"Mood Disorders and Sleep" Teresa Foley (02/23/2022)

March 01, 2022

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00:13Alright, good afternoon.
00:14I'm Melissa Conner, welcome.
00:17To state Sumita Sleep Seminar
00:18took myself back a year there
00:21a couple of years anyway,
00:23it's really my pleasure today to
00:24be here to introduce Doctor Teresa
00:27Foley before you jump into that.
00:29Just to let you know that the CME
00:32information is here on the slide and
00:34will also be posted in the chat if
00:36you need it in a few minutes and.
00:40That the this meeting is being
00:42recorded and will be posted
00:43internally on the Yale websites.
00:45For those who have access to that
00:47and then as you're listening
00:49to the presentation to Kylie,
00:51meet yourself to prevent any sound feedback.
00:53And then we'll unmute ETC
00:55for questions at the end.
00:57If you have questions as we're going on,
00:59I'll be keeping track of those and
01:00looking at the chat and also at
01:02the end you can either put them
01:04in the chat or unmute yourself.
01:05So without further ado I will
01:08introduce Doctor Teresa Foley.
01:10She is one of our.
01:11Marvelous Sleep Fellows tier at Yale.
01:13This year she went to college at
01:15Boston College of Arts and Sciences,
01:17as well as Bryn Mar,
01:18where she graduated Magna *** laude.
01:21She went to medical school at Johns
01:24Hopkins University and then did a
01:26residency also at Johns Hopkins in
01:30psychiatry and I am delighted today
01:32that she's bringing to us her her
01:35expertise in psychiatric disease
01:37and specifically mood disorders.
01:39A huge element of our practice
01:40in Sleep Medicine.
01:41In a blind sign for a blind side
01:43for a lot of us who are trained
01:46from a pulmonary perspective.
01:48So thank you very much and I'm
01:50looking forward to this talk.
01:51Great,
01:52great and can you hear me OK and
01:54see this slide alright perfect
01:57alright so thank you Doctor Cowart
02:00and I have nothing to disclose.
02:02Alright so I'll be talking about mood
02:04disorders and sleep which is a huge topic.
02:07It's like you know breathing disorders
02:08and sleep you know we're not going to be
02:11able to hit all the highlights here and so
02:13I had to be selective in choosing topics.
02:16And my main goal work goals were to,
02:20you know, get you more interested
02:21in this field if possible.
02:23And also I'm really trying to focus on
02:25what might be useful for patient care,
02:27so I'll first start with the
02:29basic overview of mood disorders,
02:31and then I'll be spending the bulk
02:33of the time talking about sleep
02:34and mood disorders and then finally
02:36end with what I hope will be some
02:38practical tools for patient care.
02:41So the objectives here are to review
02:44diagnosis and treatment of major
02:46depression and bipolar disorder to
02:48understand patterns of sleep and PSG
02:51findings in patients with mood disorders.
02:53Describe the effects of antidepressants
02:55on sleep, and then again hopefully learn
02:58some practical tools for patient care.
03:01So mood disorders are really
03:03a class of disorders.
03:04It's more than just major depression,
03:06although that's sort of
03:08the most important one.
03:09There are two chapters in the
03:11current edition of the DSM,
03:13the DSM 5 on depressive disorders
03:15and bipolar and related disorders,
03:18and so they include major depression,
03:20major depressive disorder,
03:22disruptive mood dysregulation, disorder,
03:24persistent depressive disorder,
03:26formerly known as dysthymia
03:28or double depression,
03:30premenstrual dysphoric disorder.
03:31Bipolar disorder types one and two,
03:34sometimes known as bipolar
03:36affective disorder, cyclothymia,
03:38and then others,
03:40or non specified.
03:42So mood disorders are very common both in
03:44the general population and then even more so.
03:47In Sleep Clinic,
03:48there's a lifetime prevalence of
03:51between one and 5% for bipolar disorder,
03:53depending on whether you're talking
03:56about just bipolar disorder type one or
03:58the whole class of bipolar disorders,
04:01major depression is even more common
04:03with a lifetime prevalence of about
04:0520% of the general population.
04:07Patients with insomnia are about
04:0910 times as likely as those as
04:12good sleepers to have.
04:13Major depression and patients with
04:15sleep apnea are about two to five times
04:18as likely as those excuse me two to
04:22five times as likely as those without
04:24sleep apnea yet to have major depression.
04:27Depression is one of the main
04:29contributors to suicide.
04:30It's implicated in about 50
04:32to 70% of suicides.
04:35Suicide is,
04:36unfortunately currently the 10th leading
04:38cause of death in the United States
04:41and it's the second among adolescents.
04:43And young adults.
04:44So this is a global statistic.
04:46Here in 2019,
04:48one in 100 deaths was by suicide.
04:54Depression is considered the leading
04:56cause of disability worldwide,
04:58and it's also a major contributor
05:00to the global burden of disease.
05:02It's associated with an increased
05:04risk of a host of medical problems.
05:06It associated with increased mortality,
05:09it's disruptive to family relationships,
05:11impacts careers, educational success, etc.
05:15It's estimated to cost the United
05:17States over $200 billion per year.
05:20About half of those costs are due
05:21to increase costs in health care.
05:24And about half are due to workplace
05:28costs including absenteeism
05:29and reduced productivity.
05:32And apparently it's associated
05:34with even greater health care
05:36costs than elevated blood sugar,
05:38high blood pressure, obesity,
05:40tobacco use, or physical inactivity.
05:44So we can look up, you know,
05:46lists of diagnostic criteria for
05:47all these different mood disorders.
05:49But for for our purposes I thought
05:51it would be more useful if I could
05:53provide a fairly simple framework
05:55for just thinking about what mood
05:56disorders are and what it's like
05:58for the patient to experience them,
06:00and also to kind of help you get a
06:02sense of whether a patient might
06:04be going through a mood disorder
06:07experiencing that so that we can
06:09group symptoms into three groups.
06:11So that would be mood, self attitude.
06:14And vital sense.
06:16Mood is what we're most familiar with,
06:18so that might be, you know,
06:19elevated in mania, for example down,
06:22irritable, sad, depressed mood,
06:24empty mood or no mood in a period
06:28of depression.
06:29Self attitude is 1's assessment
06:32of self worth and vital sense is,
06:35you know, sort of those physical
06:38and cognitive symptoms.
06:39You know, speed of thinking,
06:40speed of movement,
06:42sleep, energy, appetite,
06:44ability to focus and concentrate,
06:45etc.
06:48So I have a an exam patient
06:51example of low self attitude.
