According to the National Institutes of Health (NIH), "At least 40 million Americans each year suffer from chronic, long-term sleep disorders, and an additional 20 million experience occasional sleeping problems. These disorders and the resulting sleep deprivation interfere with work, driving and social activities. They also account for an estimated $16 billion in medical costs each year, while the indirect costs due to lost productivity and other factors are probably much greater. Doctors have described more than 70 sleep disorders, most of which can be managed effectively once they are correctly diagnosed."

Every spring Rachel goes to her internist for a physical. There are certain things she's come to expect from her visits, including regular poking and prodding with a short lecture on the extra five pounds she's been carrying. Despite the fact that she hasn't slept through the night since she lost her job six months ago, she doesn't even think to mention sleep. Rachel is not unlike many of us, who haven't bothered to talk to our doctors about sleep.

According to NSF's 2005 Sleep in America poll, when respondents were asked what they would do if they thought they had a sleep problem, only 45% said that they would talk to a doctor. About two in ten respondents (18%) say they would assume the problem would go away or they would do nothing. In Rachel's case, her doctor didn't initiate a conversation about her sleep. Seven in ten poll respondents (70%) report that their doctor has never asked them about their sleep.

Despite these statistics, about 75% of the Sleep in America poll respondents said they experienced a symptom of a sleep problem a few nights a week or more in the past year. But when asked directly if they think they have a sleep problem, an equal number, 76%, said no. How do you know if the quality of your sleep is a problem worth discussing with a healthcare professional? Below we have outlined some of the sleep complaints that may or may not have warranted a discussion with your doctor, but the bottom line is, according to Carl E. Hunt, MD, director of the NIH's National Center on Sleep Disorders Research at the National Heart, Lung, and Blood Institute (NHLBI), "Sleep problems are more common than people realize. If you have concerns about your sleep, have difficulty falling asleep or don't feel well refreshed after sleeping, don't view it as a problem you have to live with. There are ways to evaluate your sleep and improve your quality of life."

Betsey, an editorial assistant in New York noticed her boyfriend, Diego, snoring. When she moved into his apartment she was shocked to learn that he snored loudly and gasped for breath often throughout the night. Her complaints of sleepless nights got his attention more than the fact that he rarely felt refreshed after sleeping what he thought was a full night.

Snoring affects approximately 90 million American adults-37 million on a regular basis. According to NSF's 2005 Sleep in America poll, two-thirds of partnered adults say their partner snores, while 6 out of 10 of all adults (59%) say they snore. More than one-half (57%) of those who snore say their snoring bothers others.

The 2005 Sleep in America poll also finds that among adults with spouses or other partners, sleep problems can be disruptive and can cause relationships to suffer. A large majority of these respondents (77%) report that their partner has a sleep-related problem, and the most common problem is snoring. When disturbed by a bed partner's sleep problems, the other partner loses an average of 49 minutes of sleep a night-300 hours a year!

Many people like Diego snore but don't know whether or not the snoring is a symptom of a bigger problem. In Diego's case he knew from Betsey that he gasped for breath during the night and he later learned that this was actually interrupting his sleep, causing him to feel sleepy during the day. Loud snoring, gasping during sleep, brief awakenings and daytime sleepiness are characteristics of obstructive sleep apnea.

According to the NHLBI, it is estimated that as many as 18 million Americans have obstructive sleep apnea. More than half the people who have sleep apnea are overweight, and most snore heavily. At least one out of 25 middle-aged men and one out of 50 middle-aged women suffer from sleep apnea, which causes them to be very sleepy during the day.

Dr. Hunt explained, "If you sleep enough and you still don't feel refreshed -- on a consistent basis -- generally more than 3 or 4 nights a week, for many weeks, you should consider seeking help from your primary care physician. We need to work to educate doctors and patients about sleep. We are actively encouraging doctors to ask patients about sleep, without being prompted by their patients. However, that shouldn't stop people from asking their doctor for help."

There are several possible reasons for snoring:

• Chronic allergies
• Nasal congestion
• Upper airway resistance
• Obesity
• Alcohol or certain medicines

What should you expect from your visit with your primary care physician?

Dr. Hunt explained, "Expect to leave with guidance and determination if any symptoms need to be pursued. If it isn't congestion, based on severity and symptoms, your visit should lead to a referral to a sleep doctor or a follow up discussion with your primary care doctor in subsequent visits. A sleep evaluation would be based on daytime sleepiness, pauses in breathing, and difficulty treating other chronic medical issues."

