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Psychiatric Sequalae of Sleep Disorders

Psychiatric Sequalae of Sleep Disorders. Mark Brown, M.D. Stanford Sleep Disorders Center A.W.A.K.E. Meeting. Introduction Primary Sleep Disorders  Psychiatry Summary. Presentation Overview. Epidemiology Common Psychiatric Morbidity Sleep and Psychiatry Comorbid

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Psychiatric Sequalae of Sleep Disorders

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  1. Psychiatric Sequalae of Sleep Disorders Mark Brown, M.D. Stanford Sleep Disorders Center A.W.A.K.E. Meeting

  2. Introduction Primary Sleep Disorders  Psychiatry Summary Presentation Overview

  3. Epidemiology Common Psychiatric Morbidity Sleep and Psychiatry Comorbid Difficult to separate Etiology, consequence, or both? Introduction

  4. Insufficient Sleep Sleep Fragmenting Disorders SDB RLS/PLMD Disorders of Hypersomnolence Narcolepsy Primary Sleep Disorders

  5. Very common in today’s society 20% of 1.1 million Americans sleep less than 6.5 hrs/night Basal Sleep Need Epi studies indicate mean need of 8.16 hrs/night Insufficient Sleep Principles and Practice of Sleep Medicine, 4th Ed. 2005

  6. Neuropsychiatric Effects Cognitive, psychomotor, memory Subjective vs. Objective Insufficient Sleep Balkin et al. Sleep Loss and Sleepiness. Chest. 134(3):653-660, 2008 Sep.

  7. Individual differences Stable within individuals Varies between individuals Need vs. Resilience? Insufficient Sleep Van Dongen et al. “The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation.” Sleep. 2003 Mar 15;26(2):117-26.

  8. Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) Apnea/Hypopnea Index (AHI) <5 normal 5-15 mild 15-30 moderate >30 severe Common OSA: 4% of men and 2% of women Screening Symptoms Snoring Witnessed apneas Choking arousals Spouse report Signs BMI Neck Circumference HTN Sleep Disordered Breathing (SDB)

  9. Multiple Studies Guilleminault et al Reynolds et al Millmann et al Mosko, S et al Aikens et al SDB and Depression Schroder et al. Depression and Obstructive Sleep Apnea (OSA). Annals of General Psychiatry 2005, 4:13, 1-8.

  10. Review Harris et al Large prevalence studies Sleep-EVAL VA database Hordaland Health Study Correlational studies Cross-sectional studies Prospective longitudinal Studies Peppard et al Treatment studies SDB and Depression Harris et al. Clinical Review: Obstructive sleep apnea and depression. Sleep Medicine Reviews 13 (2009) 437-444.

  11. Review 1995-2006 OSA and Depression/Anxiety 203 total articles Rigorous exclusion criteria Final total of 55 articles Results Age 44-69 yrs Median N 54 Median male sex 83% Median AHI 48 Assessment of Mood Beck, Zung, CES-D, HADS, STAI, POMS, MMPI, SCL-90, SCID, interview, etc… SDB and Depression Saunamaki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007:116:277-288.

  12. Pretreatment Prevalence Depression 7-63% Anxiety 11-70% CPAP Treatment 7 rigorous studies Depression decreased in 4/7 studies Anxiety decreased in 2/4 studies SDB and Depression (cont) Saunamaki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007:116:277-288.

  13. Sleep Heart Health Study (SHHS) 6,441  3,078 subjects 2 PSG’s, 5 yrs apart Quality of Life Mental Component Summary Scale (MCS) Sample Age 62 55% female 75% Caucasian Results Very small changes over 5 years in RDI, BMI, ESS, PCS, and MCS. Minimal change in PCS and no change in MCS Significant association between subjective sleep quality and PCS/MCS. Not clinically significant changes over 5 years SDB and Depression Silva et al, Sleep Disordered Breathing and Quality of Life. Sleep, 32(8), 1049-1057.

  14. Review Aloia et al 1985-2002 Initial 187 articles Final analysis 37 articles Limitations Results Impairment > 60% Attention/Vigilance Exec Functioning Memory Impairment >80% Construction Motor Functioning SDB and Cognitive Dysfunction Aloia et al. Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: A Critical Review. JINS, 2004, 10, 772-785.

  15. Treatment Attention/vigilance (11/17) Global functioning, executive functioning, and memory (6/10, 7/15, 8/15) Psychomotor functioning failed to improve (0/6) SDB and Cognitive Dysfunction (cont) Aloia et al. Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: A Critical Review. JINS, 2004, 10, 772-785.

  16. Introduction ADHD comorbidity Prospective Study Adenotonsillectomy (AT) cohort and surgical control N=78, 5-12.9(8.4)yrs Mild-Moderate severity 57% male 95% f/u rate Measurements Results AT group Higher scores for hyperactivity, inattention, MSLT, and ADHD at baseline and improved to control rate 1 yr after surgery However, only sleepiness correlated with PSG SDB in Children Chervin et al. Sleep disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 117(4) 2006 e769-e778.

