SPECIAL COMMUNICATION
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Sleep Deprivation and Its Contribution to Mood
and Performance Deterioration in College Athletes
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Delmas J. Bolin, MD, PhD, FACSM
Abstract
Sleep deprivation is very common among collegiate student athletes,
resulting in impacts on mood, physiology, and performance. There are
multifactorial contributions to sleep deprivation, but resulting alterations
in sleep architecture explain impacts on learning, vigilance, mood, and
athletic performance. Recognition of the physical impacts is key. Clinical
inquiry is warranted. Medication can be helpful short term but should be
used with caution due to effects on sleep cycle and the potential for addic-
tion. Education is an effective intervention to increase sleep time, improve
mood, and improve long-term sleep habits. Sleep extension, particularly in
the setting of chronic partial sleep deprivation improves mood, vigilance,
and athletic performance in the college setting.
Introduction
Over the past 10 years, the sports medicine community has
become increasingly aware of the relationship between sleep
deprivation and diminished athletic performance. Sleep depri-
vation appears to be epidemic on campus and negatively influ-
ences every aspect of students’ lives. College students who
sleep poorly have more health issues, higher stress and depres-
sion, and are far more likely to use over-the-counter stimulant
medications to remain awake and use alcohol to promote
sleep compared with good sleepers (1). Physiologic impacts
of sleep deprivation include negative influences on hormone
balance and metabolism (2), diminished muscle glycogen stor-
age (3), and increased susceptibility to illness (4). Sleep depri-
vation is associated with depression and negative mood (5)
and is detrimental to learning, memory, and judgment (6).
Longer sleep is correlated with improved mood and academic
performance (6). Despite this, sleep medicine receives rela-
tively little coverage in medical school, primary care residency,
or sports medicine fellowship curricula.
Sports & Family Medicine, Edward Via College of Osteopathic Medicine,
Blacksburg, VA; Radford University, Radford, VA; Roanoke College, Salem, VA
Address for correspondence: Delmas J. Bolin, MD, PhD, FACSM, Edward
Via College of Osteopathic Medicine, Virginia Campus, Blacksburg, VA;
E-mail: dbolin@vt.vcom.edu.
1537-890X/1808/305–310
Current Sports Medicine Reports
Copyright © 2019 by the American College of Sports Medicine
www.acsm-csmr.org
Chronic suboptimal sleep (that is, sleep
deprivation) impairs neurologic function
and as a result, negatively impacts perfor-
mance, appropriate cognitive processing,
and mood. The collegiate athletic popula-
tion is subject to chronic sleep deprivation
for multiple reasons. Mah et al. (7) re-
cently characterized the self-reported sleep
habits of sports teams at a Division 1 insti-
tution. Nearly 40% had fewer than the
recommended 7 h sleep/night. While there
is considerable variability in individual
sleep requirements, the collegiate popula-
tion experience acute and chronic sleep
deprivation from the combined demands of collegiate academic
and athletic schedules (7). This group is further at risk for circa-
dian rhythm disturbances that are both inherent to the age group
and acquired by habit through exposure to light-emitting elec-
tronics (7). This review examines recent evidence for the effect
of sleep deprivation on the collegiate athlete’s performance,
learning, judgment, and mood as well as the evidence for po-
tential interventions for this at-risk population.
Basic Sleep Physiology and Metabolic Effects
Understanding the timing and metabolic functions of differ-
ent sleep types is essential to understanding the mechanism of
sleep deprivation's pervasive effects. Most individuals func-
tion well for 16 h of wake time, with 8 h of sleep and recovery
(5,8). Sleep and alertness is related to circadian rhythm; sleep
onset naturally coincides with decreased light (sunset), and
waking typically coincides with sunrise (8). During waking
hours, the circadian rhythm effect waxes and wanes. During
wake, this leads to periods where an individual is more alert
and during other periods is less alert. Simply put, there are
biological connections to the environment that promote/
discourage sleep. Individual performance varies with time
of day relative to the most-activating periods of the individu-
al's circadian rhythm (9). Usually, this becomes relevant for
travelling athletes crossing multiple time zones. While “jet
lag” influences performance, the athlete's biological clock
can be artificially moved without travel by inappropriate light
cues from electronic devices during dark hours (10). Although
important, circadian rhythm impact on the athletic perfor-
mance is beyond this discussion and has recently been system-
atically reviewed (11).
