Sleep Disturbances & Mental Illness: What Many Clinicians Miss
David Neubauer, MD, Associate Professor at Johns Hopkins Bayview Medical Center in Baltimore, hates when people say ‘you can always sleep when you’re dead.’ Sleep, after all, is an investment in how we feel during the day, he noted, making it no small wonder that a majority of patients visiting psychiatrists for mental health issues also complain of sleep disturbances.
Yet treating a common set of symptoms related to sleep turns out, in many cases, to be complicated. Psychiatrists often view sleep through the lens of a psychiatric setting, meaning sleep issues are classified by default as symptoms of psychiatric illness. “Sleep is trivialized,” said Vladimir Maletic, MD, Clinical Professor of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine in Columbia. “It’s sometimes seen as patients having a hard time telling the truth about another disorder.”
The problem, according to Karl Doghramji, MD, Professor of Psychiatry, Neurology, and Medicine at Thomas Jefferson University in Philadelphia, is that sleep-related complaints can be symptoms of psychiatric disorders or may represent independent disorders in their own right, a viewpoint reinforced by upcoming changes to the DSM in which primary insomnia is reclassified as insomnia disorder . To complicate matters further, sleeplessness can, in any given case, represent a symptom and an independent disorder, and this overlap raises questions for psychiatrists.
“Do we treat the underlying condition and hope that the sleep gets better? Or do we treat the insomnia directly?” asked Dr. Doghramji.
The answer is complicated, but research shows that sleep disturbances demand clinical attention. Persistent insomnia is associated with an increased risk for the development of new psychiatric illnesses  and doubles the risk of heart attack or stroke . Even regular shift work, which throws off natural sleep cycles, is classified by the World Health Organization as a human carcinogen 2A . “That’s one level below asbestos,” said Dr. Maletic.
What can clinicians do to ensure proper treatment for sleep disturbances? Psychiatrists agree that finding the correct diagnosis is the first step.
#1 Consider all diagnostic possibilities, including sleep apnea and circadian disorders
“The main advice I have for colleagues is to think broadly about the etiology of sleep complaints,” said Dr. Neubauer. “If in the first minute you think you know the cause of the patient’s sleep problems, then your conclusion might be premature.”
For example, patients who appear to have primary insomnia, may, on closer inspection, turn out to have a circadian rhythm disorder, such as delayed or advanced sleep-phase syndrome. Dr. Maletic estimates that psychiatrists may overlook circadian rhythm disorders and sleep apnea four out of five times.
Symptoms of obstructive sleep apnea, including unrefreshing sleep and daytime fatigue, often masquerade as symptoms of depression. Dr. Neubauer cautions that a patient with sleep apnea will not improve with hypnotic sleep medications or depression treatment, because the underlying problem is related to breathing.
In fact, treatment with energizing antidepressants such as bupropion or venlafaxine can make sleep apnea worse by suppressing sleep. “People with sleep apnea don’t get good enough quality sleep, and now we’re treating them with medications that further disrupt their quality of sleep,” said Dr. Maletic.
If a patient’s depressive symptoms are not improving with medication, Dr. Maletic advises that clinicians should pause before launching a second wave of depression treatment and consider whether the symptoms could result from something other than major depressive disorder.
He also will not hesitate to recommend polysomnography when necessary, despite the expense and coordination involved.
Dr. Neubauer added, “You don’t want to miss a major health problem for a patient. I think the potential for sleep apnea should be considered in every patient who complains of insomnia.”
#2 Use cognitive-behavioral therapy from the start
For many patients with sleep disturbances, insomnia is the correct diagnosis, and the clinician commences treatment with pharmacologic agents and/or cognitive-behavioral therapy (CBT). CBT helps to address habits and behaviors, as well as to alleviate the anticipatory anxiety that tends to accompany, and exacerbate, sleeplessness.
Data show that CBT can treat insomnia better than sleep agents, should be viewed as a first-line intervention for insomnia, and can improve outcomes in both the short- and long-term [5, 6]. “Don’t dismiss CBT,” said Dr. Doghramji. “I think we need to be really pushing for its usage in chronic insomniacs.”
He added that a severe insomnia case, especially if associated with significant daytime consequences, may require pharmacologic treatment from the start, since pharmacological treatments usually have a more rapid onset of action than CBT; “but you should consider weaving in CBT, right away.”