06:55I have received the cake.
06:56Many thanks but I am not worthy.
06:58I am not worthy of my birthday.
07:01I must weep myself to death.
07:03I cannot live and I cannot die
07:05because I have failed so much and
07:07that is from a patient letter in 1905.
07:14These three groups of symptoms
07:15tend to track together so mood,
07:17self attitude and vital sense are all
07:20down in an episode of depression.
07:23They're all elevated in an episode of Mania.
07:26They're all elevated,
07:27but to a lesser extent.
07:28In an episode of Hypomania and then
07:31there is this thing called a mixed
07:33episode and I just want to briefly
07:35mention that so you know that it
07:36exists and that's when these can
07:38kind of go in different directions.
07:40So you can imagine that if a patient
07:42has low mood, low self attitude,
07:44or feeling hopeless, worthless, depressed,
07:47and yet they have increased energy,
07:51that can be very dangerous in terms
07:53of risk of suicide, for example.
07:56But generally the symptoms tracked
07:58together either up or down,
08:00so looking overtime if we see
08:02the white line here,
08:03that would be considered normal,
08:05or you know,
08:06a patient without a mood disorder,
08:08and there are the general you know,
08:09sort of ups and downs of life
08:11that everyone experiences,
08:11but they're not very extreme.
08:13If you look at the blue line though,
08:15that would be in a person.
08:16A person with major depression.
08:18They have quite low and sustained
08:22period of of depression.
08:23And then there are periods in between
08:25which would be considered normal mood.
08:27Or euthymia.
08:30And then in bipolar disorder there are
08:32periods of low mood or depression,
08:34and then there are also periods
08:35of elevated mood and increased
08:36energy and vital sense,
08:38and that would be in mania or hypomania.
08:40So that would be the yellow line.
08:43So going for mood episodes to mood disorders
08:46in terms of actually diagnosing someone,
08:49if a person has a history of depressive
08:52episodes only as well as periods of euthymia
08:54that would be classified as major depression
08:57or sometimes known as unipolar depression.
09:00In other words,
09:01they only go down from normal mood.
09:04If a person has a history of depression
09:06and any history of hypomania,
09:08even just one episode,
09:10that would be considered
09:11bipolar disorder type 2.
09:13Shares of a person has a history
09:15of even just one episode of Mania,
09:18whether or not they have any
09:20history of depression that would be
09:22considered bipolar disorder type 1.
09:24So just moving on to treatment,
09:26I've grouped the treatments
09:28into four buckets,
09:30so from the top everyone you know whether
09:32you have a mood disorder or not can
09:35really benefit from healthy lifestyle.
09:37All patients with mood disorders,
09:39or at least the vast majority
09:41can benefit from psychotherapy.
09:43Many patients will benefit from
09:45medications and then some patients
09:47will need other treatments.
09:49So going through in reverse order here.
09:52Excuse me
09:55these other or experiment experimental
09:58treatments include ECT electric,
10:00convulsive therapy,
10:02transcranial magnetic stimulation,
10:03which is TMS, vagus nerve stimulation,
10:06deep brain stimulation,
10:08ketamin and sleep deprivation,
10:11and I'll talk a little bit more
10:13about sleep deprivation later.
10:16For medications in terms of major depression,
10:20antidepressants are really the
10:21primary drugs that we use.
10:23They're commonly used as you know,
10:24for anxiety, pain, and other disorders.
10:28There are many different antidepressants
10:31and generally a psychiatrist or
10:33primary care provider would choose
10:35one based on the side effect profile,
10:37the patients comorbidities and preferences,
10:40and just the you know.
10:41Clinicians experience with these medications.
10:44The first one may not work very well.
10:45So a patient may need to try more
10:47than one and they need to may need
10:49to take more than one simultaneously
10:51to have the maximum effect.
10:55Additional medications that patients with
10:57depression may be on include lithium
11:00low dose lithium may be helpful at
11:03reducing suicidality in some patients
11:05and then medications for anxiety and
11:08insomnia are also very commonly used.
11:11For bipolar disorder,
11:12the medications we call mood stabilizers
11:14are really the mainstay of treatment.
11:17It's really several classes of medication.
11:19Lithium is one of the oldest,
11:20and it's very effective mood stabilizer
11:23and then Depakote and Tegretol are
11:27anticonvulsant medications that
11:28were found to have mood stabilizing
11:31properties and then more recently the
11:33newer generation of antipsychotics
11:35have been found to be effective
11:38as mood stabilizers as well.
11:41Additional medications would
11:43include antidepressants,
11:44so sort of classic mood
11:47stabilizers that I just mentioned.
11:50Would be more effective at treating
11:51mania or hypomania and not quite
11:53as good at treating depression,
11:54but there is a possibility that
11:56if a person with bipolar disorder
11:58is only on an antidepressant,
12:00their moon may kind of flip up.
12:02They may have what we call a manic
12:04switch where their mood goes from
12:06being too low all the way up into
12:08a full blown episode of Mania.
12:09And so it's very important for a
12:12person with bipolar disorder to
12:13be on a mood stabilizer and not
12:16just an antidepressant alone.
12:18So psychotherapy again,
12:19I you know,
12:20I think basically all patients can benefit.
12:22There are many goals including illness,
12:24education,
12:25identifying underlying stressors or
12:27vulnerabilities,
12:28including personality vulnerabilities,
12:30life stresses,
12:31developing positive habits or thoughts,
12:34motivation for treatment and relapse
12:36prevention.
12:39Kay Jamison, who's a researcher in
12:42mood disorders and author of a personal
12:45memoir called An Unquiet Mind about
12:47her journey with bipolar disorder,
12:49said about lithium and psychotherapy.
12:52I need both lithium to keep me well and
12:55psychotherapy to keep me on the lithium.
12:58There are many different
13:00types of psychotherapy.
13:01There are the psychodynamic or
13:03psychoanalytic therapies cognitive
13:04or cognitive behavioral therapies.
13:06Interpersonal DBT.
13:07Accepted as a commitment,
13:09therapy, etc.
13:10But it really seems to be that the
13:12individual therapist is generally
13:14more important than the type
13:16of therapy that they're doing,
13:19and in practice many therapists will
13:21blend different types of therapy
13:23together in treating patients.
13:25It's important to note that.
13:27If a patient reports a failure
13:29of psychotherapy,
13:29most likely it just wasn't a good
13:31fit with that particular therapist,
13:33and so it's worth trying again
13:34with another person.
