Psychiatric Sequalae of Sleep Disorders
Mark Brown, M.D.Stanford Sleep Disorders
CenterA.W.A.K.E. Meeting
Presentation Overview Introduction Primary Sleep
Disorders Psychiatry
Summary
Introduction Epidemiology
Common Psychiatric Morbidity Sleep and Psychiatry
Comorbid Difficult to separate Etiology,
consequence, or both?
Primary Sleep Disorders Insufficient Sleep Sleep
Fragmenting Disorders SDB RLS/PLMD
Disorders of Hypersomnolence Narcolepsy
Insufficient Sleep Very common in
today’s society 20% of 1.1 million
Americans sleep less than 6.5 hrs/night
Basal Sleep Need Epi studies indicate
mean need of 8.16 hrs/night
Principles and Practice of Sleep Medicine, 4th Ed. 2005
Insufficient Sleep Neuropsychiatric
Effects Cognitive,
psychomotor, memory
Subjective vs. Objective
Balkin et al. Sleep Loss and Sleepiness. Chest. 134(3):653-660, 2008 Sep.
Insufficient Sleep Individual
differences Stable within
individuals Varies between
individuals Need vs.
Resilience?
Van Dongen et al. “The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation.” Sleep. 2003 Mar 15;26(2):117-26.
Sleep Disordered Breathing (SDB) Obstructive Sleep
Apnea/Hypopnea Syndrome (OSAHS)
Apnea/Hypopnea Index (AHI)
<5 normal 5-15 mild 15-30 moderate >30 severe
Common OSA: 4% of men and
2% of women
Screening Symptoms
Snoring Witnessed apneas Choking arousals Spouse report
Signs BMI Neck
Circumference HTN
SDB and Depression Multiple Studies
Guilleminault et al Reynolds et al Millmann et al Mosko, S et al Aikens et al
Schroder et al. Depression and Obstructive Sleep Apnea (OSA). Annals of General Psychiatry 2005, 4:13, 1-8.
SDB and Depression Review Harris et al
Large prevalence studies
Sleep-EVAL VA database Hordaland Health
Study Correlational
studies Cross-sectional
studies
Prospective longitudinal Studies
Peppard et al Treatment studies
Harris et al. Clinical Review: Obstructive sleep apnea and depression. Sleep Medicine Reviews 13 (2009) 437-444.
SDB and Depression Review
1995-2006 OSA and
Depression/Anxiety
203 total articles Rigorous exclusion
criteria Final total of 55
articles
Results Age 44-69 yrs Median N 54 Median male sex
83% Median AHI 48 Assessment of
Mood Beck, Zung, CES-D,
HADS, STAI, POMS, MMPI, SCL-90, SCID, interview, etc…
Saunamaki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007:116:277-288.
SDB and Depression (cont) Pretreatment
Prevalence Depression 7-63% Anxiety 11-70%
CPAP Treatment 7 rigorous studies
Depression decreased in 4/7 studies
Anxiety decreased in 2/4 studies
Saunamaki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurol Scand 2007:116:277-288.
SDB and Depression Sleep Heart Health
Study (SHHS) 6,441 3,078
subjects 2 PSG’s, 5 yrs apart
Quality of Life Mental Component
Summary Scale (MCS) Sample
Age 62 55% female 75% Caucasian
Results Very small changes
over 5 years in RDI, BMI, ESS, PCS, and MCS.
Minimal change in PCS and no change in MCS
Significant association between subjective sleep quality and PCS/MCS.
Not clinically significant changes over 5 years
Silva et al, Sleep Disordered Breathing and Quality of Life. Sleep, 32(8), 1049-1057.
SDB and Cognitive Dysfunction Review Aloia et al
1985-2002 Initial 187 articles Final analysis 37
articles Limitations
Results Impairment >
60% Attention/Vigilance Exec Functioning Memory
Impairment >80% Construction Motor Functioning
Aloia et al. Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: A Critical Review. JINS, 2004, 10, 772-785.
SDB and Cognitive Dysfunction (cont) Treatment
Attention/vigilance (11/17)
Global functioning, executive functioning, and memory (6/10, 7/15, 8/15)
Psychomotor functioning failed to improve (0/6)
Aloia et al. Neuropsychological sequelae of obstructive sleep apnea-hypopnea syndrome: A Critical Review. JINS, 2004, 10, 772-785.
SDB in Children Introduction
ADHD comorbidity Prospective Study
Adenotonsillectomy (AT) cohort and surgical control
N=78, 5-12.9(8.4)yrs Mild-Moderate severity 57% male 95% f/u rate Measurements
Results AT group
Higher scores for hyperactivity, inattention, MSLT, and ADHD at baseline and improved to control rate 1 yr after surgery
However, only sleepiness correlated with PSG
Chervin et al. Sleep disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 117(4) 2006 e769-e778.
