- Email: [email protected]
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem
BOOK FORUM
the triad of therapist, child, and image to transform perturbations of identification that have emerged from pathological patterns of primary attachment. The mirror allows a guided process of regenerative self-reflection. This small volume contains a wealth of perceptive clinical observation and original thought regarding the mirror paradigm. It illustrates Jacques Lacan`s paradoxical power to stimulate creativity even (and perhaps especially) when his reader misconceives Lacan`s theory. After all, misunderstand1 ing (me´connaissance) is at the heart of his own theory of mirrors, images, and human vicissitudes. Paul Hamburg M.D. Harvard Medical School Boston [email protected] 10.1097/01.CHI.0000270811.73561.9b
Disclosure: The author reports no conflicts of interest. 1. Lacan J. E´crits: A Selection. New York: Norton; 1977.
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine`s Committee on Sleep Medicine and Research, edited by Harvey R. Colten and Bruce M. Altevogt. Washington, DC: The National Academies Press, 2006, 404 pp. $57.50 (hardcover). In the past century, sleep has become a luxury often sacrificed for increased work, television, and Internet time. Americans sleep about 20% less than they did 100 years ago. Meanwhile, sleep research in the past 4 decades has advanced dramatically and identified a wide range of dangerous health consequences from chronic sleep loss, including depression, hypertension, diabetes, obesity, heart attack, and stroke. Chronic sleep deprivation and sleep disorders affect an estimated 50 to 70 million Americans, many of them children, adolescents, and young adults, and costs hundreds of billions of dollars annually in both direct and indirect medical costs. Most frightening of all, 20% of all serious car crashes are associated with driver sleepiness unrelated to alcohol consumption, making this a public health hazard even for teetotalers. Given the impressive damage that sleep deprivation and sleep disorders inflict on individuals and society, it is surprising there is little awareness of the serious risks among both the general public and health professionals. These conditions remain heavily underdiagnosed and undertreated. This important new interdisciplinary report published by the National Academies` Institute of Medicine seeks to change this trend and illuminate the growing public health crisis.
J. AM . ACAD. CHILD ADOLESC. PSYCH IATRY, 47:4, APRIL 2008
The peer-reviewed report, released in book form, is well organized and concise. It covers a wide range of topics, from sleep biology to systems of care. The 14-member committee on sleep medicine and research that compiled the report included two psychiatrists and three pediatricians. After an extensive literature review, the expert committee held a series of meetings and public workshops with other researchers, representatives from federal agencies, and academic, professional, and nonprofit organizations to make the following four key recommendations: improved education, both professional and public, and starting with elementary school students; advancement of diagnostic technologies, including improved ambulatory monitoring; coordination of research, clinical care, and education within academic health centers; and coordination of national research initiatives. This report should appeal to the public as well as to educators, policymakers, and care providers. For clinicians, there is a wealth of useful material, including review of basic sleep physiology across the life span, classes of sleep disorders, (including the parasomnias), and physiological and emotional consequences of chronic sleep loss. For mental health providers working with children and adolescents, awareness of the impact of impaired sleep on children`s brain development, behavior, emotional control, and academic performance could make a critical difference in diagnosis and treatment. For instance, is the problem attention-deficit/ hyperactivity disorder or undiagnosed obstructive sleep apnea? The book discusses how children with obstructive sleep apnea have roughly a three times greater risk for neurobehavioral abnormalities than children without it, and even common snoring not associated with severe sleep apnea can cause cognitive and behavioral deficits in children. The neurobehavioral effects of obstructive sleep apnea, including impaired school performance, cognition, and behavior, may be partially reversible with surgery that opens the airway. Other treatable sleep disorders affecting school performance, such as narcolepsy, are also reviewed. Although narcolepsy often manifests during the mid- to late teenage years, misdiagnosis can lead to delays in recognition and proper treatment 15 to 25 years after the onset of symptoms. The authors also explain the associations between inadequate sleep, depressed mood, anxiety, and other behavioral problems in childhood and adolescence, and delineate the public health benefits of early sleep education. Given that the majority of U.S. medical students never perform a clinical evaluation of an individual with a sleep disorder, it seems little wonder that sleep disorders and sleep deprivation remain underdiagnosed and undertreated by practicing clinicians. Compounding the issue, the Accreditation Council for Graduate Medical Education does not require training in chronic sleep loss or sleep disorders for residency programs in internal medicine, family medicine,
WWW.JAACAP.COM
473
Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BOOK FORUM
