1. What is the Relationship Between Disrupted Sleep and Psychiatric Illness? Association between persistent childhood sleep problems and development of adult anxiety disorders 1 Insomnia preceded mood disorders in 40% of cases 2 Suicidal thoughts are linked to short, nonrestorative sleep 3 Chronically disturbed sleep increases the risk of psychiatric illness and hinders recovery 2,4,5 1. Gregory AM et al. J Abnorm Child Psychol. 2005;33(2):157-163. 2. Ohayon MM, Roth T. J Psychiatr Res. 2003;37(1): 9-15. 3. Park JH et al. Psychiatry Clin Neurosci. 2013;67(1):28-34. 4. Ford DE, Kamerow DB. JAMA. 1989;262(11):1479-1484. 5. Ju YE et al. JAMA Neurol. 2013;70(5):587-593.

2. Interrelationship Between Disturbed Sleep and Dysfunction Respiratory sleep disorder Obesity Medication side effects Psychiatric disorders Substance use Morbidity Mortality Suicidality Dysfunction, impaired quality of life Disrupted or nonrestorative sleep

3. Useful Screening Tools for Assessing Sleep and Psychiatric Conditions The Consensus Sleep Diary 1 The Pittsburgh Sleep Quality Index (PSQI) 2 The Patient Health Questionnaire (PHQ)-9 3 The Generalized Anxiety Disorder 7-item (GAD-7) Scale 4 Primary Care Post-traumatic Stress Disorder (PTSD) screen 5 All tools are in the public domain. 1.Morin CM. Insomnia Rounds. 2012;1(1):1-6. 2.Sleep Quality Index (PSQI). Available at: http://www.sleep.pitt.edu/content.asp?id=1484&subid=2316. 3.Patient Health Questionnaire (PHQ)-9. Available at: http://www.phqscreeners.com. 4.Generalized Anxiety Disorder 7-item (GAD-7) Scale. Available at: http://www.phqscreeners.com. 5.The primary care PTSD screen (PCPTSD). Available at: http://www.ptsd.va.gov/professional/pages/assessments/pc-ptsd.asp.

4. Sleep Changes in Mood Disorders PSG = polysomnography; REM = rapid eye movement Patient’s complaintSleep study finding (PSG) “I can’t fall asleep”Prolonged latency to stage 1 and 2 sleep “I wake up through the night”Increased arousals and awakenings through the night “I wake up early”Early awakening without return to consolidated sleep “My sleep is too short”Reduced total sleep time “My sleep is shallow and unrefreshing” Increased stage 1 Decreased stage 3 and 4 “My dreams are disturbing”Awakening from REM sleep with difficulty returning to sleep Multiple REM sleep abnormalities, including increased REM sleep, increased eye movements in REM, etc.

5. Treatment of Insomnia Associated with a Mood Disorder MDD and bipolar I/II disorders –Pharmacotherapy –Nonpharmacological: CBT, interpersonal and social rhythm strategies, sleep hygiene Most antidepressants benefit sleep Many SSRIs/SNRIs contribute to / worsen insomnia Hypnotic agents –Short-acting BDZ –Non-BDZ receptor agonists: zopiclone, zolpidem MDD = major depressive disorder; CBT = cognitive behavioural therapy; SSRI = selective serotonin reuptake inhibitor; SNRI = serotonin norepinephrine reuptake inhibitor

6. Anxiety Disorders Associated with Insomnia: PTSD Sleep complaints after trauma predict PTSD 1 >65% of PTSD patients report significant sleep difficulties 2 –Main symptoms: insomnia and dreams/nightmares about trauma Poor sleep affects severity of PTSD symptoms and perceived mental health 2 Treatment for traumatic nightmares 3 –Prazosin –Imagery rehearsal therapy; exposure, relaxation, and rescripting therapy; and lucid dreaming therapy 1.Klein E et al. J Sleep Res. 2003;12(1):35-41. 2.Belleville G et al. J Nerv Ment Dis. 2009;197(2):126-132. 3.Escamilla M et al. Curr Psychiatry Rep. 2012;14(5):529-535.

7. Anxiety Disorders Associated with Insomnia: GAD GAD is characterized by excessive anxiety and intrusive worrying, restlessness, fatigability, muscle tension, irritability, and difficulty concentrating Anxiety ratings correlate with number of awakenings, latency to stage 1 sleep, and percentage of stage 2 sleep 1 Commonly treated with SSRIs (may worsen insomnia) –A hypnotic agent can improve sleep and daytime performance 2 Nonpharmacological therapies 3 –CBT, mindfulness, relaxation exercises 1.Rosa RR et al. Biol Psychol. 1983;16(1-2):119-126. 2.Pollack M et al. Arch Gen Psychiatry. 2008;65(5):551-562. 3.Davidson JR. Insomnia Rounds 2012;1(3):1-6.

8. Anxiety Disorders Associated with Insomnia: Panic Disorder Insomnia is a common complaint in panic disorder –Prolonged sleep initiation and frequent awakenings 1,2 Panic attacks often occur during sleep 1 –Reported by 33%–71% of patients with panic disorder; up to 1/3 have more episodes during sleep than awake Frequent nocturnal panic attacks may lead to secondary insomnia Pharmacological and nonpharmacological treatments 3 –SSRIs/SNRIs are first-line and may require an SHA 4 1.Abad VC, Guilleminault C. Dialogues Clin Neurosci. 2005;7(4):291-303. 2.Mellman TA. Sleep Med Clin. 2008;3(2):261-268. 3.American Psychiatric Association. Practice Guidelines for the Treatment of Patients With Panic Disorder, 2nd ed. 4.Cervena K et al. Sleep Med. 2005;6(2):149-153.

9. Insomnia and Schizophrenia Severe insomnia is a prodromal sign of impending exacerbation or worsening after antipsychotic discontinuation 1 Sleep-related complications with schizophrenia 2 Inconsistent associations between PSG sleep indices and schizophrenia symptoms (positive and negative) 2 Antipsychotics have sedative effect –Maximize benefit through good sleep hygiene 3,4 1.Benson KL. Sleep Med Clin. 2008;3(2):251-260. 2.Krystal AD. Neurol Clin. 2012;30(4):1389-1413. 3.Davidson JR. Insomnia Rounds 2012;1(3):1-6. 4.MacFarlane J. Insomnia Rounds. 2012;1(2):1-6. –Longer time to fall asleep –Increased nocturnal wake time –Reduced total sleep time –Decreased latency to REM sleep onset –Decreased amounts of slow- wave (delta or N3) sleep