Guns and Sleep

Gun deaths are a problem in America. Irrespective of one’s position on gun control, the statistics do not lie. According to the Centers for Disease Control and Prevention (CDC), there were 11,208 deaths caused by firearms in 2013 (1). The recent high profile cases in Cincinnati, OH, Lafayette, LA and Memphis, TN further highlight the issue. Obviously, each case of death by a firearm had its own set of underlying factors that contributed to the final fatal outcome, but one wonders whether sleep deprivation can be implicated in some of them.

Sleep duration in adults over the past approximately 30 years has been declining in the United States (2). A variety of reasons can be cited as underlying causes such as greater use of artificial lighting, an expanding 24 hour non-stop society, promotion of a work ethic that values “burning the midnight oil”, and use of electronic devices before bedtime (especially those that emit blue wavelength light). In addition, both legal and illegal drugs have important impacts on sleep quality and quantity. For example, amphetamines can cause insomnia and by extension a reduction in sleep time (3), and perhaps more importantly, caffeine will have the same effect if used to excess (4). The most recent recommendation from the American Academy of Sleep Medicine is for adults to sleep at least 7 hours per night (5). However, recent CDC data indicate that 29.2% of adults sleep less than 6 hours per night and are thus chronically sleep deprived (2).

Symptoms of sleep deprivation include longer reaction times, lapses in attention or concentration, poor short term memory, errors of omission and sleepiness. However, sleep deprivation also leads to confusion, stress, irritability and impulsivity. Importantly, decision making and the ability to formulate reasonable moral judgments are impaired. All of these negative impacts of sleep deprivation can lead to high-risk behavior. Thus, can it be posited that in some cases, sleep deprivation, perhaps fueled by the legal or illegal use of stimulant compounds, leads to impaired judgment and increased impulsivity, poor decisions and fatal shootings?

Several years ago, I was asked to be a defense expert in a case where a jilted wife fatally shot her husband’s lover. After learning about her husband’s affair, the wife had become distraught and unable to sleep for ~2 days. She then sought out the victim and shot her. Her sleep deprivation was used as a mitigating factor to reduce the charge from 1^st to 2^nd degree homicide. Although not a shooting, more recently, a Florida man was acquitted of the murder by suffocation of his father because he was sleep deprived after consuming a large amount of Red Bull (80 mg caffeine per 8.46 fluid ounces). Cases such as these have led to speculation that sleep deprivation may be an effective defense where the fatal act could plausibly be explained by a change in mood or cognitive impairment.

The potential impact of sleep deprivation is likely not limited to citizens accused of fatal shooting, but law enforcement officers as well. Police officers frequently work overnight or rotating shifts, and many accept overtime duty as well. A recent survey of 4957 police officers found that >40% screened positive for at least one sleep disorder with 28.5% being excessively sleepy, suggesting an element of sleep deprivation (5). Most troubling was that those who were identified as having a sleep disorder had a 51% greater likelihood of making an error or safety violation and a 63% greater chance of exhibiting other adverse work-related outcomes including uncontrolled anger toward suspects. Could some of the recently publicized adverse interactions between police officers and citizens be partially explained by lack of sleep?

Although a possible causal link between gun violence and sleep deprivation is speculative, there is no doubt that insufficient sleep is becoming endemic in our society and has significant personal and public health consequences. There should be a concerted effort on the part of public health officials, public and private institutions and individuals to reverse this trend by publicizing the adverse impact of insufficient sleep, undertaking policy measures to promote adequate sleep and set themselves as examples of healthy sleepers.