13:37So these are some healthy habits
13:39that can help treat and prevent
13:41recurrence of mood disorders.
13:43All of them may help.
13:44Some of them have more data than others,
13:46so I typically recommend the top 4.
13:50I'm so light I'll talk a little
13:52bit more about later that would
13:53either be using a light box for
13:55sort of formal bright light therapy,
13:57or just even getting outside
13:58for a few minutes every day,
13:59ideally in the morning.
14:01Aerobic exercise a few times a week
14:04can be helpful for sleep that's both
14:06getting enough sleep and also getting
14:08sleep at regular times for socialization.
14:10You know, getting outside of the house,
14:12getting outside of your apartment,
14:14being around other people I time
14:15with friends if at all possible,
14:17that could be really helpful
14:18for people with mood disorders.
14:20So ideally now I tell my patients every
14:22morning go for a long walk with a friend,
14:24you know,
14:24and that can kind of help with the exercise,
14:27socialization,
14:27sunlight and all of that can also help
14:30with regular and sufficient sleep.
14:36OK. And then the Bunny slippers.
14:39I just thought were kind of fun.
14:43OK, so just an overview of that you
14:46know of that overview mood disorder
14:49symptoms can be put into three groups,
14:51mood, self attitude and vital
14:53sense symptoms generally tracked
14:55together and are low in depression,
14:57elevated in hypomania and high in mania,
15:00any history of mania or hypomania
15:02would be considered bipolar disorder.
15:05Mood disorders are treated
15:06with healthy habits,
15:08including sleep and light exposure,
15:10psychotherapy and medications.
15:12Antidepressants can cause
15:13a manic switch in in.
15:16People with bipolar disorder
15:17if they're not also on and on.
15:20A mood stabilizer,
15:21and then patients may need to try a
15:24few medications and see more than one
15:26therapist before treatment is successful.
15:29So now on to the main part of the talk.
15:32It's no secret that patients with mood
15:35disorders have problems with sleep.
15:37Plato and Hippocrates apparently
15:39wrote about patients with melancholia
15:41and their problems falling asleep,
15:43staying asleep and waking up
15:45too early in the early 1900s.
15:47And milk raplin, who's?
15:49A German psychiatrist,
15:50wrote textbooks describing mental illness.
15:53He divided depression into 2 categories,
15:56and he noted that neurotic or
15:58psychological depression was associated
16:00more with sleep onset, insomnia, or.
16:03Early insomnia that endogenous or
16:06biological depression as it was called.
16:09Was associated with more sleep,
16:10maintenance,
16:11insomnia and early morning awakening.
16:14And then starting in the 1960s,
16:17sleep studies began documenting sleep
16:18problems in patients with mood disorders.
16:23So I thought this was a good description of
16:25problems in both kind of extremes of mood.
16:28Also by Kreplin about 100 years ago,
16:30the attacks of manic depressive insanity
16:33just a old term for bipolar disorder,
16:36are invariably accompanied by
16:37all kinds of bodily changes.
16:39By far the most striking are the disorders
16:42of sleep and general nourishment.
16:44In Mania, sleep is always
16:46considerably encroached upon.
16:47Sometimes there is even almost
16:49complete sleeplessness at most.
16:51Interrupted for a few hours.
16:52Which may last for weeks, even months.
16:55In the states of depression,
16:57in spite of great need for sleep,
16:58the patients lie for hours,
17:00sleepless in bed,
17:01although even in bed they
17:02find no refreshment.
17:06So looking at more modern studies on
17:09bipolar disorder and depressive episodes,
17:11insomnia is very common.
17:13About 2/3 of patients,
17:15whereas hypersomnia occurs in about 1/5
17:18to another third of patients in the
17:22manic or hypomanic episodes decrease.
17:24Need for sleep is very common.
17:26It's one of the most common
17:28symptoms of mania,
17:29and it's often the first sign,
17:31and it's possible that sleep
17:33loss may precipitate mania.
17:37So if you're wondering how to differentiate
17:39insomnia for mania in a patient,
17:41who spends hours in bed,
17:42and maybe has a history of
17:45bipolar disorder and insomnia,
17:46the person will often describe
17:48feeling tired, drained.
17:49They may also have low motivation,
17:51and they may be anxious.
17:51They may be depressed,
17:53they don't feel restored,
17:54so really they need more sleep,
17:56but their body won't sleep,
17:58whereas in mania or hypomania,
18:01the person may describe feeling energetic,
18:04you know, active, impulsive,
18:05they're revved up,
18:06they've got plenty of energy.
18:08They may lie in bed because they feel
18:09like they're supposed to sleep more,
18:11or you know they.
18:12They usually need 7 hours,
18:13let's say,
18:14but they really don't need
18:16as much sleep in that time.
18:21So turning to sleep problems
18:24in major depression.
18:25Insomnia is present in the great
18:28majority of patients over about half
18:31of patients have both difficulty
18:33falling asleep or initial insomnia,
18:35as well as early morning awakening.
18:38Hypersomnia is also fairly common
18:40and then other sleep complaints
18:42include non restorative sleep,
18:44daytime sleepiness, fatigue,
18:46nightmares and increased risk.
18:48As I mentioned of sleep apnea or you know.
18:52But daytime sleepiness has not been found.
18:56There's there's not been objective
18:58evidence of hypersomnolence on MSLT,
19:00so perhaps patients are describing fatigue.
19:06So just looking more closely at the
19:08relationship between insomnia and
19:10depression in patients with insomnia,
19:11I mentioned that there are 10 times as likely
19:15as good sleepers to have major depression
19:17if they don't have major depression.
19:20There are two to five times as
19:22likely to develop major depression.
19:24If the insomnia is not treated,
19:27and then insomnia seems to be
19:29independent risk factor for suicide,
19:32including suicidal thoughts
19:33as well as death by suicide.
19:35And in the majority of studies that
19:38remains in a risk factor even when
19:41controlled for the severity of depression.
19:43I'm looking at it from the other angle
19:46in patients with major depression.
19:48Insomnia is a residual symptom.
19:50Unfortunately, in about 20 to 40% of
19:54patients who are treated for depression.
19:56So after the depression goes away,
19:58it's the insomnia remains
20:00in about 1/3 of patients.
20:02Residual insomnia increases the risk
20:04of relapse of major depression.
20:07But the good news is treating insomnia
20:09in patients with depression even without
20:11using any kind of antidepressants.
20:14Treating insomnia with hypnotics or
20:16with cognitive behavioral therapy for
20:18insomnia can actually have improvement
20:21in their depressive symptoms.
