Sleep Medicine: Can We Regain Lost Ground

1. Sleep Medicine: Can We Regain Lost Ground? Angelos Halaris, M.D., Ph.D. Professor and Chairman and Sinan Baran, M.D. Medical Director, Sleep Disorders Center Department of Psychiatry and Human Behavior University of Mississippi Medical Center

2. Sleep MedicineSubspecialty of: Psychiatry Neurology Pulmonary Medicine Internal Medicine Pediatrics Psychology Other

3. Historical Perspective Psychiatrists were drawn to sleep research in the past because of interest in REM sleep and dreaming.

4. Decreased Interest in Sleep Medicine by Psychiatrists

5. New Diplomates of the American Board of Sleep Medicine in 2001: Pulmonologists 135 Neurologists 39 Other 18 Internists 6 Psychologists 2 Psychiatrists 0

6. Total Diplomates of the American Board of Sleep Medicine # % Pulmonologists 901 53.0 Neurologists 433 25.5 Psychologists 112 6.6 Psychiatrists 110 6.5 Internists 44 2.6 Other 99 5.8 1699

9. Possible Reasons for Decreased Interest in Sleep Medicine by Psychiatrists Sleep Medicine has become more general medical and less psychiatric: Current emphasis on sleep-disordered breathing Domination of field by pulmonologists

10. Why Should Psychiatrists Consider Subspecializing in Sleep Medicine? Professional diversity Psychiatric training of great value in the evaluation of all patients with sleep complaints more comprehensive approach increased sensitivity to contributing psychiatric factors including medication effects Insomnia: the most difficult presenting complaint Circadian rhythms

11. Obstructive Sleep Apnea Should not discourage psychiatrists from becoming involved with sleep medicine Upper airway obstruction during sleep CPAP acts as a splint to �prop open� the upper airway A relatively �fun� and easy problem (for the appropriately trained physician) to diagnose and treat, though there are subtleties CPAP compliance issues well suited for psychiatrists

12. Obstructive Sleep Apnea �Meat and potatoes� of sleep medicine Majority of cases referred to a sleep center BUT There are many other interesting cases sprinkled in to spice things up

13. Domination of Sleep Medicine by Pulmonologists is Without Scientific Basis OSA is not a pulmonary disorder Pulmonologists are not inherently more qualified to treat OSA CPAP/BiPAP treatment of OSA does not require a pulmonologist

14. Comorbidity of Sleep and Psychiatric Disorders Mood d/o can present with insomnia as chief complaint Primary sleep d/o can have psychiatric symptoms: affective pseudo-psychotic anxiety Coincidental concurrence of sleep and psychiatric disorders: special patient needs

15. PSG Patients taking Psychotropic Medications at UMMC 25.86% of 1106 patients: Antidepressants 22.97 % Mood stabilizers 1.45 % Antipsychotics 4.50 % Buspirone 1.27 % Clomipramine 0.18 % (4.89% on more than one class of medication)

16. Practical Matters Typical Practice of Sleep Medicine Training Board Certification Developing a Sleep Disorders Center Developing a Sleep Medicine Fellowship Referrals Reimbursement

17. Typical Practice of Sleep Medicine History and (focused) physical exam Interpretation of PSG visual pattern recognition skills

18. Training in Sleep Medicine Formal 1-2 year fellowship following residency accredited by AASM non-accredited Formal training + Clinical experience

19. Board Certification by American Academy of Sleep Medicine ABSM not recognized by ABMS AMA self-designated medical specialty Candidate for subspecialty of ABPN?