pediatrics, or psychiatry. Although the report strongly advocates incorporating sleep medicine curricula into medical school and residency training, it neglects a fundamental and ominous barrier to change: in the culture of medical training, sleep deprivation is a time-honored tradition and is often equated with patient dedication. The common practice of American physician trainees remaining on duty 24 to 30 hours continuously, despite impressive evidence on the dangers of these practices for patient safety and personal health, makes educating trainees about the dangers of sleep deprivation seem, at best, ironic. A quote by Goethe on the title page of the book reminds us that BKnowing is not enough: we must apply. Willing is not enough; we must do.^ Now is the time for our profession to use the growing evidence base about the perils of sleep deprivation and implement further change in medical training practices before a government regulatory body (or the public) decides to do it for us once again. Education about the serious consequences of sleep deprivation and chronic sleep loss may be the force that will transform the medical culture; the 80-hour work week regulations may have been but a start. This landmark book is comprehensive and highly illuminating of the menacing public health problem of sleep disorders. It also exposes the significant barriers to promoting and funding truly interdisciplinary care and research that face our departmental, hospital, and governmental systems. This has implications not only for the fields of sleep disorders but also for the growing numbers of areas of long-term care that transcend individual specialties. The committee that worked on this book attempted to develop workable solutions that could circumvent these formidable barriers. Leaders in the medical community, future leaders, and public health administrators whose duties include thinking creatively and developing interdisciplinary systems of care and study will likely find the report especially enlightening. By producing this worthwhile report, the Institute of Medicine has taken a vital national first step toward acknowledging good sleep habits as a primary tenet of heath, and advocating for improved sleep-related heath care. Now it is up to the rest of medicine to act. Kelli Harding, M.D. Michael Feldman, M.D. Columbia University College of Physicians and Surgeons New York [email protected] 10.1097/01.CHI.0000270812.55636.3b
Disclosure: The authors report no conflicts of interest.
474
WWW.JAACAP.COM
Thrilled to Death: How the Endless Pursuit of Pleasure Is Leaving Us Numb. By Archibald Hart. Nashville: Thomas Nelson, 2007, 288 pp., $14.99 (softcover). As parents, educators, and health care providers, we face the challenge of adapting to the changing digital world not only for our own survival but also to help our younger charges meet wide-ranging demands, from how to integrate vast amounts of data at their fingertips to how to safely navigate Web-based social networks. In his self-help book, Archibald Hart addresses the vague and unsettling notion that technology in excess cannot be a good thing and, in fact, may well be contributing to anhedonia, a Bphenomenon that is growing in leaps and boundsIoverloading the pathways to our pleasure center.^ Dr. Hart, a professor of psychology at Fuller Theological Seminary and author of several other books, including The Anxiety Cure (1999) and Unmasking Male Depression (2001), outlines his view on why so many are so unhappy at a time when many have so much. At best, he is practical and thoughtful, particularly when he offers advice to those who are unable to experience genuine pleasure; however, his ideas are backed by scant data and his treatise is less a scientific inquiry and more a descriptive how-to guidebook. The first half of Hart`s book is an exploration of the possible reasons of why we may be losing our capacity to experience joy, and he includes several self-assessment scales with which his readers can evaluate their own levels of joy and happiness, stress, multitasking, Internet addiction, and the distinct condition of sexual anhedonia. Such scales help engage the reader, but they are diminished by vague and questionable conclusions such as Byour stress level is high, and you may be at risk for developing some form of addiction.^ In the second half of Thrilled to Death, Dr. Hart proposes seven steps to Brecovering (your) pleasure center.^ This is perhaps the best part of his book, where he offers practical hints for stress reduction and tips for relaxation and meditation. Anhedonia is not, of course, a new idea. It has been one of the key diagnostic criteria for major depressive disorder since DSM-III. Dr. Hart offers a disclaimer right at the beginning, BTo the mental health professionals reading this book, let me say that I am not using the term anhedonia in the strict clinical sense.^ (p. 7) For most of his book, however, he uses the clinical term while simultaneously offering an etiology: BSimply put, anhedonia, the reduced ability to experience pleasure, is brought on, paradoxically, by the excessive pursuit of pleasure I . It is a by-product of the fantastic technological improvements in our world^ (p. 8). Dr. Hart provides few research data (he often writes Baccording to researchers^ without any further citations) and instead bases much of his theory on anecdotal evidence and folksy stories. As he fleshes out his ideas about apathy, he tries hard to define it: BIt is the
J. A M. ACAD . CHILD ADOLESC . PSYC HIAT RY , 47:4, AP RIL 2008
Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
the triad of therapist, child, and image to transform perturbations of identification that have emerged from pathological patterns of primary attachment. The mirror allows a guided process of regenerative self-reflection. This small volume contains a wealth of perceptive clinical observation and original thought regarding the mirror paradigm. It illustrates Jacques Lacan`s paradoxical power to stimulate creativity even (and perhaps especially) when his reader misconceives Lacan`s theory. After all, misunderstand1 ing (me´connaissance) is at the heart of his own theory of mirrors, images, and human vicissitudes. Paul Hamburg M.D. Harvard Medical School Boston [email protected] 10.1097/01.CHI.0000270811.73561.9b
Disclosure: The author reports no conflicts of interest. 1. Lacan J. E´crits: A Selection. New York: Norton; 1977.
Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine`s Committee on Sleep Medicine and Research, edited by Harvey R. Colten and Bruce M. Altevogt. Washington, DC: The National Academies Press, 2006, 404 pp. $57.50 (hardcover). In the past century, sleep has become a luxury often sacrificed for increased work, television, and Internet time. Americans sleep about 20% less than they did 100 years ago. Meanwhile, sleep research in the past 4 decades has advanced dramatically and identified a wide range of dangerous health consequences from chronic sleep loss, including depression, hypertension, diabetes, obesity, heart attack, and stroke. Chronic sleep deprivation and sleep disorders affect an estimated 50 to 70 million Americans, many of them children, adolescents, and young adults, and costs hundreds of billions of dollars annually in both direct and indirect medical costs. Most frightening of all, 20% of all serious car crashes are associated with driver sleepiness unrelated to alcohol consumption, making this a public health hazard even for teetotalers. Given the impressive damage that sleep deprivation and sleep disorders inflict on individuals and society, it is surprising there is little awareness of the serious risks among both the general public and health professionals. These conditions remain heavily underdiagnosed and undertreated. This important new interdisciplinary report published by the National Academies` Institute of Medicine seeks to change this trend and illuminate the growing public health crisis.
J. AM . ACAD. CHILD ADOLESC. PSYCH IATRY, 47:4, APRIL 2008
The peer-reviewed report, released in book form, is well organized and concise. It covers a wide range of topics, from sleep biology to systems of care. The 14-member committee on sleep medicine and research that compiled the report included two psychiatrists and three pediatricians. After an extensive literature review, the expert committee held a series of meetings and public workshops with other researchers, representatives from federal agencies, and academic, professional, and nonprofit organizations to make the following four key recommendations: improved education, both professional and public, and starting with elementary school students; advancement of diagnostic technologies, including improved ambulatory monitoring; coordination of research, clinical care, and education within academic health centers; and coordination of national research initiatives. This report should appeal to the public as well as to educators, policymakers, and care providers. For clinicians, there is a wealth of useful material, including review of basic sleep physiology across the life span, classes of sleep disorders, (including the parasomnias), and physiological and emotional consequences of chronic sleep loss. For mental health providers working with children and adolescents, awareness of the impact of impaired sleep on children`s brain development, behavior, emotional control, and academic performance could make a critical difference in diagnosis and treatment. For instance, is the problem attention-deficit/ hyperactivity disorder or undiagnosed obstructive sleep apnea? The book discusses how children with obstructive sleep apnea have roughly a three times greater risk for neurobehavioral abnormalities than children without it, and even common snoring not associated with severe sleep apnea can cause cognitive and behavioral deficits in children. The neurobehavioral effects of obstructive sleep apnea, including impaired school performance, cognition, and behavior, may be partially reversible with surgery that opens the airway. Other treatable sleep disorders affecting school performance, such as narcolepsy, are also reviewed. Although narcolepsy often manifests during the mid- to late teenage years, misdiagnosis can lead to delays in recognition and proper treatment 15 to 25 years after the onset of symptoms. The authors also explain the associations between inadequate sleep, depressed mood, anxiety, and other behavioral problems in childhood and adolescence, and delineate the public health benefits of early sleep education. Given that the majority of U.S. medical students never perform a clinical evaluation of an individual with a sleep disorder, it seems little wonder that sleep disorders and sleep deprivation remain underdiagnosed and undertreated by practicing clinicians. Compounding the issue, the Accreditation Council for Graduate Medical Education does not require training in chronic sleep loss or sleep disorders for residency programs in internal medicine, family medicine,
WWW.JAACAP.COM
473
Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
BOOK FORUM