20:25And so the take home points
20:27just on this section.
20:28Poor sleep is characteristic
20:29of mood disorders, insomnia,
20:31hypersomnia and reduced need
20:33for sleep in the different mood
20:36states patients with mania or
20:38hypomania may spend hours in bed
20:41awake as those do with insomnia,
20:43but they do not need more sleep.
20:46Insomnia, risk factor for
20:47new onset depression,
20:48relapse of depression and suicide
20:52and treating insomnia can
20:53reduce symptoms of depression.
20:57So Polysomnogram findings
20:58and major depression,
21:00which is the most well studied,
21:02include three groups of of of differences.
21:07So the first is poor sleep continuity.
21:11Or you could think of that as
21:14increased sleep fragmentation.
21:15So that's reduced sleep efficiency,
21:17prolonged sleep latency,
21:18increased number and duration of awakenings
21:21as well as early morning awakening.
21:24The second is reduced.
21:25Slow wave sleep or also
21:28called reduced sleep depth,
21:30and that's characterized by more more time
21:32in stage one less time in stage three,
21:35and then in some patients the longer
21:38period of slow wave sleep seems to shift
21:41from the 1st to the 2nd sleep cycle,
21:44and then the third is increased REM sleep,
21:47sometimes called increased REM
21:49pressure or disinhibition of REM sleep.
21:52Excuse me.
21:55So that's shorter latency to
21:56stage are more time in stage,
21:59are especially early in the night
22:01in the first sleep cycle and then
22:03increased rapid eye movement density
22:05and so that means the number of
22:07eye movements during stage are.
22:11So and this hypnogram,
22:12you can see those findings.
22:14So first, in terms of poor sleep continuity,
22:16the purple on the top is wake
22:18and you can see the person is
22:20just bouncing up and down in and
22:22out of wakefulness and sleep.
22:23There are a lot of awakenings,
22:25and there's also the persons waking
22:27up kind of early in the morning
22:29in terms of reduced slow wave
22:30sleep all the way at the bottom.
22:32The dark blue is stage three
22:34and you can see there's very
22:37little stage three sleep.
22:39And then increased REM.
22:40The red is rapid eye movement sleep
22:43and you can see there's reduced
22:45REM latency and there's a lot of
22:47REM sleep throughout the night,
22:49including early in the night.
22:52And some other polysomnogram findings.
22:55Patients with depression have been
22:57found to have reduced slow wave
22:59sleep and shortened REM latency
23:01even during periods of euthymia.
23:05Family studies have also shown similar
23:08changes in REM sleep. In other words,
23:10family members who don't have depression,
23:12but they're they're relatives do.
23:15So maybe there's some kind of
23:17trait versus state markers,
23:18but either way they're not
23:20specific to depression.
23:22Similar polysomnogram findings have been
23:25noted in other psychiatric disorders.
23:29Increased sleep latency and increased
23:30REM density have actually been found
23:32in all stages of bipolar disorder,
23:33including mania.
23:36And then similar findings of last
23:39slave sleep reduced REM latency and
23:41more sleep fragmentation as well as
23:44early morning awakening are also found
23:46in normal aging in patients without
23:48depression in these age related
23:51changes are more pronounced in elderly
23:54patients who also have depression.
23:58There's a lot of evidence of circadian
24:01abnormalities and depression,
24:02so depression is associated with reduced
24:04heart rate and temperature variability,
24:06and over the course of the day,
24:08circadian fluctuations and cortisol
24:10and norepinephrine tend to be
24:12phase advanced in depression and
24:14then mood and suicide rates vary
24:16diurnally over the course of the day,
24:18as well as seasonally throughout the year.
24:21So a classic symptom of depression
24:22is low mood in the morning,
24:24but it gets a little better
24:26in the evening and then also,
24:27mood tends to be worse in winter.
24:29You know, with seasonal affective disorder,
24:32and I thought this was surprising.
24:35Suicide rates also seemed to
24:37be higher in the evening,
24:39kind of evening,
24:40middle of the night or late in the night,
24:43depending on the different study in
24:45the demographic studied.
24:46But spring and summer actually had higher
24:49rates of suicide compared with winter,
24:52which I was not expecting.
24:55So people have studied,
24:57you know the relationships between mood and
24:59sleep and come up with all kinds of theories.
25:01So I just want to briefly mention them here.
25:03So one is that CNS arousal or some kind
25:06of problem with serotonin transmission
25:10leads to sleep fragmentation and
25:12then that leads to depression.
25:14Another theory is that increased rapid
25:16eye movement sleep leads to depression.
25:19Another is that depression leads
25:20to some kind of primary defect
25:23in the homeostatic sleep drive.
25:25And that causes a decrease
25:26in slow wave sleep,
25:28and then that leads to earlier and
25:30more rapid eye movement sleep.
25:32Another is that circadian phase
25:35advance advancement leads to
25:37depression and then finally there's
25:40this cholinergic energic imbalance
25:42or cholinergic supersensitivity or
25:45HPA axis activation that causes
25:47both insomnia and depression.
25:49So in other words there's a shared
25:51pathway leading to problems with
25:53mood and problems with sleep.
25:57So summary on that section Polysomnogram
26:00findings in major depression and
26:03bipolar disorder include reduced sleep,
26:05continuity, reduced slow wave sleep,
26:07and increased rapid eye movement sleep.
26:10Polysomnogram findings are not
26:12specific to mood disorders.
26:13Some are found in normal aging
26:16or other psychiatric disorders,
26:17and some maybe treat markers found in family
26:21members or during periods of euthymia.
26:24Mood disorders are impacted by
26:26seasonal and circadian rhythms and
26:28relationships between sleep and mood
26:30are complex and likely bidirectional.
26:35Alright, so now I'll briefly go over some
26:38effects of antidepressants on sleep.
26:41So this is a busy slide,
26:42but I'll just sort of go
26:44through it one line at a time,
26:45and then I'm going to repeat some of the
26:47information on the next couple of slides.
26:49So Doxepin and amitriptyline are newer,
26:52sometimes called third generation
26:55tricyclic antidepressants,
26:56and they tend to increase sleep continuity.
26:58They can help with sleep as we know
27:00they tend to increase slow wave sleep
27:03and decrease rapid eye movement sleep.
27:05They're also associated with
27:07weight gain and possibly with an
27:09increase in Russell's leg symptoms.
27:11In the asterisk I put some of the
27:14sleep changes noted with older
27:16tricyclics including nortriptyline,
27:18and they either don't seem to
27:21affect sleep as much or they have
27:23opposite effects of the of Doxepin.
