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Insufficient sleep: Definition, epidemiology, and adverse outcomes

Chiara Cirelli, MD, PhD
Section Editor
Ruth Benca, MD, PhD
Deputy Editor
April F Eichler, MD, MPH


Chronic sleep insufficiency is common in modern society and may result from a variety of factors, including work demands, social and family responsibilities, medical conditions, and sleep disorders. As sleep debt accumulates, individuals may experience reduced performance, increased risk for accidents and death, and detrimental effects on both psychological and physical health.

Sleep has two dimensions: duration (quantity) and depth (quality). When individuals fail to obtain adequate duration or quality of sleep, daytime alertness and function suffer. In response to sleep deprivation, sleep is often both longer and deeper. In many cases, however, sleep intensity can change without major changes in sleep duration. Sleep duration alone is therefore not a good indicator of how much sleep is needed to feel refreshed in the morning and function properly.

The definition, epidemiology, causes, and consequences of acute sleep deprivation and sleep insufficiency are reviewed here. The evaluation and management of insufficient sleep are reviewed separately. Insomnia, which is distinct from sleep deprivation, is also reviewed separately. (See "Insufficient sleep: Evaluation and management" and "Overview of insomnia in adults" and "Clinical features and diagnosis of insomnia in adults".)


Sleep insufficiency exists when sleep is insufficient to support adequate alertness, performance, and health, either because of reduced total sleep time (decreased quantity) or fragmentation of sleep by brief arousals (decreased quality).

Acute sleep deprivation refers to no sleep or a reduction in the usual total sleep time, usually lasting one or two days. Chronic sleep insufficiency (also called sleep restriction) exists when an individual routinely sleeps less than the amount required for optimal functioning.