Stuart F. Quan, MD

Gerald E. McGinnis Professor of Sleep Medicine

Harvard Medical School

Brigham and Women's Hospital

Boston, MA

References

1. Centers for Disease Control. Fast stats. Available at: http://www.cdc.gov/nchs/fastats/homicide.htm (accessed 8/6/15). 
2. Ford ES, Cunningham TJ, Croft JB. Trends in self-reported sleep duration among US adults from 1985 to 2012. Sleep. 2015;38(5):829-32. [CrossRef] [PubMed]
3. Coghill DR, Caballero B, Sorooshian S, Civil R. A systematic review of the safety of lisdexamfetamine dimesylate. CNS Drugs. 2014;28(6):497-511. [CrossRef] [PubMed]
4. Drake C, Roehrs T, Shambroom J, Roth T. Caffeine effects on sleep taken 0, 3, or 6 hours before going to bed. J Clin Sleep Med. 2013 Nov 15;9(11):1195-200. [CrossRef] [PubMed]
5. Watson NF, Badr MS, Belenky G, et al. Joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society on the recommended amount of sleep for a healthy adult: methodology and discussion. J Clin Sleep Med. 2015;11(6):591-2. [CrossRef] [PubMed]
6. Rajaratnam SM, Barger LK, Lockley SW, Shea SA, Wang W, Landrigan CP, O'Brien CS, Qadri S, Sullivan JP, Cade BE, Epstein LJ, White DP, Czeisler CA. Harvard work hours, health and safety group. JAMA. 2011;306(23):2567-78. [CrossRef] [PubMed]

Reference as: Quan SF. Guns and sleep. Southwest J Pulm Crit Care. 2015;11(2):68-9. doi: http://dx.doi.org/10.13175/swjpcc107-15 PDF

Identification of a Biomarker of Sleep Deficiency—Are We Tilting Windmills?

The amount of time spent asleep by adults in the United States and other developing countries is decreasing. It is estimated that over 40 years ago, adults slept in excess of 8 hours per night, but now sleep barely 7 hours per night (1) During this time frame, there has been a corresponding increase in obesity and diabetes mellitus which in part has been attributed to a reduction in time sleeping (2). In addition, sleep deficiency and other sleep disorders have been implicated as risk factors for hypertension, cardiovascular disease and cancer (3-5). Consequently, billions of excess health care dollars are spent on medical conditions associated with sleep deficiency or sleep disorders (6,7). Their impact also include substantial costs resulting from lost productivity as well as increased absenteeism, presenteeism and motor vehicle or industrial accidents (6,7).  Thus, sleep disorders and sleep deficiency are significant threats to public health and productivity in the United States and worldwide and no evidence of a decline is on the horizon. One barrier to reducing their impact is the difficulty in identifying on a societal and personal level the major consequence of sleep deficiency, sleepiness.

Despite the extraordinary progress made by sleep and circadian science in recent years, developing an accurate and easy to use biomarker for sleepiness and/or sleep deficiency has been elusive. Currently used objective assessments of sleepiness such as the multiple sleep latency test or the psychomotor vigilance test are either difficult to use outside the laboratory environment or do not evaluate all domains of sleep deficiency. Subjective assessments of sleepiness are unreliable because many individuals cannot recognize their impairment (8) and in some occupational scenarios (e.g., truck drivers, railroad engineers); there is personal incentive to deny its presence because of the fear of losing employment or income (9).

If developed, there would be several uses for a sleepiness or sleep deficiency biomarker. These include:

• Research: especially in field studies of the impact of sleep deficiency and/or sleepiness in both small and large size cohorts;
• Fitness for duty: in clinical and occupational settings (e.g., operating a motor vehicle, aircraft pilot) where objective assessment of sleepiness would be important in determining whether an individual could perform their job;
• Personal health: such testing might ultimately provide a means for an individual to determine his/her level of sleepiness and allow self adjustment of medication or positive airway pressure in the case of obstructive sleep apnea patients, analogous to currently used home glucose testing in persons with diabetes mellitus;
• Disease risk stratification: level of sleep deficiency might identify individuals with a greater likelihood of developing other medical conditions such as cardiovascular disease or diabetes.

In an attempt to “jumpstart” interest and research into developing a sleepiness or sleep deficiency biomarker, the Division of Sleep Medicine at Harvard Medical School hosted a conference on September 21-22, 2010 supported by the National Heart, Lung and Blood Institute and commercial entities entitled “Finding a Research Path for the Identification of Biomarkers of Sleepiness” (10). A number of prominent national and international speakers presented possible approaches to achieving this goal including behavioral, physiologic, genomic and proteomic solutions. This conference was followed by a panel discussion on this same topic at the annual Sleep 2011 international conference. Despite these high profile public discourses, there has been little progress in finding a sleepiness/sleep deficiency biomarker. A brief search of PubMed identified only one paper published since the conference directly relevant to this area (11).

