"Mood Disorders and Sleep" Teresa Foley (02/23/2022)
March 01, 2022ID7490
To CiteDCA Citation Guide
- 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.