Sleep disturbances are common in the general population, with the highest prevalence of insomnia observed in psychiatric patients.1 In fact, more than 40% of individuals treated as outpatients for psychiatric disorders experience symptoms of sleep disorders, with 26.3% having symptoms of 2 sleep disorders and 10.4% having features of 3 sleep disorders.1
Sleep disturbances have classically been regarded as defining features of several psychiatric disorders and are included in the diagnostic criteria.2,3 Moreover, insomnia can be a harbinger of psychiatric disorders and may increase the risk for relapse.4 There is, however, an emerging view that sleep disorders are not merely symptoms of psychiatric conditions. Rather, there may be a complex and bidirectional relationship between psychiatric and sleep disorders.2
Despite the common co-occurrence of sleep and psychiatric conditions, many sleep specialists do not take psychiatric disorders into account when evaluating patients with sleep complaints and, conversely, many psychiatrists do not look at the role of sleep in their patients’ psychiatric symptoms, according to Paul Doghramji, MD, senior faculty practice physician at Collegeville Family Practice and Medical Director of Health Services at Ursinus College in Collegeville, Pennsylvania. Dr Doghramji is also on the board of the National Sleep Foundation and the author of a textbook, Clinical Management of Insomnia.
“There is very little emphasis on sleep during medical school training, residency, and post-residency, and very little information about sleep-related problems, and yet they are pervasive and cut across all areas of medicine, including psychiatry,” he told Psychiatry Advisor. It is, therefore, “critically important to understand the intersection between sleep and a variety of psychiatric disorders,” he emphasized.
What Are We Treating?
“I think psychiatrists should proactively ask patients about sleep habits whenever they present with symptoms that could be related to insufficient sleep or sleep disturbances,” Dr Doghramji advised. Patients with primary sleep disorders present with symptoms similar to those reported by patients with psychiatric disorders.5 Many symptoms that could be caused by insufficient or poor sleep can masquerade as psychiatric conditions: daytime fatigue, anxiety, depression, poor concentration, decreased productivity, impaired problem solving and reasoning, and frequent accidents and injuries, he noted.
“As the Medical Director of a college, I see students who come [in] with these types of symptoms, thinking that they have ADHD [attention-deficit/hyperactivity disorder], mononucleosis, vitamin deficiency, depression, or anxiety and are seeking medication,” Dr Doghramji recounted. His first question to these students concerns sleep because college students “notoriously have poor sleep habits, staying up all night to study or party.” He noted that this problem affects not only college students but is pervasive throughout American society. A recent set of surveys conducted by the American Academy of Sleep Medicine (AASM) found that 88% of US adults are not getting a sufficient amount of sleep because they are staying up late binge-watching shows or sporting events, playing video games, or reading.5
Dr Doghramji educates these students about sleep hygiene and the role of sleep in facilitating the “4 R’s: Rest, Restore, Refresh, and Rejuvenate.” He also encourages them to “pace” their sleep: get the same amount of sleep nightly and a minimum of 7 hours of sleep, something he himself managed to do even while in medical school. If symptoms persist after these measures have been taken, Dr Doghramji explores the possibility of a psychiatric condition, noting that improving sleep will improve the psychiatric condition and, conversely, addressing the psychiatric condition usually improves sleep.
Wilfrid Noel Raby PhD, MD, an adjunct clinical professor at Albert Einstein College of Medicine, Bronx, New York, told Psychiatry Advisor that he always asks patients about their sleep because that tells him “a lot about their condition.” He inquires about when they go to sleep, when they wake up, whether their sleep is interrupted, whether they wake up feeling rested, and whether they oversleep. “These provide clues to what their psychiatric condition might be and its severity, as well as potential treatment approaches,” he said.