  17. Complex relationship 20+ year history of studies Comorbid Treatment implications Lack of response ADHD overlap in children SDB Summary

  18. RLS Definition/Criteria “Unpleasant” Limb Sensations Motor Restlessness Precipitated by REST and Relieved by Activity Worse in Evening/Night PLMD Definition/Criteria Repetitive, stereotypic dorsiflexions of the big toe with fanning of the small toes with flexion of the ankles, knees, & thighs Recur in intervals RLS/PLMD

  19. Primary RLS Secondary RLS Iron Deficiency Renal Failure Pregnancy Medications TCA, SSRI, Dopamine antagonists (compazine, metaclopramide) Caffeine PLMD Any cause of RLS Withdrawal of anticonvulsants, barbiturates, hypnotics Associated with SDB, CPAP titration, and Narcolepsy RLS/PLMD

  20. SHHS 2821 men and women RLS dx by 8-item questionnaire and correlated with PSG findings Health Related Quality of Life SF-36 Decrements in ALL physical domains Decrements in Psychiatric domains of ‘Mental Health’ and ‘Vitality’ Dose-response relationship RLS and QoL Winkelman et al. Polysomnographic and Health-related Quality of Life Correlates of Restless Legs Syndrome in the Sleep Heart Health Study. SLEEP 32(6) 2009 772-778.

  21. RLS in community sample of Korean Adults 6,509 subjects Age 18-64 Face-to-face interview, K-CIDI, CES-D-K and EQ-5D Prevalence Women (1.3%) Men (0.6%) Increased with age RLS and Psychiatric Disorders Cho et al. Restless Legs Syndrome in a Community Sample of Korean Adults: Prevalence, Impact on Quality of Life, and Association with DSM-IV Psychiatric Disorders. SLEEP. 32(8) 2009 1069-1076.

  22. Results Psychotropics (12.5% vs. 3%) Anxiety or depression (21.1% vs. 12.6%) Mean CES-D score (10.8 vs. 6.4) Lifetime Prevalence of DSM-IV Disorders 40.3% vs. 27.7% MDD most common (15.3% vs. 8.3%) Anxiety disorders increased as well (13.9% vs. 6.7%) RLS and Psychiatric Disorders (cont) Cho et al. Restless Legs Syndrome in a Community Sample of Korean Adults: Prevalence, Impact on Quality of Life, and Association with DSM-IV Psychiatric Disorders. SLEEP. 32(8) 2009 1069-1076.

  23. Review Depression more common in RLS RLS/PLMD exacerbated in those on SSRI’s/SNRI’s RLS/PLMD improved or similar to control for buproprion and trazodone RLS, PLMD and Depression Picchietti and Winkelman. Restless Legs Syndrome, Periodic Limb Movements in Sleep, and Depression. SLEEP. 28(7) 2005 891-898.

  24. REM Disorder Onset late childhood to 20’s Signs/Symptoms EDS Sleep Attacks Cataplexy Hypnagogic Hallucinations Sleep Paralysis Secondary Causes Head trauma Stroke MS Brain Tumors NG Disorders CNS infections Diagnosis PSG with MSLT HLA antigens CSF Narcolepsy

  25. Psychosocial Morbidity Study Cross-sectional questionnaire survey Children aged 4-18 Narcolepsy, Behavior, Mood, QoL. And Educational Assessments Subjects 42 subjects with Narcolepsy 18 with EDS without cataplexy 23 control group No demographic differences between groups Narcolepsy and Psychiatry Stores et al. The Psychosocial Problems of Children with Narcolepsy and those with Excessive Daytime Sleepiness of Uncertain Origin. Pediatrics. 118(4) 2006 e1116-e1123.

  26. Results Significant differences for peer problems, conduct, emotional symptoms and total problems Prosocial and hyperactivity not different from controls CDI increased in Narcolepsy and EDS group Mental Health QoL affect but not physical or global Greater educational difficulties Increased psychosocial morbidity Narcolepsy and Psychiatry (cont.)

  27. SANS, SAPS, BPRS Patients 2-5 (not avail for pt 1) had statistically and clinically significant improvement of SANS, SAPS, and BPRS on stimulants. Narcolepsy and Schizophrenia • Case Series (5) • All female, mean age 39+/-6.8 • Tx refractory schizophrenia and EDS • All selected had narcolepsy tetrad Douglas et al. Florid Refractory Schizophrenias that turn out to be Treatable Variants of HLA-Associated Narcolepsy. J Nerv Ment Dis. 179:012-017, 1991, 12-17.

  28. Sleep disorders are common Sleep disorders have associated morbidity/mortality Sleep disorders are under-appreciated The relationship between sleep disorders and psychiatric disorders appears bi-directional Identification and treatment of Primary Sleep disorders may improve psychiatric comorbidity Summary

  29. Questions

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