27:25Amitriptyline for SSR eyes or
27:29SSR eyes same thing.
27:32They also seem to depress rapid
27:35eye movement sleep but they seem
27:37to have the opposite effects on
27:39sleep continuity and slow wave.
27:41Sleep compared with Doxepin amitriptyline
27:43they seem to cause more sleep
27:46fragmentation and increase slow wave sleep.
27:49They're definitely associated
27:50with an increase in restless leg.
27:52Symptoms in REM without atonia
27:54in nightmares and in bruxism.
27:57Although interestingly patients often
27:59subjectively report improvement in sleep,
28:02the SNR eyes tend to be more activating,
28:07so they definitely are associated
28:08with a decrease in sleep continuity.
28:10In other words, more sleep fragmentation.
28:12They also may increase slow wave sleep,
28:16and they definitely suppress REM
28:17sleep or decrease rapid eye movement
28:20sleep and similar to the Sri's there
28:22associated with an increase in restless
28:24legs run without a Tony and nightmares
28:26in Brooks ISM bupropion is different
28:28from a lot of the other antidepressants.
28:31It doesn't work on serotonin
28:32at all as far as we know.
28:34It really seems to just work
28:36in norepinephrine and dopamine.
28:38It does seem to cause some
28:41sleep fragmentation.
28:42And also likely increases as slow wave sleep,
28:45but unlike the others,
28:47it either has no effect on rapid
28:48eye movement sleep or it seems to
28:50increase rapid eye movement sleep.
28:55It tends to be activating and so
28:57sometimes it's even used to help reduce
28:59daytime somnolence in a patient with
29:00depression who's really having a hard
29:02time focusing there sort of have that
29:05mental cloudiness bupropion can be good.
29:08Unlike many other antidepressants
29:10which are associated with weight gain,
29:13Bureau program is not associated with
29:15that and occasionally can lead to some
29:18weight loss and then another difference is
29:21that it may reduce restless leg syndrome.
29:24Symptoms so mirtazapine here
29:27is the last one on the list.
29:30And actually,
29:31trazadone has similar effects as well,
29:33and that increases as sleep continuity
29:36increases, slow wave sleep and doesn't seem
29:39to have much of an effect on REM sleep.
29:41Unfortunately,
29:42it has a strong association with an increase
29:45in restless leg symptoms and nightmares,
29:48and also can cause significant weight
29:50gain as well as daytime somnolence.
29:55And then I just have a couple of
29:56other notes here, but I'm going
29:58to go over a lot of this again,
30:00so just overall in terms of the
30:03effects of antidepressants on sleep,
30:05there are significant variability within
30:07a class of depression, medications,
30:09and also even just between individuals,
30:12especially in the SSRI group.
30:14There's a lot of variability,
30:17some sris at SNR eyes and
30:20Grupo bupropion disrupt sleep.
30:23But other antidepressants.
30:25Seem to improve sleep continuity.
30:27Generally antidepressants are used
30:29in much higher doses for depression
30:32than they are for insomnia.
30:331 exception is mirtazapine,
30:3515 to 30 milligrams may be kind of a
30:38sweet spot where it's low enough to
30:40work on histamine and improve sleep,
30:42but it's high enough to have
30:45some antidepressant benefit.
30:47Antidepressants may cause
30:48circadian rhythm disorders.
30:50There are some interesting
30:52studies showing that fluvoxamine,
30:53which is luvox and SSRI,
30:55seemed to cause delayed
30:58circadian rhythm disorder.
31:00Withdrawal from antidepressants
31:02can also disrupt sleep.
31:04Peroxy teen,
31:05which is Paxil and venlafaxine,
31:07which is a fixer,
31:08are notorious for being very
31:10difficult to come off of because
31:12of their withdrawal symptoms.
31:14Antidepressants can cause daytime sedation,
31:16so that's.
31:18Noteably in the case with mirtazapine
31:21and sometimes with Trazodone or they
31:23can improve alertness during the day,
31:24as I mentioned with bupropion.
31:28Generally antidepressants
31:29decrease rapid eye movement sleep,
31:32although there are exceptions as I mentioned.
31:36They seem to increase slow wave sleep.
31:39One exception though are
31:41the activating Tricyclics.
31:43May cause or worsen restless leg symptoms,
31:46especially mirtazapine.
31:47Again bupropion is an exception.
31:50There they can cause or worsen nightmares.
31:52Again, mirtazapine is,
31:54you know,
31:55especially noted to do that
31:57withdrawal from antidepressants
31:59can also cause nightmares,
32:01and then antidepressant medications
32:03can cause weight gain again,
32:05be appropriate as an exception
32:07there and then again,
32:08just as a reminder,
32:09antidepressants can trigger mania or
32:12hypomania in patients with bipolar disorder.
32:15Who are not also on a mood stabilizer?
32:21So, just briefly to mention the effect
32:23of sleep deprivation on mood disorders,
32:26a single night of sleep deprivation seems
32:28to have a short lived but very powerful
32:32antidepressant effect. It's in over.
32:34Half of patients seem to have a complete
32:38response of their major depression
32:41after just one night without sleep.
32:44Unfortunately, after they
32:45sleep the next time,
32:47even for just a couple of hours,
32:48the depression returns.
32:49So it's not really very practical treatment.
32:51Although I have been involved in one
32:53case where we did use that per patient
32:56who was extremely depressed for months
32:58and we just really needed some wins
33:00for her to sort of have a little bit
33:02of hope that she could get better.
33:04Partial sleep deprivation has been tried,
33:07including just sort of all stages.
33:10In other words,
33:11just restricting the total number
33:12of hours of sleep and then also
33:15selective REM sleep deprivation.
33:16So doing studies in the lab where you
33:20know when you notice the patient starts
33:21going into rapid eye movement sleep,
33:22then you wake them up and that that
33:25may have some sustained benefits,
33:27but certainly still not a practical
33:30treatment most of the time and then.
33:34Similar to antidepressants
33:35with bipolar disorder,
33:37sleep deprivation in patients
33:39with bipolar disorder has been
33:42shown in experimental studies.
33:44To increase the risk of mania.
33:46We don't know for sure if that happens in,
33:49you know,
33:50real life and but we we know we are
33:54concerned enough about that that we
33:56try to tell patients with bipolar
33:57disorder to really protect their sleep
33:58and make sure they get enough sleep.
34:00Because of this risk of triggering
34:03triggering mania from sleep deprivation.
34:07And then just briefly to talk about
34:09the impact of light on mood disorders.
