Association of Excessive Daytime Sleepiness With Psychological Distress in Medical Students.

OBJECTIVE: To determine the prevalence of excessive daytime sleepiness among medical students and establish a relationship between self-perceived sleepiness and psychological distress. METHODS: In a cross-sectional study, 441 medical students from a public-sector university in Pakistan completed a questionnaire from August to December 2018. The questionnaire included the Epworth Sleepiness Scale (ESS), which measured daytime sleepiness, and the 12-item General Health Questionnaire (GHQ-12), which measured mental health. Pearson correlations and student t tests were used for comparisons with a significance level of P < .05. RESULTS: Many of the students (44.9%) obtained a high score (≥ 10) on the ESS (ie, experience excessive daytime sleepiness). On average, higher scores on the ESS correlated with higher scores on the GHQ-12. A statistically significant correlation (P < .05) between ESS scores and GHQ-12 scores was obtained when the students with higher (≥ 10) ESS scores were compared with students with lower (< 10) ESS scores. CONCLUSIONS: Excessive daytime sleepiness is frequent among medical students and significantly associated with psychological distress. Thus, careful investment in planning appropriate university policies and class schedules is required to encourage healthy and adequate sleep among students, which could have a significant impact on learning, academic performance, and health of medical students.

Obstructive Sleep Apnea in Posttraumatic Stress Disorder Comorbid With Mood Disorder: Significantly Higher Incidence Than in Either Diagnosis Alone.

OBJECTIVE: To examine the correlations between obstructive sleep apnea (OSA) and psychiatric disorders such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), or bipolar disorder (BD) and whether comorbid psychiatric diagnosis increases the risk of OSA. METHODS: This retrospective chart review study included all patients (N = 413) seen within a randomly selected 4-month period (August 2014 to November 2014) in a Veterans Administration outpatient psychiatry clinic. Patients were screened for symptoms of OSA with the STOP-BANG Questionnaire. Those with a positive screen were referred to the sleep clinic for confirmation of the diagnosis by polysomnogram (PSG). Frequency of PSG-confirmed OSA was correlated with different psychiatric disorders and comorbid psychiatric diagnoses. RESULTS: The study showed a high prevalence of OSA in psychiatric patients, particularly with MDD (37.8%) and PTSD (35.5%) and less so with BD (16.7%). Among all patients with OSA (n = 155), those with comorbid BD and PTSD had a significantly higher rate of OSA than those with BD alone (χ² = 7.28, P < .05) but not with PTSD alone. We also found a statistically significant higher incidence of OSA in male veterans with either MDD comorbid with PTSD (χ² = 3.869, P < .05) or BD comorbid with PTSD (χ² = 6.631, P < .05) compared with either mood disorder or PTSD alone. CONCLUSIONS: The study showed a high prevalence of OSA in psychiatric patients, particularly in those with PTSD and MDD and less so with BD. There was a statistically significant increase in the incidence of OSA in male veterans with either BD with comorbid PTSD or MDD with comorbid PTSD.​​.

Violent Parasomnia With Recurrent Biting and Surgical Interventions: Case Report and Differential Diagnosis.

ABSTRACT: A case is reported of recurrent, injurious self-biting during sleep, requiring surgical interventions, in a 55-year-old obese man with a 20-year history of violent complex parasomnia, with greatly increased frequency and severity of episodes induced by work stress during the preceding 3 years. After clinical evaluation and overnight, hospital-based video-polysomnography, the cause of the chronic injurious parasomnia was deemed to be a non-rapid eye movement (NREM) sleep parasomnia comorbid with severe obstructive sleep apnea. Therapy with bedtime clonazepam and bilevel positive airway pressure was effective, with injurious parasomnia relapse occurring with cessation of either or both of these therapies. The differential diagnosis of sleep-related biting should now include NREM sleep parasomnia (with or without comorbid obstructive sleep apnea), besides previously reported cases of REM sleep behavior disorder (RBD), sleep-related dissociative disorder, sleep-related rhythmic movement disorder and anticipated cases of parasomnia overlap disorder (RBD + NREM sleep parasomnia), sleep-related biting seizures, and sleep-related eating disorder.

Restless Legs Syndrome Among Veterans With Spinal Cord Lesions.

Researchers developed a restless legs syndrome questionnaire using diagnostic criteria to assess its prevalence among veterans with spinal cord injuries and disorders.

The State of Sleep Medicine Education in North American Psychiatry Residency Training Programs in 2013: Chief Resident's Perspective.

OBJECTIVE: To assess the current state of sleep medicine educational resources and training offered by North American psychiatry residency programs. METHODS: In June 2013, a 9-item peer-reviewed Sleep Medicine Training Survey was administered to 39 chief residents of psychiatry residency training programs during a meeting in New York. RESULTS: Thirty-four percent of the participating programs offered an elective rotation in sleep medicine. A variety of innovative approaches for teaching sleep medicine were noted. The majority of the chief residents felt comfortable screening patients for obstructive sleep apnea (72%), half felt comfortable screening for restless legs syndrome (53%), and fewer than half were comfortable screening for other sleep disorders (47%). CONCLUSIONS: This is the first report in the last decade to provide any analysis of current sleep medicine training in North American psychiatry residency training programs. These data indicate that sleep medicine education in psychiatry residency programs is possibly in decline.

