Table Of ContentSleep Medicine
and Mental Health
A Guide for Psychiatrists and
Other Healthcare Professionals
Karim Sedky
Racha Nazir
David Bennett
Editors
123
Sleep Medicine and Mental Health
Karim Sedky • Racha Nazir
David Bennett
Editors
Sleep Medicine
and Mental Health
A Guide for Psychiatrists and Other
Healthcare Professionals
Editors
Karim Sedky Racha Nazir
Cooper Medical School of Rowan Mount Laurel
University NJ, USA
Mount Laurel
NJ, USA
David Bennett
College of Medicine
Drexel University
Philadelphia
PA, USA
ISBN 978-3-030-44446-4 ISBN 978-3-030-44447-1 (eBook)
https://doi.org/10.1007/978-3-030-44447-1
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resources/resources-detail-view/
divya-khurana-md-(1965-2019)
This book is dedicated to Dr. Divya Khurana,
who passed away unexpectedly in a plane
crash. Dr. Khurana was a professor of
Pediatrics and Neurology at Drexel
University College of Medicine. She was a
child neurologist with special interests in
epilepsy and sleep medicine and worked for
more than two decades at St. Christopher’s
Hospital for Children in Philadelphia. She
dedicated her career to her patients and to
educating medical students and residents.
Her sudden passing has left a void in the
hearts of all who knew and loved her. Dyvia's
infectious smile and endless energy will be
deeply missed by her colleagues and all the
families whose lives were forever impacted
by her. This book serves as an everlasting
memory to her achievements including the
two chapters that she wrote in her last few
months of her life.
Divya Khurana, MD (1965–2019)
Preface
The field of sleep disorders is relatively new, starting in the early twentieth century.
Dr. Allan Rechtshaffen and Dr. Anthony Kales developed the first manualized scor-
ing parameters in 1968 to standardize how clinicians measure sleep stages and
respiratory events. While their practice parameters manual has been updated over
the years, the basics remain the same. Dr. Kales is one of the first psychiatrists to
cultivate interest in this field. Leaders from other disciplines including medicine/
pulmonology, neurology, psychology, ear nose and throat physicians, anesthesiolo-
gist, and dentistry also emerged. This highlights the role that sleep plays across vari-
ous domains of human functioning and the importance of a multidisciplinary
approach to the assessment and treatment of sleep disorders.
As such, one growing trend in the field is the recognition that a multidisciplinary
approach can provide optimal care. While many of the current sleep centers are
directed by pulmonology programs, the involvement of mental health professionals
is empirically established and increasingly appreciated as part of a multidisciplinary
team approach. For example, pulmonary physicians excel in assessing and treating
sleep disordered breathing conditions, especially those with lung disease (including
chronic obstructive pulmonary disease), and the metabolic derangement related to
it. Neurologists, in contrast, excel in assessing and treating comorbid seizures,
movement disorders, and other sleep-related comorbidities that are neurologically
diagnosed (such as narcolepsy). Similarly, psychiatrists prescribe and treat condi-
tions that can interact significantly with sleep disorders. For example, the use of
antipsychotic or antidepressant medications that cause increased weight gain can
lead to an increased risk of sleep apnea. Psychiatrists and psychologists can also
play an integral role in providing therapies for insomnia, hypersomnia, or other
circadian rhythm disorders. Psychiatrists and psychologists can also play a major
role in bariatric surgery assessments that help to address both weight loss and sleep-
related breathing disorders. Dentists have also played a cornerstone role in creating
dental devices and other dental procedures that help to treat sleep apnea. Maxillary
facial surgeons similarly have played an integral role in correcting the airway pas-
sages of those whose sleep apnea is due to craniofacial abnormalities. In addition,
primary care physicians are usually the first line of assessment and referral for many
individuals with sleep disorders and play a very important role in identifying sleep
problems and facilitating their management. Finally, ear nose and throat physicians
have been key in treating children and adolescents who have adenotonsillar
vii
viii Preface
enlargement as well as using endoscopes to diagnose airway obstruction. While
assessment and treatment of sleep disorders, especially sleep-related breathing dis-
orders, are fairly straight-forward, the financial cost of positive pressure ventilation
(including costs associated with non-compliance) is high. Moreover, the associated
long-term medical complications to untreated respiratory events and/or insomnia
lead to higher risk of morbidity and mortality. It is thus imperative to have a multi-
disciplinary team in all sleep centers in the United States with therapists and psy-
chiatrists playing a major role, as currently mental health professionals are playing
a growing but still underutilized role in this field.
