Treating Co-Morbid Sleep Problems with Psychiatric Disorders

Treating Co-Morbid Sleep Problems with Psychiatric Disorders
Sleep dysfunction may be a symptom of mental disorders and should be targeted for treatment by clinicians.

Americans will lose an hour of sleep when Daylight Saving Time begins on March 8. Unfortunately, many of them are used to it. The Centers for Disease Control and Prevention deems insufficient sleep a public health epidemic, with approximately 50-70 million adults suffering from sleep or wakefulness disorders.1

Though there is some individual variation in the ideal amount of sleep, young children generally need at least 10 hours per night, teens require between nine and 10 hours, and adults need between seven and eight hours.2 According to the National Health Interview Survey, however,  close to 30% of adults averaged only six hours of sleep or less per night in 2005-2007, and only 31% of high school students slept at least eight hours per night in 2009.1

The consequences of sleep deficits range from safety hazards on the roads and in the workplace to increased risk of health problems like diabetes, hypertension, obesity, and cancer.1 Sleep problems also commonly occur with psychiatric disorders. According to the National Alliance on Mental Illness (NAMI), over half of insomnia cases are related to anxiety, depression or psychological stress.3 Attention-deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and substance-use disorders are other conditions in which sleep is frequently impaired. For most of these disorders, sleep dysregulation is one of the diagnostic criteria in the DSM-5.4

Until recently, the prevailing view was that sleep problems were secondary to mental disorders and that remission of the disorder would improve sleep. Newer research, however, suggests poor sleep may be not only a symptom of such disorders, but a risk factor for them.5 Some results show that sleep dysfunction remains even after successful treatment of depression, and others indicate that targeted treatment for insomnia is associated with improved clinical outcomes for patients with anxiety and depression.

Whether a patient’s sleep impairment precedes or results from mental illness, targeted treatment is crucial because such problems can exacerbate psychological symptoms and worsen outcomes. Sleep problems co-occurring with depression, for example, are linked with poorer treatment response, lower remission rates, and higher relapse rates.5 A study from the February 2014 issue of the Journal of Traumatic Stress found similar results in women with PTSD and substance-use disorders.6

What percentage of your patients have co-occuring sleep disorders?

“Our study found that when sleep disruption continued to be a problem after treatment, long-term outcomes were worse,” study co-author R. Kathryn McHugh, PhD, a professor at Harvard Medical School and psychologist at McLean Hospital told Psychiatry Advisor. “This suggests that if patients continue to have problems with sleep—even when other PTSD symptoms have improved — there is a greater risk of symptoms failing to improve, or even worsening, over time.

“If a patient’s sleep is not improving when treating the PTSD alone, additional intervention targeting the sleep may be indicated — not only because sleep disruption is highly distressing and can interfere substantially in our patients’ lives, but also because it may put them at risk for later return of their other PTSD symptoms, she added.

Medication is the most frequently used form of treatment for insomnia. According to NAMI, one in 20 Americans has been prescribed medication for sleep problems, but that involves the risk of dependence and side effects.