Several classes of medications, including benzodiazepines, antidepressants, and antipsychotics, can have sedating effects, making them useful treatments for insomnia or sleep disturbances in patients with psychiatric disorders. However, Dr Raby warns that it is “important not to confound sedation and sleep.” A person who has been sedated may be experiencing “something like sleep, but most sedatives alter sleep quality, disrupt the usual sleep cycle patterns, and interfere with the different phases of sleep,” he said.
For this reason, it is important to address sleep in a more comprehensive way, not only with sedation but by normalizing sleep patterns — an approach that “has a lot of import” because it can also help “normalize mood instability, cognitive performance, and resilience in the face of stress.” For example, many patients with psychiatric conditions suffer from circadian rhythm disorders such as delayed sleep phase syndrome, in which the patient falls asleep later and also awakens later compared with social norms and light cycles.7 This may be especially true in atypical depression, which is characterized by greater mood reactivity, rejection sensitivity, and increased carbohydrate consumption and sleep, especially during the winter.8
“In cases like these, there are surges in adrenaline and sympathetic nervous system activation that phases out much later into the night,” Dr Raby explained. A sympatholytic such as clonidine, guanfacine, or prazosin9 can be helpful because it “calms the adrenergic surge by acting on the alpha-2 receptors,” Dr Raby explained. “In particular, prazosin is useful in posttraumatic nightmares because they seem to be driven by catecholaminergic mechanisms.” By addressing this mechanism, “you allow people to get a more natural sleep, in the sense that these are not sleep medicines but rather undercut the reason why patients are having disrupted sleep.”
Another strategy Dr Raby uses in his clinical practice is prescribing very low-dose naltrexone (LDN) at night “to modulate sleep, because you are abolishing that cortisol surge in the evening, which is what sustains the sympathetic activity and contributes to the delay in falling asleep.” LDN is short-acting, causing a “rebound surge of cortisol in the morning that contributes to alertness during the daytime, but there is also improved sleep at night,” he said. LDN has been studied and found effective in alleviating depressive symptoms,10 as well as pain conditions such as fibromyalgia,11 although its use has also been associated with sleep disturbances.11
Nevertheless, Dr Raby has used this strategy in a variety of patients with comorbid psychiatric and sleep disorders, including patients with ADHD, bipolar disorder I or II, and depression with a seasonal component. The key, he explained, is in the dosing, which is “tricky” because LDN can be activating if the dose is too high. “If you are going to try this approach, it’s better to undershoot,” he cautioned.
He added an important caveat about the role of sedating medications: “I would like to emphasize that even sedated sleep is better than no sleep, especially in patients with bipolar disorder, so I am not discouraging the use of other sleep-inducing medications, simply suggesting another potential avenue of approach.”
Blue Light-Blocking Therapy
Blue wavelengths “form the portion of the visible electromagnetic spectrum that most potently regulates circadian rhythm.”12 Wearing blue light-blocking glasses in the evening may therefore influence circadian rhythm disturbances in patients with major depressive disorder (MDD), leading to improved sleep and mood.13 It has also been found helpful in delayed sleep disorder13 and as an adjunctive treatment for bipolar mania.14
Blue light-blocking therapy is “a simple nonpharmacologic intervention for insomnia and other sleep disturbances in patients with psychiatric conditions, and I use it frequently in my practice,” said Dr Raby. It is especially important in this day and age, when people with and without psychiatric disorders stay up late using their cellphones, tablets, computers, and other devices that emit blue light, he noted.
“I have found that a combination of sympatholytic drugs, low dose naltrexone, and blue light-blocking glasses has been very successful with many patients,” he said.
