INSOMNIA: A GOLDEN Opportunity to Treat Psych Dxs RHONDA MATTOX, MD DIPLOMATE, AMERICAN BOARD OF PSYCHIATRY & NEUROLOGY ASSOCIATE PROFESSOR, UAMS DEPT. OF FAMILY MEDICINE AND PREVENTIVE MEDICINE ASSOCIATE PROFESSOR, UAMS DEPT. OF PSYCHIATRY AND BEHAVIORAL HEALTH TELEPSYCHIATRIST CONSULTANT, EAST ARKANSAS FAMILY HEALTH

CAVEAT warning This is NOT an insomnia talk. This is a: “Use of the symptom of insomnia to prompt evaluation of underlying psych conditions” talk. Overcome barriers to psych treatment by selecting a “2 for 1” med to “get to yes” to meds talk. “You can evaluate for psych conditions” quickly talk. warning

OBJECTIVES At the end of this session, participants who listen should be able to: Briefly review common mental health risks of untreated insomnia Describe free, fast strategies for the busy clinician to screen for psychiatric conditions associated with sleep problems as a core symptom Review “2 for 1 opportunities” to to utilize the management of insomnia to overcome patient objections to mental health treatment

BACKGROUND SLEEPLESS IN AMERICA Insomnia is among the most common complaints that PCP encounters. Accounts for > than 5.5 million visits annually. 20-30% of the general population has poor sleep at any given time.

BACKGROUND SLEEPLESS IN AMERICA 8-10% of the population suffers from chronic insomnia. Prevalence of insomnia in the general population ranges between 8-40% (depending on the definition used).

BACKGROUND SLEEPLESS IN AMERICA INSOMNIA DEFINED DSM V Criteria Difficulty initiating sleep or Difficulty maintaining sleep or Early morning awakening or Non-restorative sleep AND For >90 days with opportunity for sleep Diagnostic and Statistical Manual of Mental Disorders V (DSM V)

BACKGROUND SLEEPLESS IN AMERICA INSOMNIA DEFINED DSM V Criteria DSM-5 has extended the duration of criterion from 1 month to 3 mo. DSM-5 has eliminated the different insomnia DX in DSM-IV-TR to reintroduce overall diagnostic criteria for “insomnia disorder” with specification of comorbid mental and/or physical conditions. Diagnostic and Statistical Manual of Mental Disorders V (DSM V)

BACKGROUND SLEEPLESS IN AMERICA INSOMNIA DEFINED Acknowledgement that chronicity is what differentiates insomnia as a disorder vs. insomnia SXS due to other identifiable physical, emotional, or drug-related factors.

BACKGROUND SLEEPLESS IN AMERICA INSOMNIA DEFINED American Academy of Sleep Medicine The perception of difficulty with: Sleep initiation Duration Consolidation Or quality Occurs despite adequate opportunity for sleep Results in some daytime impairment

BACKGROUND SLEEPLESS IN AMERICA COMORBIDITIES Sleep disorders coexist with other medical and psychiatric disorders Insomnia is present in 20-40% of individuals with with mental illness Those meeting criteria for mood disorders or anxiety disorders exhibiting even higher rates of insomnia.

BACKGROUND SLEEPLESS IN AMERICA COMORBIDITIES Sleep problems are core symptoms of common psychiatric disorders like: MDD PTSD Generalized Anxiety Disorder (GAD) Social Anxiety Disorder Other conditions

BACKGROUND SLEEPLESS IN AMERICA COMORBIDITIES May or may not be mutually exacerbating Sleep problems can have a profound effect on the course of mood and anxiety disorders. Insomnia serves as a predictor of mood and anxiety disorder onset.

PREVALENCE OF PAST-YEAR INSOMNIA AMONG ADULTS Medical Condition Insomnia Prevalence (%) DATA FROM NESARC-III (From 34, 712 individuals)

THERE ARE UNINTENDED COSTS OF INSOMNIA

SUICIDE & inSOMNIA Significant association btw sleep disturbances and increased risk of suicidal behaviors in general and clinical populations Difficulty sleeping and experiencing greater severity of insomnia symptoms have been associated with suicide ideation in youth, adult, and older adult samples across multiple settings and countries Drapeau, C. W., & Nadorff, M. R. (2017). Suicidality in sleep disorders: prevalence, impact, and management strategies.

IMPACT Individuals with major depression and insomnia report: poorer quality of life higher rates of anxiety comorbidity greater risk of depression recurrence

the impact of untreated INSOMNIA SUICIDE MENTAL HEALTH PHYSICAL HEALTH SOCIAL COSTS

Insomnia and psychosis Insomnia is 1 of the most common prodromal sxs preceding a psychotic episode May be exacerbated during the acute phase of the illness May present as a residual symptom in clinically stable pts A link has been associated btw the presence of insomnia and a paranoia in both clinical and general populations Sleep. 2016 Jun 1; 39(6): 1275–1282

PATIENT ENCOUNTER 31 year old obese male with hx of MVA, chronic pain, migraine headaches, anxiety and depression that began in childhood seen in FMC with primary complaint of insomnia. States none of the hypnotics have helped him.

