Psychiatric Dispatches

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Primary Psychiatry. 2008;15(8):21,24-26


Barriers Compromising Adherence to Positive Airway Pressure for Children with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is prevalent in 1% to 4% of the population. If untreated, it can lead to various ailments, including behavioral problems, neuropsychological deficits, and medical morbidity. Though there are effective treatments for OSA, such as tonsillectomy and adenoidectomy and positive airway pressure (PAP), not all children experience the benefits of or qualify for tonsillectomy and adenoidectomy. Further, pediatric patients undergoing PAP often have difficulty tolerating and being consistent with the procedure as prescribed. Kelly C. Byars, PsyD, CBSM, and colleagues evaluated adherence to PAP in the pediatric OSA population and found common barriers to adherence to the treatment.

The study involved a mostly male (72.7%) and white (61.4%) sample of 44 patients who were evaluated in the Accredited Sleep Center and Accredited Sleep Laboratory of the Academic Pediatric Medical Center in Cincinnati, Ohio. To qualify for the study, patients had to be ≤18 years of age (all patients were 5.37–16.13 years of age at time of diagnostic polysomnography) and experiencing PAP titration from January–December 2005. Each patient’s outpatient clinic notes were reviewed using the retrospective chart review (RCR) both prior to titration study and up through the year 2007. Scoring on the RCR was completed according to criteria from the American Academy of Sleep Medicine.

While adherence to the therapy ranged from complete rejection of the treatment to optimal usage, descriptive statistical results showed that most patients did not use PAP as required. In addition, it is important to note that most factors compromising adherence to PAP revolved around psychosocial issues.

These data indicate the need for behavioral sleep medicine practitioners in circumstances where children with OSA are using PAP therapy. Further research is still necessary for improved PAP adherence in pediatric OSA patients. (APSS 2008; Poster 0289). –ML


Changes in Sleep Pattern Often Occur in Military Personnel with Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the most prevalent injuries suffered by members of the United States military. According to the Defense and Veterans Brain Injury Center, the military formerly diagnosed 2,121 cases of TBI between October 2001 and January 2007, though actual rates of such injury may be higher. In addition, due to the types of incidents causing brain injury, such as increased use of improvised explosive devices (IEDs) and mortar attacks, the rates of traumatic brain injury are similarly increasing. Data have shown that a majority of military personnel serving in Iraq and treated by a medical unit were injured due to IEDs or mortar attacks.

A common complaint of service men and women following TBI is change in sleep patterns. Despite this higher reporting of sleep complaints, few studies have investigated the link between TBI and sleep disturbance in service men and women or in the general population. Studies that have been conducted show that patients with brain injuries have reduced rapid eye movement (REM) sleep, disruptions in sleep architecture, and increased incidence of narcolepsy. Researchers in the Department of Neurology at the University of North Carolina in Chapel Hill sought to determine the link between sleep disturbance and TBI in a population of military personnel, whom the authors found would be at higher risk for changes in typical sleep patterns due to the nature of their injuries.

Peterson F. Giallanza, MD, and colleagues, studied sleep data from 35 marines (average age=23.4 years) who incurred brain injury and compared those findings with data from 21 participants (average age=24.2 years) who had no reported brain injury. The authors recorded a polysomnogram on every participant and studied standard sleep parameters, such as frequency of REM sleep. Nasal pressure and continuous end tidal carbon dioxide were also measured. All data were evaluated using American Academy of Sleep Medicine criteria.
The authors found that numerous patients with brain injury had higher measures on certain sleep indices, including total sleep and REM sleep time, than normal controls, which was a finding contrary to their hypothesis.

Among patients with TBI, 13 had a sleep efficiency of ≥95%; this result was found in two control patients. Evaluating latency to REM onset, eight patients with brain injury showed a latency period of <60 minutes and three patients had a latency period of <30 minutes. No control participants showed a latency period of <60 minutes. Regarding sleep onset REM periods (SOREMPs), Giallanza and colleagues found that 16 patients with TBI had ≥1 SOREMP during polysomnogram while only one control participant had ≥1 SOREMP. Eight TBI patients experienced ≥2 SOREMPs, and six of those patients had a mean sleep latency of <8 minutes. Among healthy participants, one had 2 SOREMPs.

The authors concluded that although these findings were contrary to earlier reports of decreased REM sleep in service men and women with TBI, they may be due to a higher sleep/wake dysregulation in combat veterans than in the general population. The authors added that such changes in sleep patterns may be a marker for a neurologic condition. Study limitations included lack of military controls and certain findings could be attributed to other disorders, such as sleep deprivation. (APSS 2008; Poster 0872). –CP


Insomnia Severity and Incidence of Comorbid Medical and Mental Illness

 In a large, community-based study, Khaled Sarsour, PhD, and colleagues assessed the severity of insomnia across a range of medical and psychiatric comorbid conditions and evaluated the effects of insomnia on daytime functioning across the severity spectrum. They used the Insomnia Severity Index (ISI) to determine symptom severity ratings of insomnia in the study. Ratings data were then compared with the number of independently reported medical and psychiatric comorbidities, and claims-based psychiatric and chronic medical conditions.