pediatrics, or psychiatry. Although the report strongly advocates incorporating sleep medicine curricula into medical school and residency training, it neglects a fundamental and ominous barrier to change: in the culture of medical training, sleep deprivation is a time-honored tradition and is often equated with patient dedication. The common practice of American physician trainees remaining on duty 24 to 30 hours continuously, despite impressive evidence on the dangers of these practices for patient safety and personal health, makes educating trainees about the dangers of sleep deprivation seem, at best, ironic. A quote by Goethe on the title page of the book reminds us that BKnowing is not enough: we must apply. Willing is not enough; we must do.^ Now is the time for our profession to use the growing evidence base about the perils of sleep deprivation and implement further change in medical training practices before a government regulatory body (or the public) decides to do it for us once again. Education about the serious consequences of sleep deprivation and chronic sleep loss may be the force that will transform the medical culture; the 80-hour work week regulations may have been but a start. This landmark book is comprehensive and highly illuminating of the menacing public health problem of sleep disorders. It also exposes the significant barriers to promoting and funding truly interdisciplinary care and research that face our departmental, hospital, and governmental systems. This has implications not only for the fields of sleep disorders but also for the growing numbers of areas of long-term care that transcend individual specialties. The committee that worked on this book attempted to develop workable solutions that could circumvent these formidable barriers. Leaders in the medical community, future leaders, and public health administrators whose duties include thinking creatively and developing interdisciplinary systems of care and study will likely find the report especially enlightening. By producing this worthwhile report, the Institute of Medicine has taken a vital national first step toward acknowledging good sleep habits as a primary tenet of heath, and advocating for improved sleep-related heath care. Now it is up to the rest of medicine to act. Kelli Harding, M.D. Michael Feldman, M.D. Columbia University College of Physicians and Surgeons New York [email protected] 10.1097/01.CHI.0000270812.55636.3b
Disclosure: The authors report no conflicts of interest.
474
WWW.JAACAP.COM
Thrilled to Death: How the Endless Pursuit of Pleasure Is Leaving Us Numb. By Archibald Hart. Nashville: Thomas Nelson, 2007, 288 pp., $14.99 (softcover). As parents, educators, and health care providers, we face the challenge of adapting to the changing digital world not only for our own survival but also to help our younger charges meet wide-ranging demands, from how to integrate vast amounts of data at their fingertips to how to safely navigate Web-based social networks. In his self-help book, Archibald Hart addresses the vague and unsettling notion that technology in excess cannot be a good thing and, in fact, may well be contributing to anhedonia, a Bphenomenon that is growing in leaps and boundsIoverloading the pathways to our pleasure center.^ Dr. Hart, a professor of psychology at Fuller Theological Seminary and author of several other books, including The Anxiety Cure (1999) and Unmasking Male Depression (2001), outlines his view on why so many are so unhappy at a time when many have so much. At best, he is practical and thoughtful, particularly when he offers advice to those who are unable to experience genuine pleasure; however, his ideas are backed by scant data and his treatise is less a scientific inquiry and more a descriptive how-to guidebook. The first half of Hart`s book is an exploration of the possible reasons of why we may be losing our capacity to experience joy, and he includes several self-assessment scales with which his readers can evaluate their own levels of joy and happiness, stress, multitasking, Internet addiction, and the distinct condition of sexual anhedonia. Such scales help engage the reader, but they are diminished by vague and questionable conclusions such as Byour stress level is high, and you may be at risk for developing some form of addiction.^ In the second half of Thrilled to Death, Dr. Hart proposes seven steps to Brecovering (your) pleasure center.^ This is perhaps the best part of his book, where he offers practical hints for stress reduction and tips for relaxation and meditation. Anhedonia is not, of course, a new idea. It has been one of the key diagnostic criteria for major depressive disorder since DSM-III. Dr. Hart offers a disclaimer right at the beginning, BTo the mental health professionals reading this book, let me say that I am not using the term anhedonia in the strict clinical sense.^ (p. 7) For most of his book, however, he uses the clinical term while simultaneously offering an etiology: BSimply put, anhedonia, the reduced ability to experience pleasure, is brought on, paradoxically, by the excessive pursuit of pleasure I . It is a by-product of the fantastic technological improvements in our world^ (p. 8). Dr. Hart provides few research data (he often writes Baccording to researchers^ without any further citations) and instead bases much of his theory on anecdotal evidence and folksy stories. As he fleshes out his ideas about apathy, he tries hard to define it: BIt is the
J. A M. ACAD . CHILD ADOLESC . PSYC HIAT RY , 47:4, AP RIL 2008
Copyright @ 2008 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.