Current Sports Medicine Reports 305
 “Sleep quality” can be a subjective or objective description.
More than the impression of “how well they slept,” “quality”
should be viewed by the unique metabolic and physiologic
roles that occur within each sleep stage (see Fig. 1). Human
sleep has four distinct stages. Stage I is very light sleep. In this
stage, representing about 5% of total sleep time, the sleeper
often imagines falling and “jerks” awake — a “hypnic jerk.”
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The role of stage I is not fully understood. Stage II, also light
sleep, is characterized by intermittent rapid bursts of coordi-
nated neurologic activity called “sleep spindles.” During stage
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II, short-term memories stored in the hippocampus are moved
to long-term storage in the cerebral cortex (12). Stage II may
have a role in gross motor learning (13). Stage III is deep re-
storative (dreamless) sleep. Clearance of neurologic metabolic
debris occurs (14) along with long-term memory consolida-
tion; for example, a newly learned word list is converted to
long-term memory during stage III (13). Stage REM sleep
(dream sleep) further hones long-term memory.
Sleep stage organization during sleep is termed “sleep archi-
tecture” (Fig. 1). Stage III and stage REM cycle throughout the
night in 90-min intervals (a sleep cycle). In early evening, stage
III dominates, but with each subsequent cycle, REM increases.
With adequate sleep, most individuals will cycle four to six
times per night, averaging 50% stage III/stage REM and
50% of lighter stages (8). In chronic sleep restriction, stage I
and stage III sleep are preserved, but stage II and stage REM
are proportionally decreased in response to restricted sleep
time (15). Not all sleep deprivation is identical; for example,
waking 2 h early decreases total sleep time by 2 h (25% of rec-
ommended), but results in 50% of REM sleep loss.
Sleep Hygiene and the College Athlete
College dormitory life is inconsistent with good sleep
habits, described as “sleep hygiene” (Table). Approximately
77% of college students have poor sleep hygiene (16,17). To-
tal sleep amounts also are restricted: 25% of students reported
<6.5 h per night and 70% reported <8 h per night (1). Sleep
deprivation in the college setting is multifactorial. Perceived
stress is a major contributor to poor sleep (1). Insomnia due
to preperformance anxiety, sleep fragmentation (student wak-
ing during normal sleep), phone/tablet use, sleep curtailment
due to academic demands, or early morning training contrib-
ute to chronic sleep shortening. Chronic sleep deprivation
leads to significant sleep “debt” among collegiate athletes.
Figure 1: Hypnogram of normal sleep architecture. This figure demonstrates sleep architecture as a hypnogram. Data are obtained from EEG
scoring during a polysomnogram. Stage III and stage REM sleep cycles during the night at 90-min intervals (a sleep cycle, demarcated by vertical
lines). In early evening, stage III is longer, but REM increases in later cycles.
306 Volume 18  Number 8  August 2019
Table.
Sleep hygiene measures to optimize sleep.
Have a consistent presleep routine
Consistent bed and wake times
Bright, full spectrum light on waking
Limit caffeine, screen time 90 min before sleep
Avoid blue light
Bedroom dark and quiet
Do not go to bed hungry or after a large meal
Limit beverages, like alcohol, prior to sleep
Sleep in comfortable bedding
Use bedroom for sleep and relations only
Avoid reading, studying, or watching TV while in bed
To illustrate, Figure 2 shows a semester overlay of sleep and
wake times for the shortest (5.2 h and longest (7.2 h) of the
14 tested athletes at a division 3 school (18). Sleep and wake
times are relatively uniform in the early semester, consistent
with other observations (1,19). In the second half of the semes-
ter, sleep habits deteriorate. Weekend bed times and rise times
are generally later, consistent with previous studies of self-
reported sleep habits of college students (1). Sleep restriction
patterns change in response to academic and athletic sched-
ules; students sleep less immediately before academic events,
such as mid-terms or finals, and the night following a game
or team event. Finally, while the recommended nightly sleep
for this age to prevent health/performance decrements is 7 to
8 h per night (8,20), our athletes had 5.2 to 7.2 h per night. To-
tal sleep deprivation for the short sleeper relative to the recom-
mended 7 h per night over a semester was 200 h, representing
almost 1600 h over a 4-year degree (66 d). The long-term health
implications of this degree of sleep deprivation, if continued into
the postcollege years, are significant. This small sample size
only hints at the severity of the epidemic of sleep deficit on
college campuses.
