A very large gap in sleep medical knowledge, one that appears to be narrowing in the past few years, is the lack of recognition of the independent nature of most sleep disorders. We have been acutely aware of this conceptualization of sleep disorders, because we have been working with mental health patients since 1988 and have published multiple papers in the 1990s and 2000s describing this co-morbidity relationship and how it demands independent clinical attention, that is, specific sleep disorders’ treatments in addition to any therapeutic steps for the co-occurring psychiatric disorders. Others have published on this co-morbidity concept regarding co-occurring medical disorders, such as cancer, heart disease, diabetes and many others.
In mental health in particular, it is interesting that the American Psychiatric Association has outpaced the American Academy of Sleep Medicine. The APA is the main proponent and publisher of the Diagnostic and Statistical Manual aka the DSM, and their two most recent versions, DSM-IV-TR (2000) and DSM 5 (2013) have gone to great lengths to incorporate ideas on the need for thorough evaluation of sleep disorders in psychiatric patients, because of the high probability most sleep conditions will prove to be independent. And, to reiterate this crucial point in the reverse formulation, independent sleep disorders will not resolve following treatment of the psychological disorder; for example, treating anxiety, depression, or PTSD is no guarantee these patients’ sleep disorders will also improve or be cured. Thus, needing their own clinical attention means they need specific, evidence-based sleep medical treatments distinct from psychiatric treatments.
The same realization on the co-morbidity model has also been emerging in the field of cardiology, where it is now extremely common for cardiologists to serve as major referral systems to sleep center operations. Indeed, in the near future, we will probably witness the development of sleep medical centers, including both clinical and laboratory functions, integrated into the everyday operations of free-standing cardiac centers or heart hospitals. It is possible such programs are already being considered or implemented given the epidemic of sleep disorders in cardiac patients due both to the average age of these individuals and the impact of compromised heart function on sleep in general and sleep breathing in particular. Unfortunately, the same type of thinking has not yet taken hold for psychiatric hospitals where the benefits to patients would be a true game changer, given our understanding of the critical role of sleep in mental health.
I believe the AASM and many sleep experts and probably the vast majority of sleep professionals are relatively speaking all on the same page with this co-morbidity framework for sleep disorders, but the larger question may be how much longer will the field of sleep medicine embrace a defensive posture in its relationships with insurance carriers and government regulators, not to mention other major medical fields that directly intersect with sleep medicine practices? Our field should be aggressively marketing the essential concept of co-morbidity and while doing so should also be chastising those who block or reject this claim. In no uncertain terms, as one very good example, sleep professionals along with professionals in the fields of psychology and psychiatry need to be demanding that all mental health patients who complain of sleep problems receive independent clinical attention at first presentation of illness. Regardless of whether the clinical provider believes the primary psychiatric disorder instigated the co-occurring sleep symptoms, the new policy going forward must hold all physicians and therapists accountable to assess these sleep conditions subjectively or objectively and ideally both at the first opportunity to do so. Failure to complete this assessment or negligent attitudes toward the relevance of these early sleep assessments ultimately will attract the attention of medical malpractice attorneys, a phenomenon already lurking on the horizon.
While this approach would cut a wide swath across all types of mental health patients complaining of sleep issues, there is the urgent matter regarding the management of inpatient psychiatric conditions, where we suspect many of these patients have been mildly to moderately mismanaged when OSA/UARS, restless legs (RLS) and periodic limb movement (PLMD) go unrecognized and untreated. For these reasons, it may prove a life-saving strategy to push for psychiatric hospitals as well as residential substance abuse recovery programs to directly incorporate sleep laboratory testing into their facilities. Many of these patients have moderate to severe difficulties with sleep prior to their admissions for inpatient services, but the hospital environment quickly leads to deterioration in sleep in many cases. The only consistent response offered to these suffering individuals is more and more medication, either higher dosages or multiple drugs. Many of these patients might greatly benefit from PAP therapy devices or evidence-based medication for RLS or PLMD.
Using the same model of care in other fields of medicine, sleep professionals should be aggressively pushing to integrate sleep medicine practices into some of the more obvious occurrences of co-morbidity:
Urology: a great deal of prescribed medications and surgical interventions are selected as reasonable treatment options for nocturia (waking up at night to use the bathroom). Yet, OSA/UARS have clearly been shown to cause nocturia, and PAP therapy has clearly been shown to alleviate or eliminate nocturia.
Otolaryngology (ENT) and oral surgeons: many patients undergoing upper airway surgery do not obtain post-surgical polysomnography to evaluate levels of success, and when these PSGs are conducted they often neglect to measure UARS, (i.e. the RERA components of OSA) with accurate technology. Thus, many of these patients suffer residual breathing events and persistent symptoms of nonrestorative sleep and daytime tiredness and sleepiness.
Nephrology and other hypertensive clinics: by now it should almost be obligatory for any patient diagnosed with so-called essential hypertension to undergo PSG and not just those patients with poorly controlled hypertension. The very presence of high blood pressure should be raising red flags throughout the medical community, because the prevalence of OSA/UARS in patients with high blood pressure will prove astronomical. Moreover, anti-hypertensive medications are not without side-effects; therefore, conceivably, a fair number of patients using PAP will decrease or cease use of their BP drugs.
Obstetrics: several studies have shown a connection to the problem of pre-eclampsia in pregnant women and how PAP therapy for OSA/UARS has beneficial effects on this condition, not the least of which is shortening periods of hospitalization. But, this potentially serious condition (pre-eclampsia) may be the tip of the iceberg because so many women without this specific diagnosis suffer horrible sleep problems during the third trimester, and it is incredibly common for such women to report new onset snoring, worsening of nocturia, debilitating fatigue and sleepiness. Clearly these symptoms are treatable, and it behooves the medical community to find rapid ways to treat pregnant women to enhance the quality of their lives in the final months of pregnancy.
