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Tackling Insomnia As Part of the Complete Approach to Mental Healthcare

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Tackling Insomnia As Part of the Complete Approach to Mental Healthcare Tackling Insomnia as Part of the Complete Approach to Mental Healthcare Karl Doghramji, MD Professor of Psychiatry, Neurology, and Medicine Medical Director, Jefferson Sleep Disorders Center Thomas Jefferson University Philadelphia, Pennsylvania Educational grant support was provided from Eisai. Faculty Disclosure • Dr. Doghramji: Consultant—Eisai, Purdue, Merck, Pfizer; Stock—Merck. Disclosure • The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational use(s) of drugs, products, and/or devices (any use not approved by the US Food and Drug Administration). – Dr. Doghramji will be discussing off-label use of medications in this presentation and will identify those medications. • Applicable CME staff have no relationships to disclose relating to the subject matter of this activity. • This activity has been independently reviewed for balance. Learning Objectives • Discuss the relationship between insomnia and comorbid psychiatric disorders and the resulting implications for diagnosis and co-treatment • Evaluate current guideline recommendations for insomnia management with respect to the present standard of care and unmet needs with existing therapies • Review the latest clinical data surrounding the mechanisms of action and risk/benefit profiles of emerging pharmacotherapies for insomnia for informed therapeutic decision-making Mr. A • 58-year-old accountant, c/o unrefreshing sleep • Onset 4 months ago • Frequency 4 to 5 nights/week • Mind “spins” at bedtime • Feels washed out during day; low energy • Moody, irritable • Curtailed social activities • Medical history: Hypertension, controlled with losartan • Exam: Nl vital signs, BMI 38 • MSE: Psychomotor slowing; mood “fine”. Affect restricted, no h/s ideation, sensorium clear. Cognitive functions intact • Recent blood tests, including CBC, blood chemistry tests, LFTs, and TSH are WNL What additional criterion must be met to satisfy criteria for DSM-5 insomnia disorder? 1. Duration of insomnia must be > 6 months 2. Difficulty with insomnia must occur nightly 3. Sleep laboratory confirmation of a sleep latency (time to fall asleep) > 1 hour 4. Must not meet criteria for MDD 5. Meets diagnostic criteria for insomnia disorder Use your keypad to answer now! Insomnia Disorder A. Dissatisfaction with sleep quantity or quality with ≥ 1 of the following: 1. Difficulty initiating sleep (children: w/o caregiver intervention) 2. Difficulty maintaining sleep (children: w/o caregiver intervention) 3. Early morning awakening w/ inability to return to sleep B. Significant distress or impairment C. > 3 nights/week D. > 3 months E. Adequate opportunity for sleep Specify if: – With non-sleep disorder mental comorbidity – With other medical comorbidity – With other sleep disorder Criteria F, G, and H not shown; not all specifiers shown. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. Impairments Associated with Insomnia • Diminished ability to enjoy • Impaired concentration and family and social relationships memory • Decreased quality of life • Increased incidence of pain • Increased absenteeism and • Enhanced risk of present and poor job performance future psychiatric disorders • Motor vehicle crashes • Hypertension • Increased risk of falls • Diabetes • Increased health care costs • Increased mortality Which of the following would be the most appropriate next step? 1. Exploration of sleep and wake patterns 2. Asking about a family history of insomnia 3. A referral for neuropsychological testing 4. Treatment with an antidepressant agent 5. Short course of treatment with a hypnotic medication (sleeping pill) Use your keypad to answer now! Sleep Pattern Middle Terminal Initial 11 PM 7 AM W = wake; S = sleep. Copyright: Karl Doghramji, MD. Sleep Pattern: Diagnostic and Therapeutic Implications • Diagnosis – Terminal insomnia (early morning awakening) – Initial insomnia (prolonged sleep latency) • Depression • Irregular waking times or shift • Advanced sleep phase work disorder • Delayed sleep phase disorder • Shiftwork disorder • Daytime stimulants/caffeine • Therapy • Restless legs syndrome – Hypnotic medications are – Middle insomnia (sleep approved for reduction in sleep discontinuity) latency, enhancement of sleep maintenance, or both • Depression • Sleep apnea syndrome • Periodic limb movements in sleep Sleep/Wake Diary AM PM Day Date12 1 2 3 4 5 6 7 8 9 101112 1 2 3 4 5 6 7 8 9 1011 Sun 12/9 Mon 12/10 Tue 12/11 Wed 12/12 Thu 12/13 Fri 12/14 Sat 12/15 into bed; out of bed. National Heart, Lung, and Blood Institute. www.nhlbi.nih.gov/health-topics/all-publications-and-resources/sleep-diary. Accessed March 19, 2019. American Academy of Sleep Medicine. http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf. Accessed March 19, 2019. Actigraphy Morgenthaler T, et al.; Standards of Practice Committee; American Academy of Sleep Medicine. Sleep. 