Sleep Deficit on Vigilance
Sleep interruption in the collegiate dormitory setting is intui-
tively common. Most studies focus on either the effect of 1 to
3 d of acute sleep deprivation or of longitudinally restricted sleep.
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Figure 2: Longitudinal sleep patterns of a short and long sleeper through a fall semester. Wake time for short sleeper ( ); Wake time for long
sleeper ( ); bedtime for short sleeper ( ); bedtime for long sleeper ( ). Blue arrows denote weekends ( ). Red shaded areas denote academic
assignments as noted; green shaded areas are scheduled school breaks. Fourteen members of a division 3 baseball program wore Actigraph® mon-
itors throughout the fall semester. The data for the shortest (5.2 h per night) and longest sleeper (7.2 h per night) in the group are displayed above.
Data were presented at ACSM's 2018 Annual Meeting in Minneapolis, MN (18). In the first 8 wk of the semester, bed and rise times were relatively
consistent, but become more irregular in the second half of the semester. Wake and sleep times vary with breaks and examination schedules as
anticipated. Total sleep deprivation relative to the recommended 7 h per night for the shortest sleeper in our group was 200 sleep hours per semes-
ter; about 1,600 h over a 4-year degree (66 d).

The effects of sleep deprivation on perception are remarkable.
When reaction time and vigilance were measured during acute
sleep deprivation over 88 h, van Dongen and Dinges found that
during the first 16 h of wake time, there were few mistakes.
Thereafter, reaction time and missed cues increased in a pattern
that followed the circadian rhythm and accumulated with pro-
gressive sleep loss (5). Moreover, one to two nights of recovery
sleep did not completely restore performance to baseline, sug-
gesting that a weekend of “catch up” sleep may not be adequate.
Similar results were found for chronic sleep restriction. Examin-
ing the learning and vigilance of a population that included
college-aged individuals, they examined 4, 6, and 8 h sleep/
night over a 2-wk period (15). There was a dose-dependent dete-
rioration over the 2 wk where those sleeping 8 h per night had
preserved performance, but lapses increased for the 6 h per night
group and even more for the 4 h sleep per night group. Again,
2 d of recovery sleep was insufficient for the 4 h and 6 h sleep
per night groups to return to the 8 h per night group base-
line. Of significance, sleep-deprived participants consistently
underestimated their degree of impairment (5,21). Chronic
sleep deprivation over 2 wk was just as performance-limiting
as 2 d of total sleep deprivation. Sport requires recognition,
correct analysis, and then reaction/execution based on vigi-
lance; sleep deprivation increases errors in judgment and re-
sults in slower reaction time.
1.4.Sleep and Mood
Sleep time and emotional health are connected (22). Inability
to fall asleep or early wakening is one of the screening criteria
for clinical depression. Sleep deprivation as an independent risk
factor for mood disorders is less well established. After one
night of sleep deprivation, physician's moods demonstrated
statistically significant increased tension, anger, fatigue, confu-
sion, irritability, feeling jittery, and sleepiness, with a decrease
in vigor, energy, and confidence (23). Finan et al. (24) tested a
group that included college-aged students after having either
8 h of uninterrupted sleep or after 8 h of sleep with every-
hour forced awakenings. A single night of interrupted sleep
diminished the ability to recognize and respond to positive
emotional stimuli; response to negative stimuli was preserved.
A second study found that two consecutive days of interrupted
sleep diminished stage III and lead to significantly lower posi-
tive mood scores (25). Chronic sleep deprivation alters facial
cues which are recognized by others and may influence social
judgments (26). Chronic sleep deprivation could put student
athletes at risk for a “negative spiral”; sleep deficiency-fueled in-
crease in moodiness and irritability; fatigued/angry facial cues
lead to suboptimal interactions with staff, coaches, and peers,
leading to negative social outcomes and isolation, perpetuating
the cycle.