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Literature review current through: Dec 2017. | This topic last updated: Dec 15, 2017.
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  1. American Academy of Sleep Medicine. International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
  2. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 2004; 27:1255.
  3. Matricciani L, Blunden S, Rigney G, et al. Children's sleep needs: is there sufficient evidence to recommend optimal sleep for children? Sleep 2013; 36:527.
  4. http://sleepfoundation.org/how-sleep-works/how-much-sleep-do-we-really-need (Accessed on February 12, 2015).
  5. Watson NF, Badr MS, Belenky G, et al. 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; 38:843.
  6. Centers for Disease Control and Prevention (CDC). Effect of short sleep duration on daily activities--United States, 2005-2008. MMWR Morb Mortal Wkly Rep 2011; 60:239.
  7. Liu Y, Wheaton AG, Chapman DP, et al. Prevalence of Healthy Sleep Duration among Adults--United States, 2014. MMWR Morb Mortal Wkly Rep 2016; 65:137.
  8. Nunes J, Jean-Louis G, Zizi F, et al. Sleep duration among black and white Americans: results of the National Health Interview Survey. J Natl Med Assoc 2008; 100:317.
  9. Zizi F, Pandey A, Murrray-Bachmann R, et al. Race/ethnicity, sleep duration, and diabetes mellitus: analysis of the National Health Interview Survey. Am J Med 2012; 125:162.
  10. Carnethon MR, De Chavez PJ, Zee PC, et al. Disparities in sleep characteristics by race/ethnicity in a population-based sample: Chicago Area Sleep Study. Sleep Med 2016; 18:50.
  11. Petrov ME, Lichstein KL. Differences in sleep between black and white adults: an update and future directions. Sleep Med 2016; 18:74.
  12. Luckhaupt SE, Tak S, Calvert GM. The prevalence of short sleep duration by industry and occupation in the National Health Interview Survey. Sleep 2010; 33:149.
  13. Tucker P, Smith L, Macdonald I, Folkard S. The impact of early and late shift changeovers on sleep, health, and well-being in 8- and 12-hour shift systems. J Occup Health Psychol 1998; 3:265.
  14. Pilcher JJ, Lambert BJ, Huffcutt AI. Differential effects of permanent and rotating shifts on self-report sleep length: a meta-analytic review. Sleep 2000; 23:155.
  15. Basner M, Fomberstein KM, Razavi FM, et al. American time use survey: sleep time and its relationship to waking activities. Sleep 2007; 30:1085.
  16. Knutson KL, Van Cauter E, Rathouz PJ, et al. Trends in the prevalence of short sleepers in the USA: 1975-2006. Sleep 2010; 33:37.
  17. Matricciani L, Olds T, Petkov J. In search of lost sleep: secular trends in the sleep time of school-aged children and adolescents. Sleep Med Rev 2012; 16:203.
  18. Carskadon MA, Dement WC. Cumulative effects of sleep restriction on daytime sleepiness. Psychophysiology 1981; 18:107.
  19. Horne J. The end of sleep: 'sleep debt' versus biological adaptation of human sleep to waking needs. Biol Psychol 2011; 87:1.
  20. Martin SE, Engleman HM, Deary IJ, Douglas NJ. The effect of sleep fragmentation on daytime function. Am J Respir Crit Care Med 1996; 153:1328.
  21. Martin SE, Wraith PK, Deary IJ, Douglas NJ. The effect of nonvisible sleep fragmentation on daytime function. Am J Respir Crit Care Med 1997; 155:1596.
  22. Bonnet MH. Effect of sleep disruption on sleep, performance, and mood. Sleep 1985; 8:11.
  23. Goel N, Basner M, Rao H, Dinges DF. Circadian rhythms, sleep deprivation, and human performance. Prog Mol Biol Transl Sci 2013; 119:155.
  24. Goel N, Rao H, Durmer JS, Dinges DF. Neurocognitive consequences of sleep deprivation. Semin Neurol 2009; 29:320.
  25. Banks S, Dinges DF. Behavioral and physiological consequences of sleep restriction. J Clin Sleep Med 2007; 3:519.
  26. Killgore WD. Effects of sleep deprivation on cognition. Prog Brain Res 2010; 185:105.
  27. Belenky G, Wesensten NJ, Thorne DR, et al. Patterns of performance degradation and restoration during sleep restriction and subsequent recovery: a sleep dose-response study. J Sleep Res 2003; 12:1.