SDB Summary Complex
relationship 20+ year history
of studies Comorbid Treatment
implications Lack of response ADHD overlap in
children
RLS/PLMD RLS
Definition/Criteria “Unpleasant” Limb
Sensations Motor
Restlessness Precipitated by
REST and Relieved by Activity
Worse in Evening/Night
PLMD Definition/Criteria Repetitive,
stereotypic dorsiflexions of the big toe with fanning of the small toes with flexion of the ankles, knees, & thighs
Recur in intervals
RLS/PLMD Primary RLS Secondary RLS
Iron Deficiency Renal Failure Pregnancy Medications
TCA, SSRI, Dopamine antagonists (compazine, metaclopramide)
Caffeine
PLMD Any cause of RLS Withdrawal of
anticonvulsants, barbiturates, hypnotics
Associated with SDB, CPAP titration, and Narcolepsy
RLS and QoL SHHS 2821 men and
women RLS dx by 8-item
questionnaire and correlated with PSG findings
Health Related Quality of Life SF-36
Decrements in ALL physical domains
Decrements in Psychiatric domains of ‘Mental Health’ and ‘Vitality’ Dose-response
relationship
Winkelman et al. Polysomnographic and Health-related Quality of Life Correlates of Restless Legs Syndrome in the Sleep Heart Health Study. SLEEP 32(6) 2009 772-778.
RLS and Psychiatric Disorders RLS in community
sample of Korean Adults
6,509 subjects Age 18-64 Face-to-face
interview, K-CIDI, CES-D-K and EQ-5D
Prevalence Women (1.3%) Men (0.6%) Increased with
age
Cho et al. Restless Legs Syndrome in a Community Sample of Korean Adults: Prevalence, Impact on Quality of Life, and Association with DSM-IV Psychiatric Disorders. SLEEP. 32(8) 2009 1069-1076.
Results Psychotropics
(12.5% vs. 3%) Anxiety or
depression (21.1% vs. 12.6%)
Mean CES-D score (10.8 vs. 6.4)
Lifetime Prevalence of DSM-IV Disorders
40.3% vs. 27.7% MDD most
common (15.3% vs. 8.3%)
Anxiety disorders increased as well (13.9% vs. 6.7%)
Cho et al. Restless Legs Syndrome in a Community Sample of Korean Adults: Prevalence, Impact on Quality of Life, and Association with DSM-IV Psychiatric Disorders. SLEEP. 32(8) 2009 1069-1076.
RLS and Psychiatric Disorders (cont)
RLS, PLMD and Depression Review Depression more
common in RLS RLS/PLMD
exacerbated in those on SSRI’s/SNRI’s
RLS/PLMD improved or similar to control for buproprion and trazodone
Picchietti and Winkelman. Restless Legs Syndrome, Periodic Limb Movements in Sleep, and Depression. SLEEP. 28(7) 2005 891-898.
Narcolepsy REM Disorder Onset late
childhood to 20’s Signs/Symptoms
EDS Sleep Attacks Cataplexy Hypnagogic
Hallucinations Sleep Paralysis
Secondary Causes Head trauma Stroke MS Brain Tumors NG Disorders CNS infections
Diagnosis PSG with MSLT HLA antigens CSF
Narcolepsy and Psychiatry Psychosocial
Morbidity Study Cross-sectional
questionnaire survey
Children aged 4-18 Narcolepsy,
Behavior, Mood, QoL. And Educational Assessments
Subjects 42 subjects with
Narcolepsy 18 with EDS
without cataplexy 23 control group No demographic
differences between groups
Stores et al. The Psychosocial Problems of Children with Narcolepsy and those with Excessive Daytime Sleepiness of Uncertain Origin. Pediatrics. 118(4) 2006 e1116-e1123.
Narcolepsy and Psychiatry (cont.) Results
Significant differences for peer problems, conduct, emotional symptoms and total problems
Prosocial and hyperactivity not different from controls
CDI increased in Narcolepsy and EDS group
Mental Health QoL affect but not physical or global
Greater educational difficulties
Increased psychosocial morbidity
Narcolepsy and Schizophrenia
Case Series (5) All female, mean
age 39+/-6.8 Tx refractory
schizophrenia and EDS
All selected had narcolepsy tetrad
SANS, SAPS, BPRS Patients 2-5 (not
avail for pt 1) had statistically and clinically significant improvement of SANS, SAPS, and BPRS on stimulants.
Douglas et al. Florid Refractory Schizophrenias that turn out to be Treatable Variants of HLA-Associated Narcolepsy. J Nerv Ment Dis. 179:012-017, 1991, 12-17.
Summary Sleep disorders
are common Sleep disorders
have associated morbidity/mortality
Sleep disorders are under-appreciated
The relationship between sleep disorders and psychiatric disorders appears bi-directional
Identification and treatment of Primary Sleep disorders may improve psychiatric comorbidity
Questions