Sleep and Concussion Testing
Sleep deprivation may influence data obtained during
presport and in-sport testing (27). Baseline computer-based
neurocognitive measurements are frequently performed for
concussion prior to the start of competition. Interrupted
sleep is a hallmark of the immediate postconcussion period
(28,29), and history of concussion may influence sleep and
quality-of-life indices in the collegiate population (30). In
their study, low sleep quantity the night before testing was
correlated with greater number of symptoms and higher
symptom severity score (27). Examining the effect of prior
night's sleep on IMPACT® scores, McClure et al. found that
athletes with fewer than 7 h of sleep before baseline testing
performed worse on reaction time, verbal memory, and visual
memory scores compared with longer sleeping controls (31).
Finally, in the postconcussion period, athletes who were
concussed and had lost more than 1 h of their usual sleep
per night report more symptoms and increased severity on se-
rial evaluations (28). Evaluating sleep may be indicated before
baseline testing is performed since return to play decisions are
in part made in comparison to baseline.

www.acsm-csmr.org Current Sports Medicine Reports 307

 Interventions
Appropriate intervention in the college athlete depends on
the underlying cause of sleep deprivation. Sleep itself will not
improve performance; the preponderance of data suggests that
neurologic function is improved by sleep when the individual is
sleep-deprived. Mah et al. well illustrated the effect of sleep pro-
longation (32) on athletic performance. A group of Stanford
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basketball players were evaluated on skill, speed, and mood.
After a baseline of 4 wk of their usual sleep (approximately
6.7 h per night by actigraphy), athletes were asked to increase
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sleep over the next 5 to 7 wk (to an average of 8.5 h per night
by actigraphy). After sleep extension, the group demonstrated
significant improvements in free throw shooting (9%), three-
point shooting (9.2%), and faster sprint times after a 6-wk trial
of sleep extension. In addition, they had improvements in fa-
tigue and sleepiness scales as well as mood profile scores.
The effect of increased sleep on performance has been repli-
cated in other sports. An acute night of sleep deprivation
(5 h vs usual 7.5 h) resulted in decreased tennis serve accuracy
in college-aged semiprofessional players (33). In a similar pop-
ulation of college tennis players, 1 wk of 2-h sleep extension (to
9 h daily) improved serve accuracy from 35% to 42% and im-
proved sprint times (34). Sleep deprivation did not influence
power or performance in collegiate weight lifters, but did ad-
versely affect mood, confusion, fatigue, and vigor (35). Most
studies have small study populations and low power but sug-
gest that suboptimal sleep time impairs neurologic function;
whereas improvements in sleep time allow for improved neuro-
logic function and therefore improved performance in terms of
accurate replication of learned gross motor-firing patterns.
Sleep extension in this context improves performance.
Education
In search of the competitive edge, educating the college ath-
lete about sleep and its connection to performance is the new
battleground. The traditional approach to addressing college
student sleep issues has been didactic in nature. These include
classroom interventions and either direct (36) or online-based
education (37,38). Specific interventions, such as cognitive be-
havioral therapy, can be very helpful but is usually reserved
for students with specific sleep issues, such as insomnia, due
to difficulty falling asleep because of pervasive thoughts or
early waking from anxiety or depression (39,40).
Educating students about basic sleep hygiene and sleep-
habit optimization can alter their behavior. Unfortunately,
many traditional “sleep hygiene” tenets (Table) fall outside
of the control of a dormitory-dwelling athlete. For those under
their control, a more tailored, personalized approach may have
greater success. Herschel and O’Brien (41) recently reported a
relatively individualized online educational tool in a randomized
controlled study targeting sleep hygiene in college students. Stu-
dents were referred to a web-based tool (sleeptostayawake.org),
and a personalized profile was developed with education, in-
cluding the importance of total sleep time, regular bed and wake
times, avoiding electronics in the hours leading up to bed, and
obtaining adequate sleep prior to examinations by limiting
“all-nighters.” Only about 60% of those randomized for inter-
vention participated in the study. Of those who did, about
75% reported incorporating what they learned into their sleep
habits. At 8 wk, students who participated in the online educa-
tion had significantly lower depression scores, improved sleep
308 Volume 18  Number 8  August 2019
quality, and reported improvements in self-reported sleep-
promoting behaviors, including stopping electronics earlier,
earlier wake times during the week, having a more regular
sleep schedule, and taking fewer naps. Their findings are par-
ticularly important in that the improvements were seen at
8 wk, suggesting that early-semester intervention may allow
for behavior change prior to the deterioration in sleep patterns
typically seen in the second half of the semester (Fig. 2).