34:11Bright light therapy is the most effective
34:14treatment for seasonal affective disorder,
34:16and that's currently now called
34:19seasonal major depressive disorder.
34:21It's also effective in
34:22Nonseasonal major depression,
34:24especially if it's used
34:26along with antidepressants.
34:27It may be effective for bipolar depression,
34:30but again, really as an adjunctive therapy,
34:33the person also has to be
34:35on a mood stabilizer.
34:36You know,
34:37because it's not associated with weight gain,
34:39there are no drug interactions
34:40or try to genic effects.
34:42It may be something that we'll
34:44see used more commonly over.
34:46You know the next decade or so it
34:49it can cause some mild headache.
34:51Eye strain is occasionally reported
34:53agitation as occasionally reported,
34:55but it's generally very safe
34:57and well tolerated.
34:58And then though there is this potential
35:01to trigger mania or hypomania.
35:04In vulnerable patients.
35:07So just wrapping up that section
35:09on antidepressants and sleep
35:11deprivation and light.
35:12Most antidepressants suppress REM sleep,
35:15increase slow wave sleep,
35:17and can worsen restless leg symptoms
35:20and parasomnias antidepressant
35:22effects on sleep vary within the
35:24class and between individuals.
35:26Sleep deprivation may transient
35:29Lee cure depression.
35:31And then sleep deprivation
35:32can also trigger mania.
35:34Bright light therapy can improve mood,
35:37and we also know that it
35:38has powerful effects on
35:40sleep and helping to strengthen circadian
35:42rhythms and shift them and patients
35:46with bipolar disorder again should not
35:49use antidepressants or light therapy
35:51if they're not on a mood stabilizer.
35:54So just a couple of you know what I hope will
35:56be practical tools here for patient care.
36:01So you know, I think it's helpful if
36:04we assess all patients in sleep clinic
36:07for mood disorders, and you know,
36:09ask about anxiety as well as mood.
36:11So just a simple question you know.
36:12Have you been irritable
36:14down or anxious lately,
36:15or what's on your mind when you're lying
36:17in bed and you can't sleep to assess
36:20self attitude if you can sort of guess
36:23at what matters most to the patient?
36:27That's typically more helpful
36:28than saying you know,
36:29do you think you're a good person because
36:31the majority of people will say yes?
36:32Of course, I'm a good person. You know.
36:34It's like saying how are you fine,
36:36you know, but if you say you
36:38know to a woman with children,
36:40you know how are you doing as a mom you know?
36:42Or if a man you know maybe sees
36:44his career as his primary identity?
36:47You know how are you doing in your career?
36:50If you know an elderly person may
36:52feel that they're a burden on their
36:55family if they're struggling with
36:57depression and so asking you know,
36:58do you get to spend time with your grandkids?
37:00Those can really get at self attitude.
37:05You know it's better to avoid
37:07jargon and just document your
37:09observations in your own words.
37:11So instead of you know normal mood,
37:12normal affect, you know the
37:14definitions of those things are kind
37:16of inconsistent and doesn't really
37:17give us a lot of information really.
37:20Just write whatever you you notice.
37:22So for example, you know he described
37:24his mood as OK but appeared sad.
37:27He made rare eye contact,
37:28spoke slowly and did not smile.
37:31She described her mood as
37:33pretty good and looked cheerful.
37:34She made good eye contact and
37:36even laughed at my bad joke.
37:38Or the patient was animated,
37:40tapping his foot constantly and
37:41speaking quickly.
37:42He was difficult to interrupt and
37:44required frequent redirection
37:45to get through the interview.
37:49You know, as sleep clinicians,
37:51we're not going to be diagnosing and treating
37:53patients with mood disorders directly,
37:55but we can really help encourage
37:57them to get treated for their mood
38:00disorder and to stay in treatment.
38:02So one of my mentors used to tell our
38:04patients depression is like asthma.
38:06You know it's a real medical disorder.
38:08It's treated with medications
38:10and lifestyle changes.
38:11We know that it runs in families.
38:13There's a strong genetic component.
38:15There's a consistent clinical
38:16picture across time and cultures.
38:18It's a syndrome.
38:20And there are environmental triggers.
38:23And then in terms of staying in treatment,
38:25you know if the person
38:26has concerns about you,
38:28know side effects of medications
38:29or how they're progressing,
38:30or they're you know,
38:32not doing well in psychotherapy really,
38:34encourage them to talk with their
38:36mental health team about those concerns.
38:42I found this useful to try to encourage
38:44patients to stay in treatment,
38:46so this was again by the same mentor,
38:49doctor Karen Swartz at Hopkins,
38:51so she would tell patients, you know,
38:52here's how you want to get better, you know?
38:54So that's the yellow line.
38:55Just basically tomorrow.
38:57You're 100% better.
38:58And then the blue line is how
39:00you think you'll get better.
39:02And so that's kind of
39:03slow and steady overtime.
39:05But the green line is how you
39:06actually will get better,
39:07and so that's you know ups and downs.
39:09But overall,
39:10making progress overtime.
39:14In terms of thinking about
39:16psychiatric medications,
39:17you know as a sleep clinician you know.
39:20I think it's important that we don't
39:21change people psychiatric medications,
39:23but we need to thank you,
39:24know how likely is it that this
39:26medication is either causing or
39:27contributing to the problem?
39:29What other factors could be addressed besides
39:32or before changing psychiatric medications?
39:35How important is it that we
39:36get an accurate diagnosis?
39:37Sometimes it's really important, you know.
39:40In the case of like I had a patient who.
39:43Was having all kinds of legal problems
39:46because he did something when he was
39:48supposedly asleep and we needed to see.
39:49Does he really have narcolepsy?
39:50And you know in that case it was very
39:53important that you had an accurate diagnosis,
39:55but often it's not that important.
39:58How serious is the underlying
40:00psychiatric condition you know?
40:01Is this a patient who has mild
40:04depression and they just tried Zoloft
40:0650 milligrams and they're doing fine?
40:08Or is this somebody with really
40:10severe mental illness?
40:10They've been hospitalized,
40:12they've tried multiple medications,
40:13and we really don't want to
40:14mess with their regimen.
40:15And then again,
40:16I would say,
40:17you know it's probably best to
40:19not change psychiatric medications
40:20prescribed by somebody else,
40:22but I would recommend discussing
40:24the sleep effects and alternative
40:26treatments with the prescribed.
40:27Prescribing clinician because you know,
40:30it's possible that the psychiatrist
40:33or primary care provider is just
40:36not aware of these impact on
40:38sleep from these medications.
