Panelists Offer Practical Ways to Address Sleep Problems in Psychiatric Care

By the time most psychiatrists encounter a patient with insomnia, that individual is likely dealing with other complications such as depression or posttraumatic stress disorder. However, the insomnia symptoms should not be undervalued. Panelists at a session today offered some practical clinical guidance on how psychiatrists can incorporate evidence-based sleep medicine into their practice.

If a doctor happens to see a patient with pure insomnia, that offers a tremendous opportunity for prevention care, said William McCall, M.D. (pictured above), Professor and Case Distinguished Chair of Psychiatry and Health Behavior at Augusta University in Georgia. He noted data showing that people whose insomnia does not resolve within a year have a 30-fold increased risk of developing depression. Other studies have indicated insomnia increases the risk of depression relapse, so it is relevant across the depression timeline.

The first step, of course, is to assess and diagnose the patient’s sleep issues, and McCall stressed it is important to know more than just the time it takes to fall asleep and total sleep time—two measures that are commonly used in clinical studies.

“Try to find details such as whether they are a morning lark or a night owl and what their biggest dissatisfaction with their sleep routine is,” he said. One person may take 30 minutes to fall asleep but says that it is not a problem, while another may take only 20 minutes but finds it unbearable. McCall suggested that having patients do a sleep diary for one or two weeks can be useful, as are scales such as the insomnia severity index and the Epworth daytime sleepiness scale.

In terms of treatment, all the relevant professional groups including the Academy of Sleep Medicine state that cognitive-behavioral therapy for insomnia (CBT-I) is the first choice, with short-term use of medications like Z-drugs as a secondary option. McCall noted that CBT-I is indeed highly effective, but he hoped future recommendations might go beyond a one-size-fits-all approach.

Of course, there are many barriers to getting CBT-I off the ground, said Zhixing Yao, M.D., the chief resident of psychiatry at the Medical College of Georgia, also in Augusta. “There’s not enough time. All my referral providers are full—we have all been there.”

The good news is that studies have shown that digital CBT-I programs produce good results. He noted that many CBT-I apps are available for purchase, so psychiatrists can do some research to find the best ones to match their patient needs. Many patients do need that human element, however, and busy psychiatrists can assist by incorporating CBT-I into a standard 15-minute medication management visit.

CBT-I is built around three core principles: stimulus control, sleep restriction, and cognitive intervention, Yao said. Stimulus control involves encouraging sleep-promoting factors (stable bedtime routines, cool and quiet bedroom environments) and eliminating impairing factors (nighttime exercise, coffee and other caffeinated drinks, alcohol). Sleep restriction involves setting specific hours when patients can get into bed or wake up to promote sleep efficiency. Finally, cognitive interventions are focused on developing a relaxed attitude about sleep.

After psychiatrists get a sense of their patient’s biggest sleep distress, they can offer suggestions from one of the three areas that seems most relevant. For anxious patients, possible suggestions include telling them not to use sleep-tracking devices. Another option is to ask them to fill out a “worry journal.”

“Before bed, have the patient spend two minutes writing out the most important things they have to get done the next day,” Yao explained. “Then they can get up the next morning with less worry of the day ahead.” For patients who take forever to fall asleep, a restricted sleep schedule is useful. And for many people today, especially younger people, simply having them scale back their coffee intake can help.

Finally, do not forget about sleep apnea, said Richard Bogan, M.D., an associate clinical professor at the University of South Carolina. Data suggest that about 15% of adults with depression who complain of insomnia have obstructive sleep apnea. Some risk factors to look out for are older adults, overweight adults, and those with thick necks. Another clue can be found in the Epworth scale. “People with insomnia normally have relatively low sleepiness scores,” he noted. “If you see an abnormally high score, it may suggest something else is going on.” ■