pii: sp-00640-14
http://dx.doi.org/10.5665/sleep.4832
BOOK REVIEW
Sleep Deprivation, Stimulant Medications, and Cognition
Nancy J. Wesensten, Editor; Cambridge University Press, 2012, 274 pages; ISBN 978-1-1070-0409-2; Hardback
Hans P.A. Van Dongen, PhD
Sleep and Performance Research Center, College of Medical Sciences, Washington State University, Spokane, WA
Sleepiness, performance impairment and associated safety
risks are of significant concern in 24/7 operational settings
such as transportation, industry, and the military.1,2 For this
problem of “fatigue,” as it is often called in the operational
environment, a variety of countermeasures have been developed,3–5 such as planned napping, bright light exposure, and
caffeine intake. However, scientific knowledge about when
and how to best apply the available countermeasures is limited.
For example, general advice on the use of caffeine would be to
“administer in moderation”—but what exactly does that mean?
In the edited volume Sleep Deprivation, Stimulant Medications, and Cognition,6 editor Nancy Wesensten addresses this
issue with an emphasis on pharmacological countermeasures.
Focusing primarily on the use of stimulants medications as fatigue countermeasures in healthy but sleep-deprived populations, the book provides a holistic view that covers both basic
and applied science, as well as medical and ethical management of fatigue and stimulant use. This book should be of
interest to researchers, clinicians, occupational health professionals, policy makers, and anyone interested in stimulant
medications and/or fatigue risk management.
In military settings, which are of particular concern in this
book, three different stimulant medications may be used: caffeine, modafinil, and dextroamphetamine. Wesensten states
that dextroamphetamine is not specifically reviewed because
of its abuse liability. That is, dextroamphetamine is no longer
considered a viable option for maintaining alert wakefulness.
However, modafinil—a prescription drug—and caffeine—
available “over the counter” in coffee and other drinks as well
as gum—are discussed extensively in the book.
Seven chapters are devoted to stimulants, their uses and
dosing, their pharmacology and biochemistry, their effectiveness at restoring performance under conditions of sleep loss and
circadian misalignment, and their side effects and abuse potential. Initial findings on a task-dependent aspect of the efficacy
of different stimulants are described, although—as Megan St.
Peters and Martin Sarter explain in one of the chapters—this
aspect lacks a theoretical basis.7 Regardless, there is a wealth of
useful information about stimulant medications in the volume.
Several of the chapters in Wesensten’s book draw from the
leading expertise she and her colleagues at Walter Reed Army
Submitted for publication October, 2014
Accepted for publication October, 2014
Address correspondence to: Hans P.A. Van Dongen, PhD, Sleep and
Performance Research Center, Washington State University Spokane,
PO Box 1495, Spokane, WA 99210; Tel: (509) 358-7755; Fax: (509) 3587810; Email: [email protected]
SLEEP, Vol. 38, No. 7, 2015
Institute of Research (WRAIR) and other US Army research
groups have built over the years. They are interspersed with
chapters by experts in the areas of fatigue risk management
and pharmacology from other institutions. In two complementary chapters, Michael Bonnet and Donna Arand review
laboratory data on caffeine as a fatigue countermeasure, while
Christina Carvey and colleagues provide evidence from field
experiments. Wesensten reviews the available information
on modafinil. In addition to the direct stimulating effects on
waking alertness of these compounds, their effects on subsequent sleep are also considered. This is relevant in daily life
and in the context of insomnia. Additionally, it is important in
operational settings, especially when sleep opportunities are
unpredictable.
Continuing the chapters on stimulants, Jonathan Schwartz
and Aaron Henley discuss stimulant use to treat shift work disorder (SWD). They argue that the common practice of using
caffeine to overcome sleepiness while working shifts may lead
to insomnia, thereby potentiating one of the main symptoms
of SWD. Emma Childs and Harriet de Wit consider the potential for abuse of stimulants in chronically sleep-restricted
populations—a frequently voiced concern in settings where
individuals are routinely exposed to overtime and shift work.
There is more on abuse potential in the chapter by St. Peters
and Sarter, which deals with stimulant use for the purpose of
cognitive enhancement to further improve already normative
cognitive performance. This chapter also includes a discussion
of nicotine, which improves performance on cognitive tasks,
though not consistently. The main conclusion of the chapter is
that there is little evidence that pharmacological enhancement
of cognition (beyond normal performance) is effective.
