One of the most interesting sessions I attended in Baltimore delved into the impact of sleep disorders in mental health patients. As I’ve repeated, ad nauseum, how we specialize in mental health patients with sleep disorders, this topic naturally piqued my curiosity, and it did not disappoint.
Three main speakers covered specific topics often including case report information, and a fourth served as a discussant; this final speaker also brought up hypothetical cases to review to integrate the material from the earlier speakers.
The three speakers gave very thoughtful and detailed lectures, all of which pointed to the imperative to closely examine the nature of the sleep disorders in various psychiatric patients. The first presentation was entitled, “Common Psychiatric Conditions in Adults who Present with Sleep Problems.” This talk presented by Dr. Sam Fleishman set the table by clarifying the need to realize that sleep symptoms—all manner of sleep symptoms—can often be manifestations of underlying sleep disorders. He focused on insomnia, sleep apnea, restless legs, leg jerks, and circadian rhythm conditions.
Among the many important insights offered in his talk, three stood out for me. First, there is a growing recognition that circadian rhythm abnormalities may not just be associated with mental health problems, but also these schedule irregularities may be causing or aggravating these conditions. Second, the hopelessness that often arises from chronic insomnia may itself be a risk factor or otherwise contributes to suicidal ideation. Third, more attention needs to be given to residual insomnia especially in the context of failed antidepressant therapy when treating depressed patients with sleep complaints. In other words, is insomnia a co-morbid condition or still something secondary to depression? The verdict seems clear on the co-morbidity angle, but it remains uncertain how many practitioners in mental health fields recognize this distinction and how much it impacts therapeutic decision-making.
The second talk, by Dr. Ann Ivanenko, entitled “Common Psychiatric Conditions in Children and Adolescents who Present with Sleep Problems” made key points for these age groups that aligned with the first talk on adults. In addition, there is increasing recognition of the prevalence of other sleep disorders in patients with ADD/ADHD such as RLS/PLMD and sleep-disordered breathing. There was a brief mention of the problem of racing thoughts in children as a classic manifestation of insomnia, but I was expecting some commentary on assessment of enlarged tonsils in this age group, because such patients often suffer OSA/UARS. If you were not aware, many children report a decrease in racing thoughts following the T & A procedure.
The third talk, “The Impact of Psychological Issues in Parents on Management of Sleep Problems in Infants and Mothers” was presented by Dr. Reut Gruber, but unfortunately I was called out of the workshop to deal with a sleep center problem back in NM. As you can imagine, this talk would have covered the gross sleep deprivation experiences parents must struggle with when attempting to resolve insomnia and other sleep disorders in their young children.
Last, Dr. Merrill Wise, presented as a Discussant in his talk, “Navigating Through Sleep Clinic When It Seems Like Psychiatry Clinic” and spent most of his time on interesting patient case histories to highlight many of the points brought up by the earlier speakers. In so doing, he delved into an adolescent case of delayed sleep phase syndrome and an adult case where the patient had difficulties adapting to PAP therapy. In the former case, he discussed how something as simple as bright light therapy, timed for effective intervention, might be a valuable tool to employ in adolescents who commonly report this delayed schedule problem. In the adult case, he pointed to many of the behavioral interventions, such as mask habituation strategies (e.g. learning to wear it in front of a TV to overcome and distract from its sensations), and cognitive-behavioral therapy for insomnia wherein the PAP user may have to abide by the strategy to not try to go to sleep with PAP when not sleepy. In sum, the points were made repeatedly in this last talk as well as throughout the symposium that just because a sleep patient looks more like a mental health patient, we still owe it to these individuals to aggressively treat their sleep problems, often as co-morbid conditions, with a reasonable expectation their mental health symptoms will decrease in severity.
I concurred with virtually all the points made at the symposium and expressed my gratitude for the fine talks and discussion between the members of the panel. However, I expressed a need to consider making these points in a stronger and more assertive fashion. In particular, I brought up several points in the Q & A discussion afterwards, and later reiterated several facets of how we operate our sleep center in the management of mental health patients with sleep disorders. In this blog post, I will now elaborate in more detail on the various “bullet points” I offered at the end of the symposium, and my hope is that more mental health providers and sleep medicine professionals will heed this call for more aggressive strategies in dealing with sleep problems in psychiatric patients.
Here are the bullet points, after which I will elaborate:
Sub-optimal responses. This construct, or more simply, the way in which patients report less than stellar results to their treatment will one day be viewed as the most glaring error made by the professional psychiatry and psychology communities, because it prevented them from recognizing how frequent and how much these undetected and untreated sleep disorders were ravaging the mental health of their patients.
