SLEEP DISTURBANCE AND PSYCHIATRIC DISORDERS

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1 E-Resource December, 2013 SLEEP DISTURBANCE AND PSYCHIATRIC DISORDERS Between 10-18% of adults in the general population and up to 50% of adults in the primary care setting have difficulty sleeping. Sleep problems are even more prevalent in the psychiatric setting, affecting 50-80% of these patients. Though sleep problems are often viewed as a symptom of psychiatric disorders, studies demonstrate they may raise the risk for, contribute to the development of psychiatric disorders and/ or exacerbate the symptoms of existing behavioral health conditions. This newsletter contains useful information and clinical guidance for detecting and managing insomnia in primary care Insomnia, one of the most common sleep disorders, is the experience of inadequate or poor quality sleep characterized by: Difficulty falling asleep Difficulty maintaining sleep Waking up too early in the morning The occurrence of non-refreshing sleep Insomnia may lead to daytime symptoms including feeling tired, lacking energy, difficulty concentrating, and irritability. There are two types of insomnia: Acute insomnia: periods of sleep difficulty last between one night and a few weeks; may relate to a single event or emotional or physical discomfort. May result in negative mood or performance impairment. Chronic insomnia: sleep difficulty occurs at least three nights per week for a month or more; often occurs with other health problems, including psychiatric, medical and neurological disorders, medication and substance use, and specific sleep disorders (Restless Legs Syndrome, Periodic Limb Movement disorder, Obstructive Sleep Apnea and Circadian rhythm sleep disorders). May lead to fatigue, changes in mood (depression, irritability), impaired daytime functioning and difficulty concentrating. Sleep Disorders in Psychiatric Patients Depression: Sleep problems are common among depressed patients. Most suffer from insomnia, however obstructive sleep apnea is also common. Sleep problems may contribute to an increased risk of developing depression and reduce the effectiveness of depression treatment. Depressed individuals with sleep disturbances are also more likely to think about suicide and die by suicide than depressed patients who are able to sleep normally. Bipolar Disorder: Sleep problems are common among bipolar patients; some report experiencing insomnia while others report hypersomnia (excessive sleep). Insomnia may worsen during manic episodes and may also contribute to the occurrence of these episodes. Anxiety: Sleep problems affect individuals with generalized anxiety disorder, post-traumatic stress disorder, panic disorder, obsessive compulsive disorder and phobias. Insomnia may be a risk factor for developing anxiety and may worsen anxiety symptoms and prevent recovery. Recognition and assessment Obtaining information about patient sleep history is helpful in detecting insomnia. This may be done by directly questioning patients about their sleep history. Further, it may be helpful for patients to keep a 1-2 week sleep diary recording their bedtime, total sleep time, time to sleep onset, number of awakenings, use of sleep medications, time out of bed in the morning, and a subjective rating for quality of sleep and daytime symptoms (page 2). Sleep diaries also provide important baseline information upon treatment initiation. For some patients, a sleep study may be useful to measure how well they sleep and how their body responds to sleep problems. For patients with a suspected primary sleep disorder or insomnia with secondary causes, the Insomnia Screening Questionnaire (pages 3-5) can be used to assist in making a diagnosis. Management and Treatment In cases of acute insomnia, the need for treatment is based on the severity of a patients daytime symptoms, duration of insomnia episodes, and predictability of episodes. Acute insomnia may require treatment if a patient becomes significantly sleepy during the day after losing sleep on one or more nights. Acute insomnia which is left untreated may develop into a more chronic condition. In cases of chronic insomnia, multiple treatment approaches may be necessary. If there is an underlying psychiatric medical or psychiatric condition, this condition should be treated first. In the case that the insomnia is primary and persists beyond treatment of the underlying condition, there are multiple treatment options, including behavioral treatment approaches and pharmacological treatment approaches. Behavioral treatment approaches: Lifestyle changes: avoid caffeine, nicotine and alcohol (especially before bedtime) Regular physical activity: helps people fall asleep faster, spend more time in deep sleep and awaken less during sleep Relaxation therapy: meditation, guided imagery, deep breathing exercises, progressive muscle relaxation Sleep hygiene: promote a regular sleep-and-wake schedule, avoid computer/television 30 minutes before bedtime and in the bedroom and sleep retraining (stay awake longer to promote deep sleep) Cognitive therapy: identify dysfunctional beliefs and attitudes about sleep and replace them with more adaptive thoughts Pharmacological treatment approaches: When nondrug interventions are insufficient in treating sleeping disorders, treatment with medication is an additional option. An algorithm for treatment of chronic insomnia is provided (page 6). Further, a list of pharmaceutical therapy options is provided (page 7). Care should be taken to ensure patients with comorbid psychiatric conditions are treated appropriately; while some medications for insomnia can be used to treat a co-occurring psychiatric conditions, other insomnia medications may exacerbate psychiatric symptoms. About the Virtual Guidance Program JPS Health Network is proud to offer a new behavioral health clinical guidance resource to all primary care providers in our region. The JPS Behavioral Health Virtual Resource service offers: Telephone consultation with a behavioral health clinical team member Referral to community resources benefiting behavioral health patients Online reference library of behavioral health education materials Educational opportunities to increase provider understanding and comfort level in treating behavioral health conditions. Call or visit for more information and to access a free virtual consultation for your patient

2 Adult Insomnia: Assesment to Diagnosis. February Revised February 2007.

3 Adult Insomnia: Assesment to Diagnosis. February Revised February 2007.

4 Adult Insomnia: Assesment to Diagnosis. February Revised February 2007.

5 Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):

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