Insomnia is the most common sleep complaint among Americans. According to the National Institutes of Health, insomnia affects more than 60 million Americans. Jake, a doorman at a high rise apartment, is used to feeling sleepy at work and then struggles to fall asleep while it is still light out. Although he drags through his days, misses social events and dreads trying to fall asleep, he has never considered getting help for his sleep problems -- mainly because he never understood his insomnia as more than a circumstance of his lifestyle. Dr. Hunt explained, "The data tell us that an important part of helping people with insomnia is cognitive therapy, using sleep hygiene. People need to be aware that there are many ways to approach insomnia that can substantially improve one's quality of life. Sleep medicine is an option, and patients can decide that if they cannot fall asleep or stay asleep, they may need a referral to a sleep doctor."

How do you know the difference between a few nights of un-refreshing sleep and insomnia?

Although Jake didn't realize that he had a sleep disorder, his quality of life had diminished. Michael Perlis, PhD, co-author of Cognitive Behavioral Treatment of Insomnia , explained, "This is one of those things that people tend to wait on, but probably shouldn't. An ounce of intervention early on may obviate the need for a pound of cure later on. So if the insomnia lasts for more than two weeks, consider seeking out assistance."

In his book, Dr. Perlis also states, "Defining insomnia as a subjective complaint without requiring objective verification of signs and symptoms has advantages and disadvantages. The advantage of having subjective criteria is that it recognizes the primacy of the patient's experience of distress or disease.

That is, ultimately, patients seek, comply with, and discontinue treatment based on their perception of wellness. The disadvantage is that such measures, when used alone, do not allow for a complete characterization of either the patient's condition or the disorder in general."

Many people feel a lag in the afternoon. A big lunch, a boring meeting and suddenly the day feels like it will never end. The passing wish to take a nap is common but more persisting, and chronic daytime sleepiness may indicate an underlying sleep disorder. Pam, an ad executive at a big firm, would return from her daily business lunch feeling sleepy, craving a quick nap at her desk.

She continued to fight the sleepiness for the rest of the afternoon, often drinking coffee and soda to stay awake. If asked, she would blame the big lunches and late nights working, but never considered her sleepiness as part of a bigger problem. One day a friend gave her the National Sleep Foundation's Sleepiness Diary . She was surprised to learn that she rarely felt refreshed after nighttime sleep, almost always wanted to take a nap during the day, and had dozed off during meetings more than once during the two weeks while she kept the diary.

The NSF 2005 Sleep in America poll found that only half of adults can say they get a good night's sleep a few nights a week or more. One-half of all respondents (50%) report feeling tired, fatigued or not up to par during wake time at least one day a week, with 17% saying this happens every day or almost every day.

When sleep deprived, people think and move more slowly, make more mistakes, and have difficulty remembering things. These negative effects lead to lower job productivity and can cause accidents. The financial loss to U.S. businesses is estimated to be at least $18 billion each year! NSF's 2005 Sleep in America poll found that 60% of the respondents licensed to drive say they have driven drowsy in the past year, an increase over recent years; 4% have had an accident or near accident because they were too tired, or actually dozed off while driving.

Many companies are taking a hard look at fatigue and educating their employees about the signs and symptoms of a sleep issue or disorder. Union Pacific (UP) Railroad, the largest railroad in North America, employs almost 50,000 people and has created a multi-prong action plan to educate and help employees who may have a sleep problem. Through the Alertness Management Program, Union Pacific hopes to improve safety by reducing fatigue-related risks throughout the railroad, improve the work environment and improve the health and quality of life as it relates to the alertness of UP personnel.

Dennis W. Holland, PhD, Director, Health Services at Union Pacific Railroad, makes it his job to educate the employees at Union Pacific on the importance of sleep and sleep disorders. He explained, "We have trained all our operating managers in signs and symptoms of fatigue. They roll it out to their operating employees. If symptoms are persistent, it may be a sign that something deeper is going on. Employees are tested for depression as well." Union Pacific has a free phone number for its employees to call for information, assistance, assessment and counseling on compliance and treatment.

Union Pacific has also created fatigue solutions such as the Planned Nap Program, encouraging employees to sleep for less than 45 minutes when necessary and possible. They are also helping employees assess sleep issues and look for underlying health problems. For those of us who don't have round-the-clock support from our company, we have to look for signs and symptoms on our own.

Red flags that Union Pacific Railroad employees are taught to look for:

1. Acute symptoms of sleep deprivation-heavy eye lids, rubbing eyes
2. Chronically falling asleep in inappropriate places
3. Mental signs such as failure to pay attention, doing the wrong thing. Lack of focus and concentration. Depression is a significant and critical red flag.
4. Emotional symptoms-quiet and withdrawn, lacking motivation, irritable, grouchy.