  28. Van Dongen HP, Maislin G, Mullington JM, Dinges DF. The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation. Sleep 2003; 26:117.
  29. Ma N, Dinges DF, Basner M, Rao H. How acute total sleep loss affects the attending brain: a meta-analysis of neuroimaging studies. Sleep 2015; 38:233.
  30. Tucker AM, Whitney P, Belenky G, et al. Effects of sleep deprivation on dissociated components of executive functioning. Sleep 2010; 33:47.
  31. Barger LK, Ayas NT, Cade BE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med 2006; 3:e487.
  32. Benson M, Grimes I, Gopal D, et al. Influence of previous night call and sleep deprivation on screening colonoscopy quality. Am J Gastroenterol 2014; 109:1133.
  33. Rupp TL, Wesensten NJ, Bliese PD, Balkin TJ. Banking sleep: realization of benefits during subsequent sleep restriction and recovery. Sleep 2009; 32:311.
  34. Banks S, Van Dongen HP, Maislin G, Dinges DF. Neurobehavioral dynamics following chronic sleep restriction: dose-response effects of one night for recovery. Sleep 2010; 33:1013.
  35. Cirelli C, Tononi G. Is sleep essential? PLoS Biol 2008; 6:e216.
  36. Nir Y, Andrillon T, Marmelshtein A, et al. Selective neuronal lapses precede human cognitive lapses following sleep deprivation. Nat Med 2017; 23:1474.
  37. Pires GN, Bezerra AG, Tufik S, Andersen ML. Effects of acute sleep deprivation on state anxiety levels: a systematic review and meta-analysis. Sleep Med 2016; 24:109.
  38. Doran SM, Van Dongen HP, Dinges DF. Sustained attention performance during sleep deprivation: evidence of state instability. Arch Ital Biol 2001; 139:253.
  39. White DP, Douglas NJ, Pickett CK, et al. Sleep deprivation and the control of ventilation. Am Rev Respir Dis 1983; 128:984.
  40. Schiffman PL, Trontell MC, Mazar MF, Edelman NH. Sleep deprivation decreases ventilatory response to CO2 but not load compensation. Chest 1983; 84:695.
  41. Bowes G, Woolf GM, Sullivan CE, Phillipson EA. Effect of sleep fragmentation on ventilatory and arousal response of sleeping dogs to respiratory stimuli. Am Rev Respir Dis 1980; 125:286.
  42. Spengler CM, Shea SA. Sleep deprivation per se does not decrease the hypercapnic ventilatory response in humans. Am J Respir Crit Care Med 2000; 161:1124.
  43. Liu C, Cao Y, Malhotra A, Ling L. Sleep fragmentation attenuates the hypercapnic (but not hypoxic) ventilatory responses via adenosine A1 receptors in awake rats. Respir Physiol Neurobiol 2011; 175:29.
  44. Chen HI, Tang YR. Sleep loss impairs inspiratory muscle endurance. Am Rev Respir Dis 1989; 140:907.
  45. Phillips BA, Cooper KR, Burke TV. The effect of sleep loss on breathing in chronic obstructive pulmonary disease. Chest 1987; 91:29.
  46. Cajochen C, Chellappa S, Schmidt C. What keeps us awake? The role of clocks and hourglasses, light, and melatonin. Int Rev Neurobiol 2010; 93:57.
  47. Van Dongen HP, Baynard MD, Maislin G, Dinges DF. Systematic interindividual differences in neurobehavioral impairment from sleep loss: evidence of trait-like differential vulnerability. Sleep 2004; 27:423.
  48. Kuna ST, Maislin G, Pack FM, et al. Heritability of performance deficit accumulation during acute sleep deprivation in twins. Sleep 2012; 35:1223.
  49. Cui J, Tkachenko O, Gogel H, et al. Microstructure of frontoparietal connections predicts individual resistance to sleep deprivation. Neuroimage 2015; 106:123.
  50. Rocklage M, Williams V, Pacheco J, Schnyer DM. White matter differences predict cognitive vulnerability to sleep deprivation. Sleep 2009; 32:1100.
  51. Bernardi G, Cecchetti L, Siclari F, et al. Sleep reverts changes in human gray and white matter caused by wake-dependent training. Neuroimage 2016; 129:367.
  52. Saletin JM, Goldstein-Piekarski AN, Greer SM, et al. Human Hippocampal Structure: A Novel Biomarker Predicting Mnemonic Vulnerability to, and Recovery from, Sleep Deprivation. J Neurosci 2016; 36:2355.
  53. Akerstedt T, Fredlund P, Gillberg M, Jansson B. Work load and work hours in relation to disturbed sleep and fatigue in a large representative sample. J Psychosom Res 2002; 53:585.
