Is It Insomnia, Is It Hypersomnia, Is It Both? W. Vaughn McCall, MD, MS Wake Forest University Health Sciences

Is It Insomnia, Is It Hypersomnia, Is It Both? W. Vaughn McCall, MD, MS Wake Forest University Health Sciences

W. Vaughn McCall, MD, MS Disclosures Research/Grants: Mini-Mitter Co.; National Institute of Mental Health; Sanofi-aventis; Sealy, Inc.; Sepracor, Inc. Speakers Bureau: Sanofi-aventis; Sepracor, Inc. Consultant: GlaxoSmithKline; Orexo AB; Sealy, Inc.; Sepracor, Inc.; Somaxon Pharmaceuticals, Inc. Stockholder: None Other Financial Interest: None Advisory Board: None

Learning Objective Recognize and differentiate insomnia and hypersomnia in patients with psychiatric disorder

Sleep and Psychiatric Disorders A Two-Way Street Psychiatric disorders are common in patients with sleep/wake symptoms Sleep disorders are common in patients with psychiatric symptoms Sleep/wake problems are a risk factor for developing psychiatric disorders Sleep/wake disturbances are associated with worse outcome in patients with psychiatric disorders including increased risk of suicide, relapse, and poorer outcomes Sateia MJ. Chest 2009;135:1370-1379.

Definitions Insomnia: Trouble falling asleep, staying asleep, or sleep of poor quality, associated with distress or daytime impairment No objective tests Treatment fixes both daytime and night-time symptoms Hypersomnia: Recurring episodes of excessive sleepiness during normal period of vigilance or extended duration of sleep Objective test Multiple Sleep Latency Test (MSLT)

Hypersomnia 5% of the general population 40% of young depressed adults, 10% of depressed elderly 1 Differential includes Inadequate time in bed Obstructive sleep apnea RLS/PLMD Narcolepsy Effects of medications Psychiatric disorders A special case: a clinical pearl 1. Nutt D, et al. Dialogues Clin Neurosci 2008;10:329-336.

Insomnia (Chronic) 10% of the general population 60 90% of patients with depression 1 Differential diagnosis Psychiatric disorders Primary insomnia Effects of medications RLS/PLMD Medical disorders (especially COPD, asthma, and neurologic conditions) Sleep apnea 1. Mosko S, et al. J Clin Psychol 1989;45:51-60.

The Common Wisdom Insomniacs and hypersomniacs are distinct, with discrete differential diagnoses

Differential Diagnosis Overlap Hypersomnia and Insomnia Hypersomnia Inadequate time in bed Sleep apnea RLS/PLMD Effects of medications Narcolepsy Psychiatric disorders Insomnia Psychiatric disorders Primary insomnia Effects of medications RLS/PLMD Medical disorders Sleep apnea

Tracking Hypersomnolence The Epworth Sleepiness Scale (ESS) Public domain Good psychometric properties Discriminates normals, insomniacs, OSA, and narcoleptics Validated against the MSLT Responsive to treatment 8 items, each scored 0-3, max score 24; scores > 10 are abnormal

Sleepiness in Normals, Sleep Disorders Patients, and Residents Papp KK, et al. Acad Med 2004;79:394-406. Mustafa M, et al. Sleep Breath 2005;9:57-63.

Tracking Insomnia The Insomnia Severity Index (ISI) Public domain Good psychometric properties Discriminates normals from insomniacs Responsive to treatment 7 items, each scored 0-4, max score 28; scores > 14 are abnormal Not anchored to any specific number of minutes awake or asleep, but instead anchored to distress and dissatisfaction

Tracking Insomnia Sleep Diaries Public domain Many versions available Staging severity of insomnia and crafting a CBT-I treatment plan relies upon sleep latency, total sleep time, etc., as measured in minutes, over several weeks More time intensive than ISI for both patients and physicians, but Can have therapeutic value for some patients

Clinical Challenges in Managing Sleep Disorders in Psychiatric Patients Assessing sleep/wake disturbance Comorbid sleep disorder? Medication effect? Treating sleep/wake symptoms in patients with psychiatric disorders Behavioral treatments: Motivation, behavioral activation Pharmacological treatments: Risk-benefit analysis given risks of comorbid substance abuse, symptom exacerbation Measure improvement Monitor sleep status during treatment of psychiatric disorder

Clinical Pearls Hypersomnia and insomnia can co-exist Separately and collectively, they are common symptoms in mood disorders The ESS and ISI are useful tools Sleep diaries have different utility than the ISI in insomnia measurement Co-occurrence of insomnia and hypersomnia may be an indicator of a primary sleep disorder

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Is It Insomnia? Is It Hypersomnia? Is It Both? W. Vaughn McCall, MD, MS Mosko S, Zetin M, Glen S, et al. Self-reported depressive symptomatology, mood ratings, and treatment outcome in sleep disorders patients. J Clin Psychol 1989;45:51-60. Mustafa M, Erokwu N, Ebose I, Strohl K. Sleep problems and the risk for sleep disorders in an outpatient veteran population. Sleep Breath 2005;9:57-63. Nutt D, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci 2008;10:329-336. Papp KK, Stoller EP, Sage P, et al. The effects of sleep loss and fatigue on resident-physicians: a multi-institutional, mixed-method study. Acad Med 2004;79:394-406. Sateia MJ. Update on sleep and psychiatric disorders. Chest 2009;135:1370-1379.