Mark W. Mahowald, MD explained daytime sleepiness in Postgraduate Medicine in 2000, "True excessive daytime sleepiness is rarely, if ever, due to a psychological or psychiatric condition (e.g., depression), laziness, or boredom. In the absence of sleep deprivation, daytime sleepiness is almost inevitably caused by an identifiable and treatable sleep disorder." Dr. Holland suggests, "If you are having trouble remembering, concentrating, focusing, you are not doing the right thing at work or are experiencing lapses in attention, you should consider the possibility of a sleep-related issue. Emotional symptoms, lack of energy, feeling irritable, trouble communicating are also signs of a problem. If you are getting 7 to 8 hours of sleep and can't stay awake or can't focus on work, it could be a sleep issue or disorder."

Restless Legs Syndrome (RLS), an overwhelming urge to move the legs usually caused by uncomfortable or unpleasant sensations in the legs, is often hard to imagine unless you are the one experiencing it. According to the Restless Legs Syndrome Foundation, the sensations have the following features:

• Occur during periods of inactivity
• Become more sensitive in the evening and at night
• Are relieved by movement of the limb
• Often cause difficulty staying or falling asleep, which leads to feelings of daytime tiredness or fatigue
• May cause involuntary jerking of the limbs during sleep and sometimes during wakefulness

Doug, a retired police officer, had experienced a tingly sensation when he flew back and forth to China to visit family, but other than flying long trips, he had rarely experienced the symptoms of RLS. However, over time the symptoms increased to almost nightly. He found himself having a "night cap" to ease his discomfort and he even thought it was helping him sleep.

Merrill Mitler, PhD, Program Director, Extramural Research Program at NIH's National Institute of Neurological Disorders and Stroke, explained, "The rule of thumb is that if you have disturbed sleep-persevering nighttime waking, having difficulty falling back to sleep after awakening at night, or having difficulty getting to sleep night after night-for a month or more, you should see your doctor. You should also seek help if you fall asleep in a dangerous situation, like while driving, or at inappropriate times, like while eating dinner or being out with friends. Alcohol at bedtime is never a good idea -it is the most commonly used sleep aid but it is never beneficial. It may help you fall asleep, but the night is still disturbed."

Dr. Mitler suggests finding someone in the community who treats RLS, such as a neurologist affiliated with a local sleep center. If your insurance allows, you can find one directly or ask your primary care physician for a referral.

Dr. Mitler also suggests looking for support from other people with RLS. He explains, "It helps to know that patients are not alone. You don't need to lie in bed and suffer or try to self medicate."

More than 80 percent of people with RLS also suffer from a condition known as periodic limb movement disorder (PLMD). Characteristics of PLMD include involuntary leg twitching or jerking movements during sleep that occur repeatedly throughout the night and result in disrupted sleep.

Dr. Mitler explains, "RLS is a sensory condition and PLMD is a motor condition.

PLMD may very well be unnoticed by the patient but in severe cases will be noticed by a significant other. Patients can tell you about their RLS symptoms; PLMD patients need to be observed in a lab or by a bed partner." RLS and PLMD can be symptoms of other health problems, so it is important to take them seriously. PLMD could be a sign of a more serious condition, like Parkinson's disease.

RLS can also develop during pregnancy. The National Sleep Foundation's 1998 Omnibus Sleep in America poll showed that up to 15 percent of pregnant women develop restless legs syndrome during the third trimester. The symptoms include crawling or uncomfortable feelings in the foot, calf or upper leg, momentarily disrupting sleep.

Dr. Mitler explains, "A patient has got to recognize the general discomforts with pregnancy. If the discomfort is beyond what others experience, they can (and should) seek help. Pregnant women should not pass up the opportunity to get much needed rest. A pregnant woman experiencing symptoms of RLS would start with her obstetrician, and go from there. She may not be able to take any medication, but she will find relief in knowing that she isn't alone. It is also important to understand that RLS could be a symptom of other problems -- even if you cannot find relief-you can still find necessary diagnosis and rule out other conditions that should be identified and may need treatment. Meir Kryger, MD author of A Woman's Guide to Sleep Disorders and director of the Sleep Disorders Centre at St. Boniface Hospital Research Centre, explains, "Those who developed restless legs syndrome were found to be iron deficient and/or folic acid deficient before becoming pregnant. So common sense suggests that women who develop RLS during pregnancy have their iron status checked by a doctor." The good news is that for most women, according to Dr. Kryger, restless legs syndrome goes away with childbirth.

The bottom line is that when you experience sleep problems or their consequences such as daytime sleepiness, there is no reason to lie awake in discomfort or drag through every day. Dr. Hunt explained, "We are all affected by sleep problems at one time or another. Even if you personally get sufficient sleep and feel refreshed each day, chances are you interact with someone who has a sleep problem. It could be your mother, whose sleep apnea increases her chances of developing heart disease; your carpool driver, who might be at increased risk for a car crash because of poor sleep; or your child, who has trouble in school because she doesn't get enough sleep at night."