  54. Akerstedt T, Fredlund P, Gillberg M, Jansson B. A prospective study of fatal occupational accidents -- relationship to sleeping difficulties and occupational factors. J Sleep Res 2002; 11:69.
  55. Vakulin A, Baulk SD, Catcheside PG, et al. Effects of alcohol and sleep restriction on simulated driving performance in untreated patients with obstructive sleep apnea. Ann Intern Med 2009; 151:447.
  56. Vakulin A, Baulk SD, Catcheside PG, et al. Effects of moderate sleep deprivation and low-dose alcohol on driving simulator performance and perception in young men. Sleep 2007; 30:1327.
  57. Howard ME, Jackson ML, Kennedy GA, et al. The interactive effects of extended wakefulness and low-dose alcohol on simulated driving and vigilance. Sleep 2007; 30:1334.
  58. Ayas NT, Barger LK, Cade BE, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006; 296:1055.
  59. Rajaratnam SM, Barger LK, Lockley SW, et al. Sleep disorders, health, and safety in police officers. JAMA 2011; 306:2567.
  60. Knutson KL, Van Cauter E, Rathouz PJ, et al. Association between sleep and blood pressure in midlife: the CARDIA sleep study. Arch Intern Med 2009; 169:1055.
  61. King CR, Knutson KL, Rathouz PJ, et al. Short sleep duration and incident coronary artery calcification. JAMA 2008; 300:2859.
  62. Sabanayagam C, Shankar A. Sleep duration and cardiovascular disease: results from the National Health Interview Survey. Sleep 2010; 33:1037.
  63. Hoevenaar-Blom MP, Spijkerman AM, Kromhout D, Verschuren WM. Sufficient sleep duration contributes to lower cardiovascular disease risk in addition to four traditional lifestyle factors: the MORGEN study. Eur J Prev Cardiol 2014; 21:1367.
  64. St-Onge MP, Grandner MA, Brown D, et al. Sleep Duration and Quality: Impact on Lifestyle Behaviors and Cardiometabolic Health: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e367.
  65. Deng HB, Tam T, Zee BC, et al. Short Sleep Duration Increases Metabolic Impact in Healthy Adults: A Population-Based Cohort Study. Sleep 2017; 40.
  66. Mullington JM, Simpson NS, Meier-Ewert HK, Haack M. Sleep loss and inflammation. Best Pract Res Clin Endocrinol Metab 2010; 24:775.
  67. Grandner MA, Sands-Lincoln MR, Pak VM, Garland SN. Sleep duration, cardiovascular disease, and proinflammatory biomarkers. Nat Sci Sleep 2013; 5:93.
  68. Besedovsky L, Lange T, Born J. Sleep and immune function. Pflugers Arch 2012; 463:121.
  69. Spiegel K, Sheridan JF, Van Cauter E. Effect of sleep deprivation on response to immunization. JAMA 2002; 288:1471.
  70. Cohen S, Doyle WJ, Alper CM, et al. Sleep habits and susceptibility to the common cold. Arch Intern Med 2009; 169:62.
  71. Rechtschaffen A, Bergmann BM, Everson CA, et al. Sleep deprivation in the rat: X. Integration and discussion of the findings. Sleep 1989; 12:68.
  72. Rechtschaffen A, Bergmann BM. Sleep deprivation in the rat: an update of the 1989 paper. Sleep 2002; 25:18.
  73. Gallicchio L, Kalesan B. Sleep duration and mortality: a systematic review and meta-analysis. J Sleep Res 2009; 18:148.
  74. Cappuccio FP, D'Elia L, Strazzullo P, Miller MA. Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep 2010; 33:585.
  75. Kurina LM, McClintock MK, Chen JH, et al. Sleep duration and all-cause mortality: a critical review of measurement and associations. Ann Epidemiol 2013; 23:361.
  76. Kripke DF, Garfinkel L, Wingard DL, et al. Mortality associated with sleep duration and insomnia. Arch Gen Psychiatry 2002; 59:131.
  77. Kripke DF, Langer RD, Elliott JA, et al. Mortality related to actigraphic long and short sleep. Sleep Med 2011; 12:28.
  78. Vgontzas AN, Liao D, Pejovic S, et al. Insomnia with short sleep duration and mortality: the Penn State cohort. Sleep 2010; 33:1159.
  79. Dew MA, Hoch CC, Buysse DJ, et al. Healthy older adults' sleep predicts all-cause mortality at 4 to 19 years of follow-up. Psychosom Med 2003; 65:63.
  80. McMullan CJ, Curhan GC, Forman JP. Association of short sleep duration and rapid decline in renal function. Kidney Int 2016; 89:1324.