Neurology and Neurosurgery: injuries to or diseases in the head or central nervous system frequently trigger the typically less common problem of central sleep apnea. Take the burgeoning epidemic of traumatic brain injury (TBI). TBI patients are often seen by a host of healthcare providers, including neurologists, neurosurgeons, neuropsychiatrists, psychiatrists, psychologists, behavioral health specialists, other mental health therapists, and occupational health therapists and now more than ever before, PTSD experts. In other words, the range of their symptoms is so vast and complex, it is quite likely some aspect of their evaluation with respect to sleep goes unnoticed, and the current theory is many of these patients are suffering from central sleep apnea.
Ophthalmologists and optometrists: increasing evidence is suggesting links between OSA and glaucoma, a condition routinely screened for when patients visit any type of eye doctor. Just think of the healthcare cost-savings when eye doctors start referring their patients for sleep evaluations.
Putting this altogether, the AASM and the entire sleep professional community must assert itself in very direct and authoritative ways to call out other fields of medicine for their negligence in refusing to conduct screening to evaluate sleep disorders in their patients. Unfortunately, all the areas described in this post are ripe for medical-legal encounters, which are likely to result in serious malpractice cases that could have otherwise been prevented by early screening prior to exposing patients to years of medications or invasive surgical procedures, not to mention prolonged hospitalizations and related morbidity, if not mortality when patients do not undergo comprehensive care connecting the dots between their medical or psychiatric illnesses and their undiagnosed and untreated sleep disorders, most commonly OSA/UARS.
We will finish this post by pointing out how the general concepts related to many of the gaps discussed in this series often play out in very specific ways in the mismanagement of many of these co-occurring conditions.
Urology: because so many medical professionals are wedded to the idea that nocturia must be an exclusive urologic condition, even after nocturia episodes are decreased from say three per night to once per night, the prevailing belief systems will insist the once per night episode can only be explained by a urologic pathophysiology. Yet, the more likely explanation will often turn out that the patient’s PAP therapy pressures were not fine-tuned. So, unless the gaps in knowledge on how to normalize an airflow curve are vigorously researched and promulgated such patients even when using PAP therapy will continue to receive inadequate sleep medical care.
Otolaryngology (ENT) and oral surgeons: we already stated that residual breathing events may not be accurately measured post-surgery, but an additional issue continually arises in the surgical approach to sleep apnea beyond this initial phase of under-treatment. Going down this pathway, most patients will want to believe the surgery must have done something positive and therefore must have improved the breathing problem at some level. Which means that for anywhere from 1 to 10 years later, when the patient continues to struggle with daytime symptoms, his or her focus will almost invariably be steered in all sorts of directions unrelated to OSA/UARS. Though no definitive resolution of symptoms occurs—for the obvious reasons that the OSA/UARS condition has not been cured—now, the problems are actually getting worse with aging.
Nephrology and other hypertensive clinics: the main issue with hypertension is the longer the sleep breathing condition goes undiagnosed and untreated, then the more the patient suffers the increased potential for worsening of cardiovascular disease. Now, the good news here is that recent evidence shows that even in OSA patients there is considerable protection from cardiovascular disease when the anti-hypertensives work well. Unfortunately, the bad news is untreated sleep apnea patients with hypertension are likely to need multiple medications at stronger drug dosages, which means greater risks for side-effects.
Obstetrics: Notwithstanding the nonsense spewed from the world of political correctness, many pregnant women suffer clear deteriorations in the quality of their lives in the final trimester. Undoubtedly, the clear loss of energy and drive in these women, affected by undiagnosed and untreated OSA/UARS will take a toll on family life, child-rearing and work performance. If someone were brave enough to publish the data on the loss of productivity at home or at work in these women, the economic losses would likely be quite high, which then might spur action to help them.
Neurology and Neurosurgery: brain injuries and diseases are risks for central apneas, but the problem here is that many sleep professionals have developed jaded views about CSA, either because they do not understand some of the mechanisms that cause the problem, or they believe that using advanced technology such as ASV is cost-prohibitive. Until these gaps in knowledge are overcome, many TBI and other neurological or neurosurgical patients will not receive the most advanced PAP devices to treat their ASV.
Ophthalmologists and optometrists: this area of medicine represents a newer field of research, so not much else can be stated beyond the decrease in quality of life when proper screening for sleep disorders is ignored.
In sum, there are many glaring knowledge gaps about specific co-morbid medical and psychiatric disorders that may lead directly to misdiagnosis, under-diagnosis or poor treatment of sleep disorders. And, these specific gaps in sleep knowledge will likely persist for some time and continue to plague these complex patients who are also suffering co-occurring health problems.
Read more from this series:
Gaps in Sleep Medical Knowledge: Part I (Normal Sleep)
Gaps in Sleep Medical Knowledge: Part II (Normal Breathing)
Gaps in Sleep Medical Knowledge: Part III (The Medicare Hypopnea Scoring Maze)
Gaps in Sleep Medical Knowledge: Part IV (The Unsolved Puzzle of UARS)
Gaps in Sleep Medical Knowledge: Part V (Coding Issues for Billing and Reimbursement)
Gaps in Sleep Medical Knowledge: Part VI (Prior Authorizations and Atypical Patients)
Gaps in Sleep Medical Knowledge: Part VII (Confusing Compliance with Outcomes)
Gaps in Sleep Medical Knowledge: Part VIII (Comorbid Sleep Disorders)
Gaps in Sleep Medical Knowledge: Part IX (Miscellaneous Topics)