40:40And one more thing for medications.
40:43I mentioned that some antidepressants
40:45can be very difficult to stop,
40:48and I had a patient actually,
40:50a couple of patients in sleep
40:51clinic this year who needed to
40:53come off of tricky medications.
40:54And I used this technique for them.
40:57So one person in particular was on Effexor,
41:01which has been the vaccine 150 milligrams.
41:04He was on it for years,
41:05kept trying to come off,
41:06just couldn't tolerate the taper
41:08and his primary care doctor was
41:10prescribing it for him and.
41:12And you know,
41:12it was probably just not aware
41:14of this technique,
41:16so I didn't directly tell him to do this.
41:18But I said, you know,
41:18talk with your prescribing
41:21clinician about a slow taper,
41:23and this can also be useful for
41:25coming up for patients who've
41:26been on benzos for decades.
41:28You know for sleep or they're addicted
41:29to their 20 milligrams of Ambien,
41:31for example.
41:32So so the idea is to just think
41:34in terms of weekly dosage,
41:36and then just gradually reduce
41:38the total weekly dosage.
41:39So in the patient,
41:41who's on 150 milligrams of venlafaxine a day?
41:45First,
41:45you can change to 437 1/2 milligram pills,
41:48so whatever the smallest increment is,
41:50and then in week one you have them.
41:52Take 3 pills just one day out
41:54of the week and then 4 pills,
41:56which would be the full 150 milligram dose.
41:58All the other dates so you're just
42:01gradually reducing the weekly dose
42:03from 1050 milligrams to 1012.5.
42:05And then the second week they
42:07would take 3 pills on two days
42:09like on Monday and Thursday,
42:11and then they take the full 4
42:13pills all the other days and just
42:15gradually chip away often on this
42:17regimen people will will kind of go
42:20go down more quickly towards the end
42:22because they're feeling optimistic
42:23and they know that they can do it,
42:25but if they're having trouble
42:26at the very end of the taper,
42:28another trick is to talk with
42:30the pharmacist about getting
42:31a liquid formulation,
42:33and then you can have them dilute
42:35the medication and just do a very,
42:37very gradual taper.
42:37At the end.
42:42And then last point is,
42:44we're in a really good position to
42:46help patients with mood disorders
42:47by protecting their sleep.
42:49We can really optimize sleep
42:51in many different ways,
42:52so I think it's important that we
42:55don't ignore insomnia or delay care.
42:57You know, I've certainly ordered
42:58sleep studies in patients with
42:59insomnia because I was thinking, well,
43:01maybe there's a chance they have sleep apnea,
43:02but it can take several months.
43:05You know, for those studies to
43:06happen and then get the results,
43:07and then you know the home test is negative,
43:09and then you do an in lab and.
43:10And really, the person is suffering
43:12with their insomnia for a long time.
43:15We have CBT,
43:15I you know it's really the best
43:17treatment that we have for insomnia.
43:19But there are also medication options,
43:22low dose, Doxepin the benzo days of
43:25pain receptor agonist like Ambien etc.
43:28Low dose mirtazapine and so on
43:31and then I think that even if some
43:33of these other problems impacting
43:35sleep aren't directly within our
43:37field of Sleep Medicine I think we
43:39can really help the patients by.
43:40Either directly treating them
43:42or trying to refer for care.
43:44So sleep apnea.
43:45Of course we treat, but also nightmares,
43:47anxiety, leg cramps, you know,
43:50restless leg symptoms syndrome.
43:52Ivy Iron has a much faster.
43:55Time, you know until it's effective,
43:58then oral supplements if needed.
44:01Is there a bad partner who snores
44:03are their children or pets,
44:04disrupting sleep etc.
44:05And then finally just reminding patients
44:08with mood disorders to protect their sleep?
44:11We can help them brainstorm if they have
44:12periods of stress coming up or transition,
44:14such as a baby,
44:16new job or shift work.
44:18Alright,
44:18and then there's just a summary here,
44:22so suspect mood disorders in all
44:24patients in sleep clinic document
44:26observations in your own words,
44:28encourage patients to get
44:30treated and stay in treatment.
44:32Avoid changing psychiatric medications,
44:34but do discuss the sleep effects and
44:37alternatives with the prescribing clinician.
44:39Consider a slow taper for
44:41problematic medications.
44:42Don't wait to treat insomnia and
44:45then help patients with mood
44:46disorders protect their sleep.
44:50And that's it.
44:56OK, thank you.
45:01Thanks, Theresa, that was a extraordinarily
45:04helpful and interesting talk.
45:06And I was just giving folks a
45:08chance 'cause I like your cartoons.
45:09I like the Bunny slope the best.
45:12But anyway folks have questions.
45:13They can unmute or they can pop something
45:16in the chat and I think I'll start just
45:19as folks get their questions together.
45:21You know, something that you
45:22and I have talked about.
45:24In a slightly different context,
45:25this year is is how do we take care of?
45:30Patients were more at the
45:32edge of our of of expertise.
45:34Sometimes in this multidisciplinary sleep
45:36world where some of us come from neurology,
45:38some from pulmonary and from
45:40some psychotic psych psychiatry,
45:42and then N beyond surgery,
45:44family medicine and so on.
45:47Is there a space or a model or a
45:49way to better serve these patients,
45:51which sounds like a really significant
45:53population of folks who have both
45:54mood disorders and insomnia?
45:59Yeah, I mean I think that some
46:01kind of like you know Team meeting
46:03sort of thing or you know,
46:05once a month sort of talking about
46:07different difficult cases you know
46:09something like that could be helpful.
46:14Yeah, I I think really I think I don't know.
46:17I think taking the patients
46:20complaints seriously,
46:21even if we don't directly have a
46:23solution for them I think is helpful,
46:25you know and saying, yeah,
46:26that's that's an important problem.
46:28You know, I don't know the answer.
46:29I don't know how to treat leg cramps,
46:30but I really recommend you talk to your
46:32primary care doctor about it because it's
46:34so important that you get good sleep.
46:36You know, like something like that.
46:38I think may be helpful.
46:41And thank you also for validating
46:43my general fear of changing
46:46people psychiatric committee.
46:48Alright, thank you, that's how.
46:49And actually that's great.
46:50You're right.
46:51Like almost like a tumor board,
46:53but uh, asleep asleep board for
46:55these multi disciplinary cases.
46:57Or are there other folks with questions?
47:15There's a question if there's
47:16are natural supplements that
47:18could also help folks sleep.
