General Approaches to the Clinical Management of Sleep Disorders in Psychiatric Patients

General Approaches to the Clinical Management of Sleep Disorders in Psychiatric Patients

The sleep complaint in the patient with an apparent psychiatric disorder deserves the same careful diagnostic and therapeutic at-tention that it does in any patient. Just because a patient is de-pressed does not mean that the complaint of insomnia or hyper-somnia can be explained away as a symptom of depression. Too many patients with depression have been found to have a BRSD; too many patients with panic disorder to have insomnia second-ary to caffeinism. Chronic sleep complaints are multidetermined and multifaceted, even in many psychiatric patients. Differential diagnosis remains the first obligation of the psychiatrist before definitive treatment, which should be aimed at the underlying cause or causes.

Nonspecific treatments, such as use of sleep hygiene principles, are often helpful for both the sleep complaints and the underlying psychiatric disorders. In particular, bipolar dis-order patients and patients whose daily activities are poorly or-ganized (like patients with chronic schizophrenia and patients with certain personality disorders) may benefit from fairly rigid sleep–wake and light–dark schedules to synchronize circadian rhythms and impose structure on their behavior. Physical exer-cise, meditation, relaxation methods, sleep restriction therapy and cognitive psychotherapy may help patients manage anxiety, rumination and conditioned psychophysiological insomnia that often cause sleeplessness at night and fatigue during the day. Partial or total sleep deprivation may be like “paradoxical inten-tion” therapy in the treatment of major depressive disorder or pre-menstrual dysphoric disorder but should probably be avoided in bipolar depression.

Medications may either help or hurt. Whether the patient should have drugs with sedating or activating properties should be considered. Timing and dose are important considerations in the context of pharmacokinetic and pharmacodynamic proper-ties of drugs. Night-time administration of sedating drugs may improve sleep and reduce daytime oversedation. Clinically sig-nificant drug side effects such as oversedation or activation maybe more likely early in treatment than later, after tolerance has developed. On the other hand, some sedating medications, even short half-life sleeping aids, may have disinhibiting effects, even late into the next day, especially in elderly and cognitively im-paired individuals. Doses of sleeping pills and other medications should usually be reduced by about half in the elderly compared with the dose for a young adult.

In general, avoid polypharmacy. Sleeping pills should be prescribed reluctantly to patients who receive adequate doses of antidepressants. Although coadministration of a benzodiazepine may improve sleep during the first week of antidepressant ther-apy, a low dose of zolpidem, zaleplon, trazodone, or other se-dating antidepressant at night in addition to the antidepressant may be less likely to produce tolerance and may have additive antidepressant benefits. Antipsychotic medications should not be administered as sleeping aids unless the patient is psychotic or otherwise unresponsive to other medications.