (Clinical research ed.). 2001 Nov 24:323(7323):1222-3 [PubMed PMID: 11719413]
Silber JH, Bellini LM, Shea JA, Desai SV, Dinges DF, Basner M, Even-Shoshan O, Hill AS, Hochman LL, Katz JT, Ross RN, Shade DM, Small DS, Sternberg AL, Tonascia J, Volpp KG, Asch DA, iCOMPARE Research Group. Patient Safety Outcomes under Flexible and Standard Resident Duty-Hour Rules. The New England journal of medicine. 2019 Mar 7:380(10):905-914. doi: 10.1056/NEJMoa1810642. Epub [PubMed PMID: 30855740]
Anderson C, Sullivan JP, Flynn-Evans EE, Cade BE, Czeisler CA, Lockley SW. Deterioration of neurobehavioral performance in resident physicians during repeated exposure to extended duration work shifts. Sleep. 2012 Aug 1:35(8):1137-46. doi: 10.5665/sleep.2004. Epub 2012 Aug 1 [PubMed PMID: 22851809]