20. Board Certification by American Academy of Sleep Medicine Must 1st complete ACGME accredited residency or its equivalent prior to sleep training Currently, several options and waivers to qualify 2005: training must be in AASM accredited fellowship program to qualify for exam

21. Components of a Sleep Disorders Center Sleep specialist Technical staff Chief technologist maximum 2:1 patient to technologist ratio mainly night shift work Secretarial staff key issue: booking/maintaining PSG schedule Facility/Hardware Rooms Computerized (�paperless�) systems Infrastructure

22. Accreditation of Center ABSM certified or �eligible� physician PSG technologists Chief technologist preferably certified by BPSGT 3rd party reimbursement implications

23. Accreditation of Fellowship Accredited Center Clinical exposure: volume breadth Formal academic curriculum

24. Referrals Initial office evaluation prior to consideration of PSG for most patients Direct PSG referral only available to physicians with some experience with sleep disorders report must be reviewed and approved by sleep specialist prior to PSG

25. Reimbursement for Sleep Procedures in MS: Professional Fee Procedure BC/BS Medicare Medicaid PSG 164.00 124.53 164.88 PSG/CPAP 175.00 133.69 176.64 MSLT 71.20 69.76 73.63

26. Reimbursement for Sleep Procedures in MS: Technical Fee Procedure BC/BS Medicare Medicaid PSG 531.00 484.35 528.94 PSG/CPAP 533.00 490.39 547.81 MSLT 309.00 165.15 280.67

27. Relations with Neurology and Pulmonary Medicine Appropriate referral (not for sleep disorders) seizures during sleep intrinsic lung disease In multidisciplinary sleep centers: psychiatrists should maintain exposure to all sleep disorders avoid pitfall of receiving only psychiatric referrals

28. Additional Information American Board of Sleep Medicine: www.absm.org American Academy of Sleep Medicine: www.aasmnet.org Board of Registered Polysomnographic Technologists: www.brpt.org Association of Polysomnographic Technologists: www.aptweb.org

29. www.aasmnet.org

30. www.aasmnet.org

31. Conclusions Sleep medicine is not just about OSA, but OSA can be satisfying for psychiatrists to diagnose and treat Psychiatrists can practice the full spectrum of Sleep Medicine and are particularly well suited for cases of psychiatric comorbidity An active, full-service sleep disorders center can function well within and enhance a department of psychiatry

32. Recommendations Educate psychiatrists about sleep medicine and the need for psychiatry to increase its visibility and involvement (through APA) increase activity at psychiatric conferences increase sleep-related publications in psychiatric journals (rather than focus on Sleep Medicine journals) Mandate a rotation in sleep medicine for general psychiatry residents (off-site if in-house sleep lab not present)

33. Recommendations (cont.) Consider sleep medicine a subspecialty of ABPN AACDP to develop a consulting mechanism to assist departments of psychiatry in developing sleep laboratories and fellowships Provide community education about sleep disorders spearheaded by psychiatrists with expertise in sleep medicine

35. Sleep Medicine at the University of Mississippi Medical Center(UMMC) A full-service center that diagnoses and treats all sleep disorders Established 1980�s in the Department of Psychiatry Currently on staff: 4 physicians (1 full-time) certified by ABPN and ABSM 5 polysomnographic technologists

36. UMMC Sleep Disorders Center: Credentials One of 368 Sleep Disorders Centers accredited by the American Academy of Sleep Medicine One of 21 Sleep Medicine training programs accredited by the American Academy of Sleep Medicine

37. Sleep Studies in 2001 Academic Year Nocturnal Polysomnogram 687 Multiple Sleep Latency Test* 8 indicated in evaluation of narcolepsy or when quantification of daytime sleepiness is required

38. Referral Patterns Internal Medicine Family Medicine Pulmonary Medicine Pediatrics Otolaryngology Psychiatry

39. Training Full-time fellowship position (1-2 year) 1-2 month elective rotations for residents/fellows from following departments: Psychiatry Neurology Pulmonology Internal Medicine

40. Patient Population Adult 76 % Pediatric 24 %

41. Patient Distribution 68% Sleep-disordered Breathing 11% Periodic Limb Movement Disorder/Restless Legs Syndrome 10% Insomnia 7% Narcolepsy 2% Parasomnias

43. Obstructive Sleep Apnea Should not discourage psychiatrists from becoming involved with sleep medicine Upper airway obstruction during sleep CPAP acts as a splint to �prop open� the upper airway A relatively �fun� and easy problem (for the appropriately trained physician) to diagnose and treat, though there are subtleties CPAP compliance issues well suited for psychiatrists

