1. 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

3. 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

4. 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

6. 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.

7. 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).

10. 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)

11. 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)

12. 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.

13. 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

14. 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.

15. 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

16. 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.

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

18. THERE ARE UNINTENDED COSTS OF INSOMNIA

19. 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.

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

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

23. 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 Jun 1; 39(6): 1275–1282

24. 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.

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

26. PATIENT ENCOUNTER
What does the word
patient
mean to
you?

27. 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?

33. 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.

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

35. 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:

36. PATIENT ENCOUNTER

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

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

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

41. PATIENT ENCOUNTER

44. MOOD DISORDER QUESTIONAIRE

45. 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

48. PATIENT ENCOUNTER

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

51. marketing strategy FOR THE super duper BUSY CLINICIAN

54. 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 Jun 1; 39(6): 1275–1282

55. 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)

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

59. 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.

60. 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.

61. RESOURCES

62. 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.

64. 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.

66. 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

67. 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

68. 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

69. TAKE THE BACKDOOR Opportunity to Treat Psych DXs
RHONDA MATTOX, MD
DIRECT ADDITIONAL QUESTIONS TO:

73. ADDITIONAL QUESTIONS