Throughout all of medicine, a sub-optimal response almost invariably triggers further exploration of additional contributing factors to someone’s poor health. When a diabetic is not responding to medications, we evaluate the timing and dosage of meds. If the meds check out, we go back to the basics of diet and exercise. When things are persistently subpar, we look for other contributing factors such as whether the diabetes represents a more complex problem, needing not just one or two medications, but maybe 3 medications and possibly insulin. And, in some cases, it becomes imperative for an obese patient to commit to losing at least 10% of their excess weight.
This same phenomenon occurs in a much more narrowed scheme among numerous psychiatric patients, particularly those suffering from depression. There may be a discussion of adding psychotherapy, prescribing regular exercise, and of course adjusting and revising medications. But, dealing with the sleep disturbances falls to the bottom of the list of things to reevaluate or newly explore. Yet, the sub-optimal results routinely look just like an undiagnosed and untreated case of insomnia or OSA/UARS or both. The patient says the depression is somewhat better, but they still feel tired or fatigued throughout the day. Sleep is a little better, but there are still far too many awakenings during the night and not much pep in the morning upon awakening. Small or not so small clues also could be noted if the patient reports persistent nocturia, a symptom rarely discussed between psychiatric patients and their mental health providers. Another issue would be hypertension creeping up slightly or concerns about cardiac arrhythmias. These two symptoms could easily be explained away by a psychiatrist or psychologist as stress-related, if they do not know how these common medical conditions connect to OSA/UARS. To repeat, the report of a sub-optimal response to psychiatric treatment should be an automatic, “do not pass GO, do not collect $200…go straight to the sleep center!”
DSM-V Sleep Disorders Section. The fields of psychiatry and psychology are now very fortunate because their main guiding manual for diagnosing patients was re-written just a few years back to focus on the critical importance of looking at sleep disorders as independent conditions affecting psychiatric disorders instead of the older and conventional way of relegating the sleep disturbance to secondary status as if the mental disorder was the sole cause of the sleep complaint. This traditional view has been extremely problematic because it meant and still proposes that the vast majority of mental health patients must traverse tortuous pathways to eventually have a healthcare provider of assorted stripes recognize an ongoing and undetected independent sleep disorder is playing a much larger role in the clinical picture. Sadly, most mental health providers continue to misdiagnose their patients in this way, that is focus on the mental issues and avoid the sleep complaints. Yet, now they have this wonderfully concise and accurate section in the DSM-V. If they would read and study this material, it would advance their practice skills enormously, and it would lead to much more accurate and timely diagnoses of sleep disorders in their patients.
Concepts of Co-Morbidity. This issue reprises the one above by seeking to eliminate the old terminology of “sleep disturbances due to a mental illness,” which had been in use for arguably a century or more, starting well before the use of the DSM manuals. The great value that arises from the use of the “co-morbidity” construct is that ultimately it will change the way both sleep and psychiatry are practiced. As I alluded to in other posts and which I discussed with several colleagues at the conference, the field of sleep medicine should prepare itself for the inexorable slicing up into various niches.
If we look just at the fields of psychiatry and psychology we can make several predictions that to my way of thinking are virtually inevitable. First, training to become a psychiatrist or psychologist is going to change sooner than later, where these professionals will likely be required to complete six to twelve months of sleep medicine training. Some might argue that we already have programs called “sleep fellowships” similar to other types of fellowships for medical subspecialties. But, I do not see such an approach maintaining itself long term for mental health providers. Because their work and training directly involves care of patients, millions of whom are actively suffering from sleep disorders, it is common sense to start training these healthcare providers in the trenches where they work, not separately in some other sleep-oriented facility.
Moreover, this problem is so widespread, we could be talking about 80 to 90% of mental health patients, because when you just glance at the DSM-V, you notice virtually every disorder listed includes a sleep disorder factor, which Dr. Lieberman noted in his talk. And, making matters more acute, psychiatric hospitals in particular will need to insert sleep testing equipment into their facilities, because so many inpatients also suffer from these undetected and untreated conditions, which most likely are delaying patients from receiving optimal care in the hospital and quite possibly prolonging their hospitalization. I would anticipate most psychiatric hospitals will need to employ a sleep specialist at their facilities, and once this process embeds itself, a short time later, all the psychiatric residents or fellows (the next levels of training after medical school) will clamor for education from the sleep specialist.
While the above will create major disruptions to current care in mental health, I believe such processes are inevitable given the obvious improvement in outcomes that will follow. Currently, just among public awareness, tons of people are describing their experiences through social media and mainstream media on how life-changing their sleep treatments have been. Chief among these treatments are PAP therapy. Therefore, the earliest disruption we will see could be family members demanding that their loved ones be permitted to bring their PAP devices with them during their psychiatric hospitalizations.