From a total of 2,292 enrollees (age range=18–80 years), all from a Midwest health plan, 1,181 were identified as having an insomnia-related claim, and the remaining 1,111 enrollees were chosen randomly. Mean age of the sample was 51.74 years (SD±14.3 years), 30.4% were male, and 87.1% lived in urban areas. Prevalence of subthreshold insomnia in this sample was 33.6%, according to the ISI. Prevalence rates of moderate and severe insomnia were 21.2% and 6%, respectively; 39.3% had no insomnia.

For subjects with severe insomnia, worry was the most severe comorbidity, with 91% experiencing it. Depression (79%), pain (70%), and sleep apnea (60%) were the next most prominent comorbidities. Less comorbidities were commensurate with decreasing insomnia severity in subjects with moderate and subthreshold insomnia. Similarly, subjects with severe insomnia reported the most difficulty initiating sleep (93%), difficulty maintaining sleep (97%), and early morning awakening (90%). Eighty-two percent reported all three symptoms.

Overall, for subjects with severe insomnia, the odds of having ≥1 psychiatric comorbidity and ≥1 chronic medical comorbidity are 5.26 and 2.22 times higher, respectively, compared to those with no insomnia. Aside from indicating that psychiatric and chronic medical comorbidities are strongly related to increased severity of insomnia, this study also provides an overview of the daytime effects of insomnia across all ranges of severity.

Funding for this research was provided by Eli Lilly. (APSS 2008; Poster 0724) –LS


Increased Probability of an Accident After Using Certain Insomnia Medications

In 2005, the National Sleep Foundation conducted a survey that found 54% of American adults endure at least one symptom of insomnia a few nights per week. Numerous treatments for insomnia can lead to next-day somnolence and possibly increased risk of accidental events. Alon Y. Avidan, MD, MPH, and colleagues of the Department of Neurology at the University of California in Los Angeles examined the risk of accidents in patients prescribed either a benzodiazepine receptor agonist or sedating antidepressant compared to that in patients prescribed a selective melatonin receptor agonist.

The researchers used a retrospective cohort analysis to compare the occurrence of accidental events in a commercial population with ≥9 months of health insurance eligibility data. Accidental events such as falls, open wounds, and motor vehicle accidents were distinguished from medical claims using External Causes of Injury codes from the International Classification of Diseases, 9th Revision. Patients initiated insomnia medication, including long-acting benzodiazepines (LABs; n=344,557), short-acting benzodiazepines (SABs; n=127,252), nonbenzodiazepines (nBzs; n=563,298), sedating antidepressants (n=175,564), and selective melatonin receptor agonists (n=132), and were evaluated over a 60-day period after initial prescription. During this time, probit models assessed the probability of an accidental event while proportional hazard models measured the time to an accidental event.

Results found that subjects taking an LAB, SAB, nBz, or sedating antidepressants experienced greater risk of an accidental event following treatment initiation than those taking a selective melatonin receptor agonist. Further, subjects taking a selective melatonin receptor agonist faced less time to an accidental event than those taking other insomnia medications.
The data indicated that there is apparent lower risk of accidental events in the selective melatonin receptor agonist cohort. However, this conclusion is limited, as the number of patients in this particular group was significantly smaller than those in the other treatment arrays. (APSS 2008; Poster 0776). –ML


Obstructive Sleep Apnea Patients at Increased Risk for Restless Legs Syndrome

Obstructive sleep apnea (OSA) and restless legs syndrome (RLS) are common conditions that patients often report negatively impact sleep and alter quality of life. Prior studies have shown that among patients who experience RLS symptoms—disruptive sensations in the legs and an urge to move during rest for relief—many report symptoms on multiple evenings per week, resulting in a high impact on quality of life. In addition, studies have shown that patients with OSA often have clinically significant RLS symptoms on multiple evenings per week. Nevertheless, there have been few studies examining the co-occurrence of RLS and OSA.

James M. Thompson, MD, of the Sleep Disorders Center of Lexington in Kentucky, and colleagues studied overnight polysomnography data from 357 adults (>18 years of age) with possible RLS and OSA or without the disorders to determine the prevalence and severity of both disorders in a patient population. Specifically, the authors sought to determine how often RLS co-occurs with OSA in patients with either condition.

All polysomnographs were conducted at two American Academy of Sleep Medicine-accredited community-based sleep centers. Patients were either referred for polysomnographs by sleep center physicians or other physicians, such as pulmonary specialists, to test for OSA or for continuous positive airway pressure titration.