44. Obstructive Sleep Apnea �Meat and potatoes� of sleep medicine Majority of cases referred to a sleep center BUT There are many other types of interesting cases sprinkled in to spice things up narcolepsy parasomnias insomnia

45. Domination of Sleep Medicine by Pulmonologists is Without Scientific Basis OSA is not a pulmonary disorder Pulmonologists are not inherently more qualified to treat OSA CPAP/BiPAP treatment of OSA does not require a pulmonologist

46. Conclusions Sleep medicine is not just about OSA, but OSA can be satisfying for psychiatrists to diagnose and treat Psychiatrists can practice the full spectrum of Sleep Medicine and are particularly well suited for cases of psychiatric comorbidity An active, full-service sleep disorders center can function well within and enhance a department of psychiatry

47. Recommendations Educate psychiatrists about sleep medicine and the need for psychiatry to increase its visibility and involvement (through APA) increase activity at psychiatric conferences increase sleep-related publications in psychiatric journals (rather than focus on Sleep Medicine journals) Mandate a rotation in sleep medicine for general psychiatry residents (off-site if in-house sleep lab not present)

48. Recommendations (cont.) Declare sleep medicine a subspecialty of ABPN AACDP to develop a consulting mechanism to assist departments of psychiatry in developing sleep laboratories and fellowships Provide community education about sleep disorders spearheaded by psychiatrists with expertise in sleep medicine

50. Results

51. Comorbidity of Sleep and Psychiatric Disorders Angelos Halaris, M.D., Ph.D. Professor and Chairman University of Mississippi Medical Center

52. Purpose To determine the prevalence of psychiatric disorders in our patient population over the past 3 years. The majority of our patients are referred by non-psychiatrists for the evaluation of primary sleep disorders other than insomnia.

53. Methods Our PSG database was reviewed to identify patients who were taking psychotropic medications. Presence of psychiatric disorders was presumed on the basis of patients� medications, and chart review was conducted to clarify ambiguous cases.

54. OSA patients on Antidepressant Medication Of 254 patients on antidepressants, 207 had OSA (81.50 %) (True depression?)

55. Conclusions The prevalence of psychiatric disorders is high in a typical sleep disorders center patient population, and may be even higher than these numbers suggest, since patients were not evaluated psychiatrically by us and may have had psychiatric symptoms that were not formally identified by referring physicians.

56. Discussion

57. Does OSA Cause MDD? OSA patients with depressive symptoms can be misdiagnosed as having MDD. In our experience, Depressive symptoms due to OSA resolve with treatment of OSA and do not require separate treatment Antidepressants are sometimes discontinued by referring MD after CPAP treatment

58. Overlap of OSA and MDD Sx Fatigue/anergia Sleep disturbance Amotivation Decreased concentration Decreased libido

59. Depressive Sx Not Typically Seen in OSA Crying Hopelessness Decreased appetite Weight loss Suicidal ideation

60. Reversal of Depression With CPAP 55 patients with OSA completed Zung Self-Rating Depression Scale (SDS) 45% had score > 50 All 11 patients with elevated scores showed improvement with CPAP (60.5+1.9 to 44.4+2.6 [p<0.001]) Millman RP, Fogel BS, McNamara ME, Carlisle CC: Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry. 1989 Sep;50(9):348-51.

61. Advantages of Psychiatrist Sleep Specialist: Increased sensitivity to needs of psychiatric patients with sleep disorders e.g., compliance with CPAP Ability to differentiate major depressive disorder from depressive symptoms due to OSA. Increased familiarity with effects of psychotropic medications on sleep

62. Polysomnograms Currently Performed 3 studies/night 5 nights/week

63. Concurrent Psychiatric Disorders in 1999 Affective Disorders 12 % Psychotic Disorders 3 % (typically not the reason for referral)

64. Sleep Diagnoses of Sample Population 1106 Patients: % Obstructive sleep apnea 82.10 Upper airway resistance syndrome 11.23 Periodic leg movement disorder 2.72 Narcolepsy 0.45 Parasomnias 0.18 Sleep-related GERD 0.36 Other 2.90