deprivation in 2014 found that 27 metabolites are increased after 24 waking hours and suggested serotonin, tryptophan, and taurine may contribute to the antidepressive effect. the incidence of relapse can be decreased by combining sleep deprivation with medication or a combination of light therapy and phase advance (going to bed substantially earlier than one's normal time). many tricyclic antidepressants suppress rem sleep, providing an additional evidence for a link between mood and sleep. similarly, tranylcypromine has been shown to completely suppress rem sleep at adequate doses. treating insomnia sleep deprivation can be implemented for a short period of time in the treatment of insomnia. some common sleep disorders have been shown to respond to cognitive behavioral therapy for insomnia. cognitive behavioral therapy for insomnia is a multicomponent process that is composed of stimulus control therapy, sleep restriction therapy (srt), and sleep hygiene therapy. one of the components is a controlled regime of "sleep restriction" in order to restore the homeostatic drive to sleep and encourage normal "sleep efficiency". stimulus control therapy is intended to limit behaviors intended to condition the body to sleep while in bed. the main goal of stimulus control and sleep restriction therapy is to create an association between bed and sleep. although sleep restriction therapy shows efficacy when applied as an element of cognitive-behavioral therapy, its efficacy is yet to be proven when used alone. sleep hygiene therapy is intended to help patients develop and maintain good sleeping habits. sleep hygiene therapy is not helpful however, when used as a monotherapy without the pairing of stimulus control therapy and sleep restriction therapy. in addition to the cognitive behavioral treatment of insomnia there are also generally four approaches to treating insomnia medically. these are through the use of barbiturates, benzodiazepines, and benzodiazepine receptor agonists. barbiturates are not considered to be a primary source of treatment due to the fact that they have a low therapeutic index, while melatonin agonists are shown to have a higher therapeutic index. military training sleep deprivation has been used by the military in training programs to prepare personnel combat experiences when proper sleep schedules aren't realistic. sleep deprivation is used to create a different time schedule pattern that is beyond a typical 24 hour day. sleep deprivation is pivotal in training games such as "keep in memory" exercises where personnel practice memorizing everything they can while under intense stress physically and mentally and being able to describe in as much detail as they can remember of what they remember seeing days later. sleep deprivation is used in training to create soldiers who are used to only going off of a few hours or minutes of sleep randomly when available. changes in american sleep habits national geographic magazine has reported that the demands of work, social activities, and the availability of 24-hour home entertainment and internet access have caused people to sleep less now than in premodern times. usa today reported in 2007 that most adults in the usa get about an hour less than the average sleep time 40 years ago. other researchers have questioned these claims. a 2004 editorial in the journal sleep stated that according to the available data, the average number of hours of sleep in a 24-hour period has not changed significantly in recent decades among adults. furthermore, the editorial suggests that there is a range of normal sleep time required by healthy adults, and many indicators used to suggest chronic sleepiness among the population as a whole do not stand up to scientific scrutiny. a comparison of data collected from the bureau of labor statistics' american time use survey from 1965 to 1985 and 1998–2001 has been used to show that the median amount of sleep, napping, and resting done by the average adult american has changed by less than 0.7%, from a median of 482 minutes per day from 1965 through 1985, to 479 minutes per day from 1998 through 2001. longest periods without sleep randy gardner holds the scientifically documented record for the longest period of time a human being has intentionally gone without sleep not using stimulants of any kind. gardner stayed awake for 264 hours (11 days), breaking the previous record of 260 hours held by tom rounds of honolulu. lieutenant commander john j. ross of the u.s. navy medical neuropsychiatric research unit later published an account of this event, which became well known among sleep-deprivation researchers. the guinness world record stands at 449 hours (18 days, 17 hours), held by maureen weston, of peterborough, cambridgeshire in april 1977, in a rocking-chair marathon. claims of total sleep deprivation lasting years have been made several times, but none are scientifically verified. claims of partial sleep deprivation are better documented. for example, rhett lamb of st. petersburg, florida was initially reported to not sleep at all, but actually had a rare condition permitting him to sleep only one to two hours per day in the first three years of his life. he had a rare abnormality called an arnold–chiari malformation where brain tissue protrudes into the spinal canal and the skull puts pressure on the protruding part of the brain. the boy was operated on at all children's hospital in st. petersburg in may 2008. two days after surgery he slept through the night. french sleep expert michel jouvet and his team reported the case of a patient who was quasi-sleep-deprived for four months, as confirmed by repeated polygraphic recordings showing less than 30 minutes (of stage-1 sleep) per night, a condition they named "agrypnia". the 27-year-old man had morvan's fibrillary chorea, a rare disease that leads to involuntary movements, and in this particular case, extreme insomnia. the researchers found that treatment with 5-htp restored almost normal sleep stages. however some months after this recovery the patient died during a relapse which was unresponsive to 5-htp. the cause of death was pulmonary edema. despite the extreme insomnia, psychological investigation showed no sign of cognitive deficits, except for some hallucinations. fatal insomnia is a neurodegenerative disease eventually resulting in a complete inability to go past stage 1 of nrem sleep. in addition to insomnia, patients may experience panic attacks, paranoia, phobias, hallucinations, rapid weight loss, and dementia. death usually occurs between 7 and 36 months from onset.