2007;30(4):519-529. Insomnia Evaluation and Management Algorithm Insomnia Disorder Treat Is insomnia NO No further comorbid persistent? treatment needed condition first Obtain details about YES YES course of insomnia Treat with Is insomnia behavioral therapy associated with comorbid medical Is use of insomnia YES Is insomnia contributing or psychiatric medication unsafe condition? in this patient? NO to decreased daytime YES Treat with behavioral functioning and quality and/or pharmacologic of life or worsening NO therapy of chief complaint? Does insomnia YES NO occur in isolation? Possible short sleeper; supportive reassurance Doghramji K, et al. Clinical Management of Insomnia. Second Edition. 2015. Department of Psychiatry and Human Behavior Faculty Papers. Paper 25. Increased Prevalence of Medical Disorders in Individuals with Insomnia 100 90 No Insomnia (n=401) P<.001 80 Insomnia (n=137) 70 60 P<.001 50 P<.001 40 P<.001 Patients (%) 30 P<.05 P<.01 20 P<.05 P<.05 10 0 Heart Cancer Hyper- Neuro- Breathing Urinary Diabetes Chronic GI Any Disease tension logical Problems Problems Pain Problems Medical Disease Problems Community-based population of 772 adults. GI = gastrointestinal. Taylor DJ, et al. Sleep. 2007;30(2):213-218. Psychiatric Disorders Comorbid with Insomnia Point Prevalence Drug Abuse 4.2 Other Psychiatric Disorders 5.1 Alcohol Abuse 7.0 Dysthymia 8.6 Major Depression 14.0 Anxiety Disorder 23.9 No Psychiatric Disorder 59.5 0 10 20 30 40 50 60 Patients (%) • Insomnia is highly prevalent in psychiatric patients • It has consequences: Daytime impairment, risk of future psychiatric and medical disorders, and others N=580. Ford DE, et al. JAMA. 1989;262(11):1479-1484. Additional Information • Sleep study negative for OSA (AHI < 5) • Sleep/wake pattern – Reads, watches TV until bedtime – Bedtime 10 PM – Sleep latency 1–2 hours – Wakes up 4–5 × @ 10–30 minutes – Has a midnight snack – Can’t fall back to sleep after 4:30 AM – Lies in bed until 6 AM (9–11 AM on weekends) • 3–4 drinks with dinner • 2 espressos to stay awake in the afternoon AHI = Apnea-Hypopnea Index; OSA = obstructive sleep apnea. The Dos of Sleep Hygiene • Get OOB at the same time every morning • Increase exposure to bright light during the day • Establish a daily activity routine • Exercise regularly in the morning and/or afternoon • Set aside a worry time • Establish a comfortable sleep environment • Do something relaxing prior to bedtime • Try a warm bath OOB = out of bed. Hauri PJ. In: Hauri PJ, ed. Case Studies in Insomnia; New York, NY: Plenum; 1991:65 The Don’ts of Sleep Hygiene Avoid… • Alcohol • Caffeine, nicotine, and other stimulants • Exposure to bright light during the night • Exercise within 3 hours of bedtime • Heavy meals or drinking within 3 hours of bedtime • Using your bed for things other than sleep (or sex) • Napping, unless a shift worker • Watching the clock • Trying to sleep • Noise • Excessive heat/cold in room Hauri PJ. In: Hauri PJ, ed. Case Studies in Insomnia; New York, NY: Plenum; 1991:65 . Effect of Blue Light Blocking on Sleep Psychological and Behavioral Treatments for Primary Insomnia Techniques Method Stimulus control therapy* If unable to fall asleep within 20 minutes, get OOB and repeat as necessary Relaxation therapies* Biofeedback, progressive muscle relaxation Restriction of time in bed Decrease time in bed to equal time actually asleep and increase as sleep efficiency improves (sleep restriction) Cognitive therapy Talk therapy to dispel unrealistic and exaggerated notions about sleep Paradoxic intention Try to stay awake Sleep hygiene education Promote habits that help sleep; eliminate habits that interfere with sleep Combines sleep restriction, stimulus control, and sleep hygiene education with cognitive CBT* therapy *Standard Treatment according to American Academy of Sleep Medicine. CBT = cognitive-behavioral therapy. Morgenthaler T, et al.; American Academy of Sleep Medicine. Sleep. 2006;29(11):1415-1419. Bootzin RR, et al. J Clin Psychiatry. 1992;53 Suppl:37-41. Meta-analytic Support for Efficacy of CBT-i • 20 RCTs (1162 participants [64% female; mean age, 56 years]) • Approaches to CBT-i incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation • At the posttreatment time point – SOL improved by 19.03 (95% CI, 14.12 to 23.93) minutes, – WASO improved by 26.00 (CI, 15.48 to 36.52) minutes, – TST improved by 7.61 (CI, 0.51 to 15.74) minutes, and – SE% improved by 9.91%
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