47:22I don't know. I mean, you know melatonin,
47:26you know can be helpful sometimes.
47:31I think what is it valerian that
47:32people would take sometimes?
47:35Yeah, that's that's a good question.
47:37I don't know I'd have to
47:38learn more about that.
47:42There was a recent melatonin.
47:44There was a recent article I can't remember.
47:47It was it was a major news outlet,
47:50but sort of highlighting.
47:52The challenges of supplements that are
47:54not regulated and what's what's in there
47:57actually making it hard to figure out
47:59effective effectiveness and efficacy?
48:02Yeah, yeah. I mean, I,
48:04you know I would always just
48:06really try to push CBT.
48:07I think it's so helpful even if
48:11a person ultimately needs you,
48:13know a hypnotic as well.
48:14I think just learning
48:15those skills having that.
48:19You know healthier framework for thinking
48:20about how much sleep they need and
48:22you know what to do in the middle of
48:23the night when they're not sleeping.
48:24I think really just about
48:25anyone can benefit from CBT.
48:27I and then exercise and sunlight can also
48:29have a huge impact on sleep, you know.
48:34You know better than I do
48:35with circadian rhythms.
48:39Alright.
48:43Thanks so much Teresa.
48:44Great talk this is Andre,
48:46I'm just curious about your
48:48thoughts and other thoughts
48:49on CBT in the setting of.
48:52Individuals who already have
48:53a short sleep duration,
48:55so people with insomnia
48:57with you know somewhere between
48:58six to four hours of sleep.
49:01You know, maybe their time in
49:02bed is 8 hours or whatnot, but
49:05they're still have a short duration
49:07of sleep, and so since the tenant
49:08of CBT oftentimes is restriction.
49:11How effective is that therapy
49:13in that setting and water might
49:15be some alternatives. And and so,
49:17just to make sure I understand.
49:18So you're saying people who spend
49:208 hours in bed but they're only
49:21sleeping for four to six hours?
49:23Is that right? That's right, that's
49:26right, and so they already feel like they
49:29so not so much. Just the.
49:31Opportunity of sleep is too long,
49:33but the actual duration of sleep is short,
49:36right, right, so you know, yeah,
49:38it's it can be sort of counter intuitive
49:41to tell somebody to spend less time in
49:43bed when they're not sleeping enough,
49:45but generally, of course you know Doctor,
49:47Schneeberg and other people who do CBT.
49:49I, you know, will know better than I do,
49:53but but, but generally you don't
49:55have to restrict it even more
49:57than the four or six hours.
49:58You could even just say OK
50:00instead of eight hours in bed.
50:01Don't spend more than six hours in bed
50:04and what that's going to do is for one.
50:07If they actually are sleeping
50:08for more than the six hours,
50:09you know maybe there's some sleep
50:11sleep state misperception there.
50:12Then they're going to just get
50:14more tired during the day,
50:15and they're going to have
50:16a stronger sleep drive.
50:16And then they'll sleep through
50:18the night better.
50:19The other thing is going to decrease that
50:22association of wakefulness and being in bed,
50:25you know,
50:25because if you're lying in bed,
50:27awake for a couple of hours every day,
50:30that's going to increase.
50:31You know arousal in bed worries is
50:33going to be your place of not sleeping.
50:35Instead of your place to sleep,
50:36so you know there are lots of
50:38other techniques in CBT besides
50:40just sleep restriction,
50:41but I think even in those cases,
50:43sleep restriction could be helpful,
50:45but just not as not very extreme.
50:47And then then one other thought is.
50:51In patients with bipolar disorder,
50:53they can also benefit from CBT I,
50:56but generally the period
50:59of sleep restriction is,
51:01it's just more kind of reduced. It's not.
51:04It's not as severely restricted,
51:06so maybe you know perhaps 7 hours
51:08or so instead of like five or six.
51:10I if Doctor Schneeberg is here,
51:12she certainly would know better than I do,
51:14but but you do want to be careful
51:16in somebody with either bipolar
51:18disorder or any history of psychosis,
51:20whether it's severe depression.
51:22Or schizophrenia or bipolar
51:24disorder with psychosis?
51:26Restricting their sleep too much
51:28could trigger mania or psychosis,
51:30so you want to be kind of careful there.
51:41Another question in the chat.
51:43I don't know if you can see it,
51:44but I think it's sort of an interesting
51:46concern that I was thinking of
51:48as well as if a patient does not
51:50have an outpatient psychiatrist.
51:53Are the recommendations that could
51:54be offered for patients to obtain
51:56therapy or considerations to offer?
51:58Primary or or or considerations
52:02to offer to primary providers
52:04with respect to sleep and mood.
52:06So so I don't pin bar.
52:09If you want to clarify but but
52:10things that we can do to to
52:12meet that gap I guess is how I'm
52:14interpreting the question between.
52:16Also, sleep providers and a patient who
52:18may not have a primary mental health.
52:21Sure, so so I I think so.
52:24If a person doesn't have a
52:26psychiatrist but but you're pretty
52:28sure they have a mood disorder,
52:30you know, you know,
52:30we don't need to diagnose that.
52:32Of course, as sleep clinicians but but
52:35I think we are in a really good role.
52:36You know we're in a position of authority.
52:38We're also in a position
52:39of caring for the person,
52:40and so you know if we recommend that
52:43they talk with their primary care doctor
52:46or primary care provider about mood.
52:48You know, then there's a chance
52:50that their primary care.
52:51Provider would diagnose them
52:52with depression for example,
52:54and be able to prescribe the medication.
52:57We do probably know more than
53:00many primary care providers
53:01about the importance of sleep,
53:03and so hopefully I've convinced I've
53:04convinced you that you know sleep
53:06is important for mood disorders,
53:07so we can, you know,
53:09tell that to the patient that it's
53:12really important that they get
53:14enough sleep and you know they
53:15have a regular sleep schedule,
53:17and then if we're concerned,
53:19let's say they have restless
53:21leg syndrome already.
53:22And they're depressed.
53:23We may not want to worsen
53:25that with an antidepressant,
53:26so we may say, you know,
53:28talk with your primary care provider
53:31about the possibility of bupropion.
53:33You know that may be a
53:34good medication for you,
53:35for example.
53:35If I understand the the question correctly.
53:41Thank you. Alright,
53:42well thank you for a tremendous
53:44talk into something that was both
53:47really educational and pragmatic.
53:48I really appreciate it and it
53:50will definitely help me and I'm
53:51sure others here as we go forward.
53:53Thanks everyone.
53:54Alright thank you.