How would you proceed? Any additional info needed? Which conditions may be related? How would you proceed? How would you proceed?

PATIENT ENCOUNTER What does the word patient mean to you?

PATIENT ENCOUNTER The first step in the management of treatment-resistant depression (TRD) is adequate history taking and assessment for comorbidities and bipolar depression. Has there been a family history of substance abuse, bipolar disorder, schizophrenia, suicide? What other medicines have they taken? What was there response to other meds? What were the side effects?

PATIENT HEALTH QUESTIONAIRE 9 (PHQ-9) Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, et al. No permission required to reproduce, translate, display, or distribute.

How would you proceed? Any additional info needed? Which conditions may be related? How would you proceed? How would you proceed?

GENERALIZED ANXIETY DISORDER GAD-7 gad Robert L. Spitzer, MD; Kurt Kroenke, MD; Janet B. W. Williams, DSW; Bernd Löwe, MD, PhD A brief,measure for assessing generalized anxiety disorder. The GAD-7, Arch Intern Med. 2006;166:1092-1097.

PATIENT ENCOUNTER

Erman MK. Primary Psychiatry. Vol 14, No 9. 207 ANTIDEPRESSANTS Sedating antidepressants Activating antidepressants Erman MK. Primary Psychiatry. Vol 14, No 9. 207

What additional info do you need? How would you proceed?

Symptom domains of bipolar disorder BIPOLAR DISORDER SYMPTOMS Symptom domains of bipolar disorder

PATIENT ENCOUNTER

MOOD DISORDER QUESTIONAIRE

A=more severe b=less severe Adapted from DSM-5 BIPOLAR DISORDER Mania & Hypomania Criteria A=more severe b=less severe Adapted from DSM-5

PATIENT ENCOUNTER

TO MEDICATE OR NOT TO MEDICATE? Suicidal thoughts? History of suicide attempts? Hearing voices? Seeing things? Delusional beliefs? Manic? Hypomanic?

marketing strategy FOR THE super duper BUSY CLINICIAN

INSOMNIA AND SCHIZOPHRENIA Different pharmacological approaches have been suggested to manage residual sleep disturbances in schizophrenia There remains a concern with potentially increasing suicide risk by prescribing sedatives and hypnotic agents in vulnerable individuals. The use of antipsychotics with sedating properties should be strongly considered. Sleep. 2016 Jun 1; 39(6): 1275–1282

Sedating mood stabilizers Includes sedating antipsychotics Many antipsychotic medications cause sedation, but not all medications have the same sedative effect. Chlorpromazine (Thorazine, Sonazine, and others) Fluphenazine (Prolixin, Permitil, and others) Haloperidol (Haldol and others), Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone (Risperdal) Ziprasidone (Geodon)

& OVER DELIVER UNDER PROMISE ALWAYS SET EXPECTIONS SO THAT YOU CAN MEET THEM!

But I WANT you to treat me. I like YOU! Let’s schedule with someone with more expertise in this area than I have. I will still be a part of your treatment team.

RESOURCES 1. 1. ID referrals for sleep in your area 2. ID referrals for specialty mental health that has treatment team (psychiatrist, therapist, CBT trained providers) 3. Sleep hygiene handouts 4. 5. 6.

RESOURCES

CBT- Icoach CBT-i Coach is for people who: Are engaged in Cognitive Behavioral Therapy for Insomnia with a health provider Have experienced symptoms of insomnia and would like to improve their sleep habits The app will guide you through: Process of learning about sleep Development of positive sleep routines Improvement in your sleep environment. Provides a structured program Teaches strategies proven to improve sleep and help alleviate symptoms of insomnia.

CBT-I coach CBT-i Coach is for people who: Are engaged in Cognitive Behavioral Therapy for Insomnia with a health provider Have experienced symptoms of insomnia and would like to improve their sleep habits The app will guide you through: Process of learning about sleep Development of positive sleep routines Improvement in your sleep environment. Provides a structured program Teaches strategies proven to improve sleep and help alleviate symptoms of insomnia.

PRACTICAL TIPS risk reduction Documentation of treatment indications linked to prescriptions Always practice indication-based prescribing. Identify why you are giving the medication Vijay, Becker, et al 2018 , Patterns and Predictors of Off Label Prescription Patterns of Psychiatric Drugs

PRACTICAL TIPS risk reduction Identify how long you plan to keep them on medication and that you discussed that they should not drive or operate heavy machinery. Review and document potential teratogenic effects in child bearing women and their method of birth control. Vijay, Becker, et al 2018 , Patterns and Predictors of Off Label Prescription Patterns of Psychiatric Drugs

let’s recap At the end of this session, participants who listen should be able to: Briefly review common mental health risks of untreated insomnia Describe free, fast strategies for the busy clinician to screen for psychiatric conditions associated with sleep problems as a core symptom Review “2 for 1 opportunities” to to utilize the management of insomnia to overcome patient objections to mental health treatment

TAKE THE BACKDOOR Opportunity to Treat Psych DXs RHONDA MATTOX, MD DIRECT ADDITIONAL QUESTIONS TO: Rmmattox@uams.edu 501-258-4656

ADDITIONAL QUESTIONS rmmattox@uams.edu 501-258-4656