Why has there been so little progress? I would propose the major reason is lack of a public “outcry”. Despite high profile incidences such as the crash of Colgan Air Flight #3407 (12) and the grounding of the Exxon Valdez (13), and a report from the Institute of Medicine (6) the general public has not adopted sleep issues as a major public health concern. In contrast, cancer, heart disease, obesity and diabetes, all of which may in part be consequences of sleep deficiency or a sleep disorder, are higher in the public consciousness. As a result, it is unlikely that funding initiatives such as a RFA on research into sleepiness or sleep deficiency biomarkers from the National Institutes of Health will be forthcoming.

What can be done? It should be the mission of all of us who are involved in sleep research and clinical Sleep Medicine to promote to the public the importance of sleep deficiency and sleep disorders in adversely impacting public health. Until there is a ground swell of public support, I fear attempts to identify biomarkers for sleepiness or sleep deficiency may be similar to “tilting at windmills.”

Stuart F. Quan, M.D.

Division of Sleep Medicine,

Brigham and Women’s Hospital and Harvard Medical School

401 Park Dr., 2^nd Floor East

Boston, MA 02215

Voice: 617-998-8842

Fax: 617-998-8823

Email: Stuart_Quan@hms.harvard.edu

References

1. McAllister EJ, Dhurandhar NV, Keith SW, et al. Ten putative contributors to the obesity epidemic. Crit Rev Food Sci Nutr 2009;49:868-913.
2. Spiegel K, Tasali E, Leproult R, Van Cauter E. Effects of poor and short sleep on glucose metabolism and obesity risk. Nat Rev Endocrinol 2009;5:253-261.
3. Budhiraja R, Sharief I, Quan SF. Sleep disordered breathing and hypertension. J Clin Sleep Med 2005; 1:401-4.
4. Kakizaki M, Kuriyama S, Sone T, et al. Sleep duration and the risk of breast cancer: the Ohsaki Cohort Study. Br J Cancer 2008; 99:1502-5.
5. Quan SF. Sleep Disturbances and their Relationship to Cardiovascular Disease. Am J Lifestyle Med 2009; 3:55s-59s.
6. Colten HR, Altevogt BM, Institute of Medicine. Committee on Sleep Medicine and Research. Sleep disorders and sleep deprivation: an unmet public health problem. Washington, DC: Institute of Medicine: National Academies Press, 2006; 404.
7. Anonymous. The Price of Fatigue: the surprising economic costs of unmanaged sleep apnea. 2010. https://sleep.med.harvard.edu/what-we-do/public-policy-research
8. Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Semin Neurol 2005;25:117-129.
9. Smith B, Phillips BA. Truckers drive their own assessment for obstructive sleep apnea: a collaborative approach to online self-assessment for obstructive sleep apnea. J Clin Sleep Med 2011;7:241-245.
10. Anonymous. Harvard Biomarkers of Sleepiness Conference. 2011. https://sleep.med.harvard.edu/what-we-do/biomarkers-conference
11. Goel N, Banks S, Lin L, Mignot E, Dinges DF. Catechol-O-methyltransferase Val158Met polymorphism associates with individual differences in sleep physiologic responses to chronic sleep loss. PLoS One 2011;6:e29283.
12. Anonymous. Colgan Air Flight 3407. 2012. http://en.wikipedia.org/wiki/Colgan_Air_Flight_3407#cite_note-ntsb.2Faar-10.2F01-20
13. Anonymous. Details about the Accident SPILL: The wreck of the Exxon Valdez Final Report, Alaska Oil Spill Commission. 1990. http://www.evostc.state.ak.us/facts/details.cfm

Reference as: Quan SF. Identification of a biomarker of sleep deficiency-Are we tilting windmills? Southwest J Pulm Crit Care 2012;4:58-60. (Click here for a PDF version of the editorial)