The introduction of simplified in-home polysomnography in recent years repre-
sents a second trend that has increased access to the assessment of sleep disorders
as an alternative to the costly, time-consuming, and inconvenient laboratory-based
sleep study. These in-home studies are increasing in their reliability and validity
compared to earlier equipment, although still not as diagnostically accurate as those
studies conducted in the laboratory. While one would imagine that more individuals
would be treated with improved outcomes, issues around adherence continue to be
a major factor hindering optimal outcomes. Again, our field of mental healthcare
professionals can thus play a major role in working with patients to enhance adher-
ence, especially when it comes to medication, behavioral therapy for insomnia, and
positive pressure ventilation. The use of substances such as alcohol, nicotine, opi-
oids, and other substances can further complicate sleep-related breathing disorders.
Addiction medicine providers can thus also play a major role in managing comorbid
addiction, which can improve the patient’s overall psychological and sleep
conditions.
Despite progress in assessing and developing evidence-based interventions for
sleep disorders, healthcare providers’ knowledge about sleep disorders remains
relatively limited. For example, not all medical schools and residency training pro-
grams offer access to sleep medicine (whether through didactics or access to clinics
that evaluate sleep disorders). In addition, older trainees have had limited exposure
to this field given the recent evolution of this specialty. As such, the aim of this book
is to address the need for a third trend, increased education among mental health and
other healthcare professionals about the assessment, classification, and treatment of
sleep disorders. In doing so, we highlight the strong relationship between psychiat-
ric conditions and sleep disorders. Sleep disorders are very prevalent among indi-
viduals with psychiatric conditions. This relationship appears to be a bidirectional
one, with an increased risk for non-response and/or relapse of psychiatric conditions
if sleep disorders persist; but likewise, psychiatric conditions can lead to insomnia
and to other sleep disorders. It is thus imperative for mental health professionals to
be able to appropriately assess, refer, and if appropriate treat sleep problems. During
our clinical careers, the editors have encountered a significant number of patients
who struggled with insomnia, hypersomnia, and/or sleep disordered breathing that
was often missed in prior treatment planning. These individuals often did not
respond to psychiatric therapy until their comorbid sleep disorders were addressed.
It is important to note the increasing depth and knowledge currently occurring in
the field of sleep and its disorders. While this book is an attempt to cover the most
Preface ix
important topics on sleep disorders, it is by no means inclusive of every sleep condi-
tion. Its aim, however, is to educate clinicians and trainees on the field of sleep
problems and to stimulate their increased reading and practice about the field for the
patients they manage. The editors hope that readers will find this book helpful as a
first step toward this goal.
Mount Laurel, NJ, USA Karim Sedky
Mount Laurel, NJ, USA Racha Nazir
Philadelphia, PA, USA David Bennett
Introduction
How the brain works has long been an unfolding mystery, with psychiatry and psy-
chology representing two of the fields that seek to understand the interaction
between brain biology and behavior. Even after decades of major developments,
many mysteries remain. Earlier neuropsychiatrists such as Sigmund Freud posited a
correlation between sleep and psychological functioning (e.g., suggesting that
dreams reflected unconscious wishes). Yet despite progress in both psychiatry and
sleep medicine, much is still unknown in both fields. This has sometimes led to
rather limited sleep medicine education for psychiatrists and other healthcare pro-
fessionals, with studies consistently showing minimal sleep education for trainees
[1, 2]. While there are no recent studies that assess training in sleep medicine for
physicians, a more recent study among psychology trainees found similarly limited
training, with only 6% of training programs offering courses in sleep [3]. Efforts to
improve sleep training persist, however, as neurology and neuroscience educators
recently recommended at least 2–4 hours of sleep medicine education during medi-
cal school to enhance students’ education [4].