Nonrestorative sleep. This factor has also been crucial in understanding the sleep problems in psychiatric patients. The concept was brought up several times during the symposium. A singular point I brought up was the imperative to appreciate that this particular complaint almost always is sufficient to qualify a patient for a sleep study or most certainly a comprehensive sleep medicine review of symptoms and complaints.
However, my concern remains that most people linked to mental health professional facilities and institutions imagine that feelings of fatigue or daytime lethargy or not feeling rested in the morning (all three can be signs of nonrestorative sleep) are simply signs of depression or some other psychiatric co-occurring symptom or disorder. I am in no way suggesting these mental health factors would not contribute to these feelings; I am urging my colleagues to realize that sleep disorders are in the equation as well. And, for years, we have often used the single question: “is your sleep refreshing or unrefreshing?” to rapidly assess a patient’s probability for an objectively diagnosable sleep disorder. In our clinical experience, the “unrefreshing” answer is linked to diagnosable and treatable sleep disorders in well over 90% of cases. I trust mental health professionals will find the same to be true once they push to evaluate these patients with comprehensive or diagnostic sleep tools.
CPAP Traumatization. This problem remains my greatest concern of all because of the many patients who suffer from the consensus opinion that nearly anyone can adapt to CPAP if they just try hard enough. What a joke!? If more than half the patients who try CPAP are quitting in the first few weeks or months, among which are many who reject CPAP after just one night in the lab or just one night at home, I do not see how it is reasonable to make the assumption there is something “wrong” with all these patients. Logic dictates it would be just the opposite—there must be something wrong with CPAP!
There is something wrong with CPAP, and it centers around two key features of this technology. The first and most obvious is that CPAP, even auto-CPAP provides exactly the same pressure on inspiration and on expiration at any given moment in time and space. In other words, even if the CPAP is auto-adjusting, breath by breath you get the same pressure breathing in or out. You may turn on your back or enter into REM sleep, but once the CPAP device (if in auto mode) adjusts, the pressure is fixed on inhalation and exhalation. This constraining feature of CPAP sets the stage for expiratory pressure intolerance, because the human body in responding to PAP in general needs higher pressures when breathing in, but lower pressures when breathing out. Expiratory pressure intolerance occurs because it is unnatural to breathe out again such high pressures. This finding was established in 1992 in a study first demonstrating that bilevel settings were different anywhere from 2.5 to 7.5 units higher on inspiration as on expiration, and yet still established normal breathing on both limbs of respiration.
So, CPAP is wrong because the pressure is too rigidly delivered, and it’s wrong again because it cannot adjust sufficiently during expiration. Even with the use of expiratory pressure relief (EPR) systems, we do not find an adequate or consistent response, because EPR is more or less a mini-bilevel response. Thus, we move nearly all our patients onto auto-adjusting dual pressure devices, such as ABPAP and ASV.
Advanced PAP and Revisiting the Sleep Lab
On this blog, you have seen many past references to our use of advanced PAP devices and the need to return patients to the sleep lab where we can fine tune their experiences with these sophisticated technological devices. The key driver in this approach derives from auto-adjusting algorithms in the ABPAP and ASV devices, which on the one hand provide much greater sensitivity to necessary changes in the pressures for the individual (e.g. when changing sleep positions, entering REM sleep), but on the other hand are not consistently effective in managing the common residual problem of flow limitation or RERAs in the attempt to fully normalize the airflow signal.
This problem fits into the OSA equation under the general question: “How do we diagnose and how do we treat upper airway resistance syndrome (UARS)?” UARS has been a controversial diagnosis for many years, and the greatest of all ironies from our perspective is that this variant of OSA appears to be especially common in mental health patients. A further barrier to care in treating UARS is that it almost always requires higher pressure settings to attain a fully normalized airflow signal. In other words, mental health patients often need much higher pressure than might other patients with less UARS activity in their sleep breathing disorder, yet because of the nearly ubiquitous problem of anxiety among psychiatric patients, we often observe they cannot tolerate the higher pressures.
If you look at the two slides below, you can understand the general nature of this problem. When you suffer from a fully collapsed airway, an apnea, it takes very little pressurized air to re-open your airway, if just a little bit. This treatment is not like inflating a balloon, where you need lots of pressure in the very beginning to start inflating. Just a little pressure converts the apnea to a hypopnea. Then, adding just a little more air pressure converts the hypopnea to the flow limitation event. Finally, the highest pressures are needed to bring the airway fully open. The pictures with my hands are offered as a figurative example of how the airway transitions from apnea to hypopnea to flow limitation and finally fully open and normal airway.
This understanding of the treatment of OSA/UARS with PAP led us nearly a decade ago to use these devices in mental health patients and with that our publication of several research papers describing these processes and their advantages over CPAP in this patient population.