Cognitive behavioral therapy (CBT) for insomnia has gained traction as a helpful short-term intervention designed to address maladaptive sleep habits, lower cognitive or physiologic sleep-disrupting arousal, and alter sleep-related misconceptions and thought patterns.15 For treating primary insomnia, CBT has been found to be equal to pharmacologic treatment in the short-term and to have longer lasting effects.15 Several studies have found that CBT not only improves insomnia symptoms but also symptoms of psychiatric comorbidities16 including depression,17,18 anxiety,19 PTSD,16 and alcohol dependence.16
It may be important to sequence treatments for comorbid conditions rather than treat them concurrently. In patients with depression, for example, if the patient’s primary depressive symptoms involve a lack of motivation, treatment for depression can be prioritized initially to build the patient’s capacity to engage in CBT.16
CBT has been shown to improve symptoms of nightmares or fear of sleep in patients with PTSD, but patients who are actively undergoing exposure therapy should not receive concurrent CBT due to the possibility of interference between PTSD symptoms elicited during exposure therapy and CBT engagement. Therefore, treatment for PTSD symptoms before CBT may be the most effective sequence.16
A number of mind-body techniques have been found to be helpful with sleep disturbances, including those that occur comorbidly with psychiatric conditions.
Patricia Gerbarg, MD, an assistant professor of psychiatry at New York Medical College in Valhalla, New York, told Psychiatry Advisor that breathing techniques are useful because they “address the underlying neurophysiological imbalances that contribute to many different disorders, so the same basic techniques can be used, perhaps with modifications, across a wide range of psychiatric conditions.”
Dr Gerbarg explained that many psychiatric conditions “involve dysregulation of the autonomic nervous system and the emotional regulatory systems.”20 Particularly in conditions such as anxiety disorder and PTSD, there is an imbalance in the autonomic nervous system, with overactive sympathetic activity and underactive parasympathetic activity.21,22
A slow, gentle breathing practice called Coherent Breathing, which involves taking 4 to 6 breathes per minute, is a “simple and rapid way to reduce the overactivity of the sympathetic branch of the nervous system and increase and strengthen the activity of the parasympathetic branch, leading to optimal sympathovagal balance and robust heart rate variability (an indicator of health and longevity),”21 she explained. This type of breathing can be helpful in sleep disorders because many individuals cannot “turn off” their excessive worrying.
“We have found that slow breathing can reduce activity in the thinking centers at night to create a calm, emotional state,” she reported. She emphasized that these breathing practices are not a substitute for medication, but can create a deeper, more refreshing sleep than many medications, such as benzodiazepines. “Because the person is calmer, he or she feels safer, which can ameliorate one of the main reasons for the disrupted sleep,” she said.
In addition to improving sleep, calming breathing exercises can be used during the day to stay calm and think clearly during stressful situations and can be combined with more energizing practices that enhance alertness and attention. Yoga and Qigong practiced during the day, especially when combined with breathing techniques, can improve stress resilience and sleep in the general population and psychiatric patients.21 Mindfulness meditation has likewise been shown to improve sleep in general, as well as in specific medical or psychiatric conditions.23,24,25
Improving Sleep Hygiene
“Attending to sleep disturbances is a critical component of treating psychiatric illness; treating both in tandem, using multiple approaches, can have a synergistic effect in bringing improvement in both conditions,” Dr Raby emphasized. Improving sleep habits is important for all people, whether or not they have a sleep or psychiatric disorder.26 Tips for improving sleep hygiene are found in the table below.27-29
Table: Lifestyle Tips for Improving Sleep
· Maintain a regular sleep schedule
· Set the alarm for rising time, but do not watch the clock
· After lunch, avoid caffeine or other agents that may activate the nervous system (eg, chocolate, cocoa, over-the-counter weight-control aids, pain relievers, and certain allergy/sinus remedies)
· Avoid daytime napping
· Make the bedroom quiet and comfortable
· Avoid alcohol within 3 hours of bedtime
· Avoid nicotine products within 2 hours of bedtime
· Exercise during the day but avoid exercise during the 2 hours before bedtime
· Wind down before bedtime, allowing ≥1 hour to relax
· Avoid excessive time in bed
· Use the bed only for sleeping and sex
· Eat a light snack before bed if hungry
· Avoid using electronic devices close to bedtime
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