Sleep medicine and psychiatry share significant overlap in both the pathophysi-
ology of disorders and symptom presentation. For example, monoamine neurotrans-
mitters (e.g., serotonin, norepinephrine, and dopamine) play a major role in
depression and anxiety as well as in the control of sleep staging. It is thus not sur-
prising to find that serotonin deficiency can lead to both depression and sleep disor-
ders. In addition, serotonin affects airway muscular tone and can lead to increased
respiratory events in those with serotonin deficiency. However, psychotropic medi-
cations that increase serotonin can also lead to restless leg syndrome, a condition
that often leads to the interruption of sleep. Similarly, many psychotropic medica-
tions lead to weight gain and obesity, increasing risk for the development of
sleep apnea.
Since psychiatric conditions are often diagnosed only after excluding other pri-
mary medical conditions, it would make sense to offer enhanced sleep medicine
education to psychiatrists. For example, it is important to recognize that thyroid
conditions can cause depression, and as such thyroid stimulating hormone (TSH)
levels are commonly requested by psychiatrists when evaluating a patient for a
mood disorder. In contrast, however, many mental health professionals fail to screen
for sleep apnea symptoms, even in high-risk individuals. Given that sleep apnea can
elicit a variety of psychiatric symptoms, this represents a missed opportunity to not
xi
xii Introduction
only treat the sleep apnea but to also relieve psychiatric symptoms, possibly leading
to unnecessary psychiatric interventions. As such, the aim of this book is to increase
mental health professionals’ awareness of normal sleep, sleep pathologies, and how
such pathologies can interact with psychiatric conditions.
While several classifications of sleep disorders exist, we will primarily use the
International Classification of Sleep Disorders – Third Edition (ICSD-3). However,
when relevant to highlight differences, criteria from the Diagnostic and Statistical
Manual of Classification – Fifth Edition (DSM-5) and from the International
Classification of Disorders – Tenth Edition (ICD-10) are also presented.
The book includes 17 chapters, with the first chapter providing an overview of
normal sleep. The second chapter provides an overview of insomnia, followed by
Chapters 3 through 6, which address the treatment of this common sleep problem
using: cognitive behavioral therapy for insomnia (CBT-I), yoga and mindfulness
based cognitive behavioral therapy for insomnia (Y-MBCTi), Acceptance and
Commitment Therapy for insomnia (ABC-I), and pharmacological interventions.
Chapters 7 and 8 address sleep disordered breathing (e.g., obstructive sleep apnea)
and psychosocial approaches to enhance adherence to positive airway pressure
(PAP). Chapters 9, 10, 11, and 12 cover the sleep disorders of hypersomnia, narco-
lepsy, circadian rhythm disorders, movement disorders, and parasomnias. Next,
Chapters 13, 14, 15, and 16 discuss sleep in special populations including children
and adolescents, women, older adults, and veterans. The book concludes with a
chapter examining the overlap between sleep disorders and psychiatric disorders.
We hope that this book will be valuable to clinicians who are interested in furthering
their education in sleep medicine and will further enhance clinicians’ ability to help
their patients with sleep problems.
References
1. Orr WC, Stahl ML, Dement WC, Reddington D. Physician education in sleep disorders. J Med
Educ. 1980;55:367–9.
2. Rosen R, Mahowald M, Chesson A, Doghramji K, Goldberg R, Moline M, Millman R, Zammit
G, Mark B, Dement W. The Taskforce 2000 survey on medical education in sleep and sleep
disorders. Sleep. 1998;21(3):235–8.
3. Meltzer LJ, Phillips C, Mindell JA. Clinical psychology training in sleep and sleep disorders. J
Clinic Psychol. 2009;65(3):305–18.
4. Salas RME, Strowd RE, Ali I, Soni M Schneider L, Safdieh J, Vaughn BV, Avidan AY, Jeffery
JB, Gamaldo CE. Incorporating sleep medicine content into medical school through neurosci-
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