The final two stimulant-focused chapters, one by John
Renger and the other by Ravi Pasumarthi and Thomas Kilduff,
provide a peek into the future. These chapters review the ongoing development of novel histaminergic and orexinergic/
hypocretinergic stimulants. To fully understand these chapters,
a solid background in neuroanatomy and brain biochemistry is
needed, which the book provides. Robert Strecker and James
McKenna review the neurochemistry of wakefulness and sleep,
which lays a foundation for understanding the biochemical
effects of stimulant medications. Philip Quartana and Tracy
Rupp discuss inter-individual differences in the effects of sleep
loss on performance and in the efficacy of countermeasures,
with an emphasis on the genetic underpinnings. Michael Chee
and Su Mei Lee provide an exceptionally clear explanation of
the use of functional magnetic resonance imaging (fMRI) to
study cognitive function in sleep-deprived individuals. The
book does not include a chapter that is specifically devoted to
the temporal dynamics of fatigue and performance impairment
1145
Book Review—Van Dongen
due to sleep insufficiency and circadian misalignment.8,9 Such
a chapter would have provided an even more comprehensive
basis for the rest of the book.
The remaining chapters are thoughtful reviews of alternative fatigue countermeasures and their limitations. Ken Wright
and colleagues discuss the alerting effect of light exposure and
its relatively modest effectiveness under conditions of sleep
loss, as compared to stimulants. Caroline Mahoney and Harris
Lieberman review nutritional options and conclude that, with
the exception of caffeine, there is no unequivocal evidence of
their effectiveness as fatigue countermeasures. Melissa Mallis
and Francine James describe research on alertness monitoring
technologies. The development of these technologies was met
with significant technical and practical challenges, although
progress continues to be made.10 Janine Hall-Porter and James
Walsh consider pharmacological and non-pharmacological
methods for enhancement of slow waves during prior sleep
periods as a potential approach to improving cognitive performance. The approach may be effective, but it appears to be
difficult to implement in practice. The closing chapter of the
book, by Rupp and colleagues, suggests a strategy developed
at WRAIR for using biomathematical model predictions11 to
help manage fatigue and guide stimulant administration. This
particular chapter disregards most of the foundational work
and recent developments outside the US military, but the ideas
that are laid out are promising.
A real gem in this book is a chapter by Nicholas Davenport
and colleagues, who discuss the real-world practice of stimulant administration in military and other operational contexts.
They explain why, under certain conditions, use of stimulant
medications is allowed in US military aviation but not in
commercial aviation—in brief, because drug use by military
pilots is overseen by a flight surgeon and because military operations sometimes require waivers from crew rest guidelines
to maintain operational tempo.12 The chapter considers the
ethical complexities of administering stimulants, as well as of
withholding stimulants at times when they could protect missions and save lives. Davenport and colleagues outline 7 core
principles of stimulant use in the US military (e.g., use only
to restore fatigue-degraded performance, monitor adverse reactions), which would serve as an excellent starting point for
judicious stimulant use in other operational settings if such use
were to be sanctioned in the future.
The opening chapter of the book cautions the reader not to be
too optimistic about the value of sleep deprivation studies for
understanding the secrets of sleep. While those secrets may not
be elucidated by sleep deprivation studies alone, this may be
too pessimistic a view. Carefully documented observations of
attentional lapsing, wake state instability, interaction between
sleep loss and the time-on-task effect, and localized responses
in the EEG of recovery sleep in laboratory sleep deprivation
experiments—placed in the context of neuroscience theories
of brain organization—lead to new, falsifiable accounts of cognitive dysfunction during sleep deprivation.13,14 This in turn
drives new experimentation to falsify those accounts, which
is one of the fundamental bases for advancing our scientific
SLEEP, Vol. 38, No. 7, 2015
knowledge of sleep.15 As amply illustrated in the chapters of
Wesensten’s edited volume, sleep deprivation studies—and
stimulant administration and other interventions—do advance
our understanding of the secrets of sleep.
In conclusion, no other book on sleep, sleep loss, and cognition discusses the topic of stimulant use to counter fatigue as
comprehensively and in depth as Sleep Deprivation, Stimulant
Medications, and Cognition. The volume is carefully edited
to be informative, balanced, and easy to read. It fills a critical
gap for anyone involved in the basic or applied aspects of pharmacological and non-pharmacological management of fatigue.
CITATION
Van Dongen HPA. Sleep deprivation, stimulant medications,
and cognition. SLEEP 2015;38(7):1145–1146.
1146
DISCLOSURE STATEMENT
Dr. Van Dongen has indicated no financial conflicts of
interest.
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Book Review—Van Dongen