Prior to the study beginning, included patients could have been diagnosed with and been receiving treatment for RLS as well as receiving treatment for other sleep conditions. Various questionnaires were also used to assess patients, including the Cambridge RLS questionnaire, the International Restless Legs Syndrome Scale (IRLS), the Epworth Sleepiness Scale, and the Sleep Disorders Center questionnaire that assesses rates of insomnia in the home.

Thompson and colleagues found that 319 patients had OSA, with 103 of those patients (32.3%) also experiencing RLS symptoms. Among patients with both OSA and RLS, 42 reported moderate RLS symptoms while a lower number of patients reported experiencing mild (IRLS score ≤10; n=31) or severe (IRLS score ≥20; n=30) RLS symptoms, according to the IRLS. In addition, 23% of all OSA patients reported RLS symptoms on ≥2 days per week. Patients with OSA and RLS also had latency to sleep times of >35 minutes, but those without RLS symptoms showed lower latency to sleep times (29.6 minutes).

The authors concluded that these findings show that RLS commonly co-occurs with OSA, as the prevalence rate of RLS (32.3%) is three times higher than the rate in the general population, according to prior studies. The rate of clinically significant RLS, as defined as an IRLS score of ≥20, is also three times higher in OSA patients than in the general population. Thus, the authors recommend that any patient presenting for polysomnography due to sleep disturbance be considered at risk for RLS, which can cause insomnia by increasing latency to sleep times. Thompson and colleagues suggest future reseach to determine the cause of the co-occurrence of RLS and OSA.

Funding for this research was provided by GlaxoSmithKline. (APSS 2008; Poster 0850). —CP

Indicators of Resilience to Effects of Sleep Deprivation in Adolescents

Approximately 50% of adolescents sleep <7 hours per school night and 16% sleep <6 hours, defying the optimal time of 9 hours. As a result of inadequate sleep, negative behavioral outcomes (eg, academic performance, mood difficulties, risk-taking behaviors) can affect teenagers’ long-term development. A small-sample study by Dean W. Beebe, PhD, ABPP-Cn, of the Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine in Ohio, and colleagues, examined potential indicators of resilience to effects of sleep deprivation in adolescents.

The 3-week study involved 19 teenagers (11 males; 8 females) 13.9–16.9 years of age. Participants were asked to neither nap nor drink caffeine Monday through Friday. Though they were allowed to self-select their bedtimes every Saturday and Sunday, the time at which they needed to arise for an 8:30 a.m. class (ie, “wake time”) was the same for all 3 weeks. Prior to sleep manipulation, the School Sleep Habits Survey was conducted to measure participants’ typical sleep duration on school nights and weekends. Four-item short forms of the fatigue and vigor subscales of the Profile of Mood States were given as well to determine how much participants thought sleep deprivation affected their mood. Experimental week 1 incorporated the sleep-restricted condition (ie, 6.5 hours in bed with lights out) and experimental week 2 employed the optimized sleep condition (ie, 10 hours in bed with lights out). As a resilience measure, participants rated their moods “over the past 2–3 days” every Saturday morning at the end of each experimental week. These scores reflected how much sleep deprivation actually affected their mood. Actual resilience scores were calculated as the difference between a participant’s mood rating for the optimized-sleep week and that of the sleep-restricted week. Actigraphs and nightly sleep diaries were collected every week to monitor adherence to the experimentally induced sleep manipulation.

Results revealed participants slept less and reported more fatigue in the sleep-restricted week than in the optimized-sleep week. Participants who thought they were more resilient to the effects of sleep deprivation slept less on school nights (P<.05) while those who showed greater actual resilience consistently slept less on weekends (P<.05) and showed no difference on school nights (P>0.8). Participants’ predictions concerning how vigorous they would feel during the experimental weeks were relatively accurate (P<.01), but predictions regarding levels of fatigue were not (P>0.5).

Though the data indicate a correlation between adolescents’ expectations of resilience to sleep restriction and their actual resilience and habitual sleep patterns, it is important to note that the study’s fatigue scores were reversed to show more resilience resulted in higher actual resilience scores. Future research should involve replication in larger samples and address different aspects, including attention and learning. It is also necessary to assess whether changes in sleep behaviors followed changes in beliefs about sleep and whether resilience is a stable trait.

Funding for this research was provided by the Cincinnati Children’s Hospital Medical Center in Ohio and the National Institutes of Health. (APSS 2008; Poster 0235) –ML

Posters were drawn from the 22nd Annual Meeting of the Associated Professional Sleep Societies, LLC (APSS; June 7–12, 2008, Baltimore, MD). Psychiatric dispatches is written by Michelisa Lanche, Carlos Perkins, Jr, and Lonnie Stoltzfoos.