RHONDA MATTOX MD DIPLOMATE AMERICAN BOARD OF PSYCHIATRY amp NEUROLOGY ID: 773903
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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 INSOMNIA: A GOLDEN Opportunity to Treat Psych Dxs
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. CAVEAT
OBJECTIVES At the end of this session, participants who listen should be able to:Briefly review common mental health risks of untreated insomniaDescribe 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 AMERICAInsomnia 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 AMERICA8-10% 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 AMERICADSM V Criteria Difficulty initiating sleep orDifficulty maintaining sleep or Early morning awakening orNon-restorative sleep AND For >90 days with opportunity for sleep INSOMNIA DEFINED Diagnostic and Statistical Manual of Mental Disorders V (DSM V)
BACKGROUND SLEEPLESS IN AMERICADSM 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) INSOMNIA DEFINED
BACKGROUND SLEEPLESS IN AMERICAAcknowledgement that chronicity is what differentiates insomnia as a disorder vs. insomnia SXS due to other identifiable physical, emotional, or drug-related factors.INSOMNIA DEFINED
BACKGROUND SLEEPLESS IN AMERICAAmerican Academy of Sleep MedicineThe perception of difficulty with: Sleep initiationDurationConsolidationOr quality Occurs despite adequate opportunity for sleepResults in some daytime impairment INSOMNIA DEFINED
BACKGROUND SLEEPLESS IN AMERICASleep disorders coexist with other medical and psychiatric disordersInsomnia 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. COMORBIDITIES
BACKGROUND SLEEPLESS IN AMERICA Sleep problems are core symptoms of common psychiatric disorders like:MDDPTSDGeneralized Anxiety Disorder (GAD)Social Anxiety DisorderOther conditionsCOMORBIDITIES
BACKGROUND SLEEPLESS IN AMERICA May or may not be mutually exacerbatingSleep 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. COMORBIDITIES
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 populationsDifficulty 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 countriesDrapeau, 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 lifehigher rates of anxietycomorbiditygreater risk of depression recurrence
the impact of untreated INSOMNIA SUICIDEMENTAL HEALTHPHYSICAL HEALTHSOCIALSOCIAL COSTS
Insomnia and psychosis Insomnia is 1 of the most common prodromal sxs preceding a psychotic episodeMay be exacerbated during the acute phase of the illness May present as a residual symptom in clinically stable ptsA link has been associated btw the presence of insomnia and a paranoia in both clinical and general populationsSleep. 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? How would you proceed? Any additional info needed?Which conditions may be related?
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? How would you proceed? Any additional info needed?Which conditions may be related?
gad GENERALIZED ANXIETY DISORDER GAD-7Robert 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
ANTIDEPRESSANTS Sedating antidepressants Activating antidepressants Erman MK. Primary Psychiatry. Vol 14, No 9. 207
How would you proceed? What additional info do you need?
BIPOLAR DISORDER SYMPTOMS Symptom domains of bipolar disorder
PATIENT ENCOUNTER
MOOD DISORDER QUESTIONAIRE
BIPOLAR DISORDER Mania & Hypomania CriteriaA=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 schizophreniaThere 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 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) Includes sedating antipsychotics
& OVER DELIVERALWAYS SET EXPECTIONS SO THAT YOU CAN MEET THEM!UNDER PROMISE
Let’s schedule with someone with more expertise in this area than I have. I will still be a part of your treatment team.But I WANT you to treat me. I like YOU!
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
C BT- IcoachCBT-i Coach is for people who: Are engaged in Cognitive Behavioral Therapy for Insomnia with a health providerHave 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 medicationVijay, 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 insomniaDescribe 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
RHONDA MATTOX, MD DIRECT ADDITIONAL QUESTIONS TO: Rmmattox@uams.edu 501-258-4656 TAKE THE BACKDOOR Opportunity to Treat Psych DXs
ADDITIONAL QUESTIONS rmmattox@uams.edu501-258-4656