CBT includes techniques such as sleep restriction therapy, in which patients who frequently wake up during the night are told to limit their time in bed as a way of consolidating sleep. In addition, treatment might involve relaxation techniques, biofeedback, and education about sleep hygiene and caffeine intake.
As part of sleep hygiene, patients may be told to make their room as dark and quiet as possible, keep the temperature comfortable, and avoid using light-emitting electronic devices just before bedtime.
“The biggest mistake is delaying the introduction of CBT until it’s too late in the game, so patients become psychologically dependent on sleeping medications,” said Dr. Doghramji.
#3 Personalize treatment
Given the array of CBT techniques, the key to effective treatment is personalization. “Don’t just give patients a pamphlet with one-size-fits-all information,” said Dr. Maletic. “Spend some time inquiring about sleep habits and environment.”
Dr. Neubauer stressed the importance of exploring a patient’s broad, 24-hour sleep/wake cycle before customizing solutions. For example, if worrying about the next day’s tasks keeps a particular patient awake, he will advise that patient to jot thoughts on a piece of paper before heading to bed.
“I say, ‘describe for me what you do after 9 p.m.,’” said Dr. Maletic. “And I listen to everything.”
Instead of a general statement about noise reduction, he may home in on a patient’s loud air conditioner or on a gas station across the street with continual traffic sounds. When faced with reluctant patients, customized solutions can make all the difference—if a patient balks at the idea of putting down the smartphone before bed, Dr. Maletic might persuade her to use sunglasses to block the phone’s light.
Dr. Maletic recommends structuring the patient conversation to include both identification of undesirable practices and reinforcement of practices patients already perform correctly. “I always emphasize and reinforce the things they’re doing right and tell them to continue. I might say, ‘Great, keep up the good bedtime ritual, but now we need to worry about sound or light insulation.’”
#4 Gain patients’ buy-in so they become active participants in treatment
Although research supports the efficacy of behavioral techniques,  the success of those treatments is tied to patients’ motivation to follow through. “That’s the art of sleep medicine,” said Dr. Doghramji. “These techniques rely 100% on patient collaboration and initiative.”
The key to motivation is spending time with patients to explain the success rates of sleep hygiene practices and to educate them about the detrimental possibilities of overreliance on medication. Dr. Doghramji presents the treatment as a team effort in which the patient is a co-owner of the therapy. “I tell the patient that if they fail, then we both fail, and if they succeed then we both succeed. This is very different from the unidirectional model in which the doctor administers the sleeping pill.”
Yet incorporating time-intensive CBT is difficult for psychiatrists with busy practices and tightly scheduled patients. In some offices, psychiatrists may see upwards of 30 patients a day for 15-minute medication checks. “Finding the time is tough in this day and age,” said Dr. Doghramji.
If a psychiatrist has the type of practice that does not allow sufficient time for the institution and monitoring of behavioral treatments such as sleep-focused CBT, an alternative is to collaborate with a psychologist or other mental health professional with an appropriate practice.
“Don’t refer to just anybody though,” said Dr. Doghramji. “Choose someone with specific training in this area.”
When Dr. Doghramji is out of options, he will maximize even minimal patient time by focusing on the most effective, quick-to-understand behavioral treatments. “You really want to nail down sleep hygiene before you go to anything else. You can’t teach relaxation techniques in a short amount of time.” He recommends focusing on regularity of bedtimes, eliminating light and electronics, and eliminating caffeine consumption close to bedtime.
Still, some psychiatrists have sufficient time to spend with patients, making them well suited for treating sleep conditions. “If a psychiatrist can afford to spend at least half an hour with their patients and spend an hour getting the diagnosis right, then by all means the psychiatrist can treat these conditions,” said Dr. Maletic.
Dr. Doghramji recalled the gratification that comes from helping a patient solve what seems to be an intractable problem. After an older patient came to his office with lifelong, unresolved insomnia, Dr. Doghramji diagnosed him with a circadian rhythm disorder and treated him by implementing a gradual phase delay in his sleep/wake cycle. “After a few weeks the patient came back and said, ‘My God, I’m cured. Thank you doctor.’”
1. Psychiatric Association. DSM-5 Development. Insomnia Disorder. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=65#.
2. Soehner AM, Harvey AG. Prevalence and functional consequences of severe insomnia symptoms in mood and anxiety disorders: results from a nationally representative sample. Sleep. 2012;35(10):1367-1375.