Obtaining a simple sleep history during the preparticipation
physical or during introductory student-athlete meetings that
precede most athletic seasons may be helpful. Those athletes
who score poorly on Epworth Sleepiness Scale (42), Pittsburgh
Sleep Quality Index (43), or newer tools designed by sports physi-
cians for elite athletes (44) may indicate need for intervention.
While education is effective, it does require time for the ath-
lete to adjust and implement change. For faster results, stu-
dents will often turn to either over-the-counter or prescribed
medications to increase alertness or promote sleep. Caffeine
is among the most commonly used and will promote alertness,
especially the day after shortened sleep. Caffeine blocks aden-
osine receptors; adenosine accumulates in the CSF during
wakefulness and promotes sleep onset. Taken late in the day,
caffeine can cause insomnia by preventing the onset of sleep.
There are several common medications for inducing
sleep. All have side effects, and some can be addictive and
should be used with caution in the collegiate population.
Over-the-counter (diphenhydramine) or prescription (doxepin
(3 to 6 mg) antihistamines will induce sleep but may have re-
sidual morning grogginess and so should be used with caution
for sleep induction if early morning function is required.
Trazedone, commonly prescribed for insomnia, is not rec-
ommended for the college population. Common medications
classes, such as benzo-diazepines (temazepam) and nonben-
zodiazepine benzodiazepine-receptor antagonists (Zolpidem),
have variable half-lives and are effective for sleep induction.
Both types of drugs are known to promote sleep while also
suppressing stage III and stage REM sleep. This latter effect
also is observed as a side effect in several commonly pre-
scribed drugs, including the antidepressant selective-seritonin
reuptake inhibitors (fluoxetine). Medications to promote
sleep may be best used sparingly, for short durations, and in
conjunction with an education program designed to retrain
students’ sleep hygiene habits (45).
Naps
Napping is common among college athletes. At Stanford,
80% of athletes reported taking at least one nap during the
week and 11% routinely took pregame/competition naps
(7). Napping is associated with higher academic performance
(6). Naps may be insufficient to overcome accumulated defi-
cits from several months or years of poor sleep and the data
on effectiveness is mixed; naps have been shown to mitigate
the effect of short-term sleep deprivation (5). The rationale
for naps being ergogenic is based on the observation that alert-
ness, reaction time, and sprint performance improved with a
30-min afternoon nap in the setting of sleep restriction the previ-
ous night (46). In karate, a 30-min nap improved subjective feel-
ings of alertness and fatigue regardless if there was adequate
sleep or partial sleep deprivation the previous night. Naps im-
proved both cognitive and physical performance (47). Other
data are conflicting, with a 40-min afternoon nap contributing
Special Communication
 to some deterioration in cognitive task performance in college
students who habitually nap (48). Petit et al. found that a
20-min nap did not improve cycling performance and also did
not alter postexercise sleep architecture (49). Short naps of
30 min or less are likely restorative, particularly in the setting
of sleep deprivation. They are most effective for performance
preservation when stage II sleep is present (50), are less likely
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to have postnap grogginess (sleep inertia) than naps of longer du-
ration which have potential to disturb normal sleep architecture.
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Summary
Sleep is essential for health, mood, academic, and athletic
performance. Deficient sleep, regardless of cause, decreases neu-
rologic function and is manifested by decreased performance.
Sleep extension or napping, particularly in the context of sleep
deprivation, improves neurologic function and as a result im-
proves performance. Although further research investigation
is warranted, there is sufficient evidence to justify clinical in-
quiry regarding sleep and sleep habits of student athletes. Edu-
cational intervention provides an opportunity for athletes to
make lifestyle changes with goals of better performance and im-
provement in health and mental well-being.
The author declares no conflict of interest and does not
have any financial disclosures.
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Ankle Sprains: Evaluation, Rehabilitation, and Prevention: Erratum

In the article “Ankle Sprains: Evaluation, Rehabilitation, and Prevention” published in the June 2019 issue of Current Sports
Medicine Reports, the author order should read: Eric T. Chen, MD; Joanne Borg Stein, MD; Kelly C. McInnis, DO.
Reference
Chen ET, McInnis KC, Borg-Stein J. Ankle sprains: evaluation, rehabilitation, and prevention. Curr. Sports Med Reports.
2019; 18:217–23.

310 Volume 18  Number 8  August 2019 Special Communication