Sleep-Related Abnormal Sexual Behaviors (Sexsomnia) Successfully Treated With a Mandibular Advancement Device: A Case Report.

ABSTRACT: Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of non-rapid eye movement sleep parasomnias. There are reported cases of control of sexsomnia with treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure. We present a case of sexsomnia controlled with the treatment of OSA with a mandibular advancement device.

Sleep Disturbances in Posttraumatic Stress Disorder: Updated Review and Implications for Treatment.

Sleep disturbances are common in adults with PTSD and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together these findings suggest profound disturbances in rapid eye movement (REM) and non-REM (NREM) sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective, longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiological mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma exposed populations. A number of psychological and pharmacological treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD focused clinical care.

Insomnia during pregnancy: Diagnosis and Rational Interventions.

UNLABELLED: Sleep disturbances are common in pregnancy. Insomnia is a frequent sleep disturbance experienced by pregnant women which can be primary or due to co-morbid conditions. The differential diagnosis of insomnia in pregnancy includes anxiety disorders, mood disorders, breathing related sleep disorders and restless legs syndrome. Early interventions to treat the sleep disturbance are recommended to avoid adverse pregnancy outcomes. Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications. METHODS: We searched PubMed and Google Scholar employing a combination of key words: pregnancy, sleep disturbances, Obstructive Sleep Apnea, Sleep disorders and insomnia. We included original studies, review articles, meta-analysis and systematic reviews in our search prioritizing articles from the last 10-15 years. Articles older than 15 years were only included if their findings had not been superseded by more recent data. Further selection of articles was done from bibliographies and references of selected articles. CONCLUSION: Sleep disturbances in pregnancy are common and cause considerable morbidity. Management includes a combination of non-pharmacological and pharmacological treatments carefully weighing the risks and benefits of each for the expectant mother and fetus.

Pharmacologic Treatment of Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

BACKGROUND: Pharmacologic interventions are often prescribed for insomnia disorder. PURPOSE: To assess the benefits, harms, and comparative effectiveness of pharmacologic treatments for adults with insomnia disorder. DATA SOURCES: Several electronic databases (2004-September 2015), reference lists, and U.S. Food and Drug Administration (FDA) documents. STUDY SELECTION: 35 randomized, controlled trials of at least 4 weeks' duration that evaluated pharmacotherapies available in the United States and that reported global or sleep outcomes; 11 long-term observational studies that reported harm information; FDA review data for nonbenzodiazepine hypnotics and orexin receptor antagonists; and product labels for all agents. DATA EXTRACTION: Data extraction by single investigator confirmed by a second reviewer; dual-investigator assessment of risk of bias; consensus determination of strength of evidence. DATA SYNTHESIS: Eszopiclone, zolpidem, and suvorexant improved short-term global and sleep outcomes compared with placebo, although absolute effect sizes were small (low- to moderate-strength evidence). Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants, and for most pharmacologic interventions in older adults, was insufficient or low strength. Evidence was also insufficient to compare efficacy within or across pharmacotherapy classes or versus behavioral therapy. Harms evidence reported in trials was judged insufficient or low strength; observational studies suggested that use of hypnotics for insomnia was associated with increased risk for dementia, fractures, and major injury. The FDA documents reported that most pharmacotherapies had risks for cognitive and behavioral changes, including driving impairment, and other adverse effects, and they advised dose reduction in women and in older adults. LIMITATIONS: Most trials were small and short term and enrolled individuals meeting stringent criteria. Minimum important differences in outcomes were often not established or reported. Data were scant for many treatments. CONCLUSION: Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Pharmacotherapies for insomnia may cause cognitive and behavioral changes and may be associated with infrequent but serious harms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. ( PROSPERO: CRD42014009908).

Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

BACKGROUND: Psychological and behavioral interventions are frequently used for insomnia disorder. PURPOSE: To assess benefits and harms of psychological and behavioral interventions for insomnia disorder in adults. DATA SOURCES: Ovid MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and PsycINFO through September 2015, supplemented with hand-searching. STUDY SELECTION: Randomized, controlled trials of psychological or behavioral interventions that were published in English and enrolled adults with insomnia disorder lasting 4 or more weeks. DATA EXTRACTION: Data extraction by single investigator confirmed by a second reviewer; dual investigator assessment of risk of bias; consensus determination of strength of evidence. DATA SYNTHESIS: Sixty trials with low to moderate risk of bias compared psychological and behavioral interventions with inactive controls or other psychological and behavioral interventions. Cognitive behavioral therapy for insomnia (CBT-I) improved posttreatment global and most sleep outcomes, often compared with information or waitlist controls (moderate-strength evidence). Use of CBT-I improved several sleep outcomes in older adults (low- to moderate-strength evidence). Multicomponent behavioral therapy improved several sleep outcomes in older adults (low- to moderate-strength evidence). Stimulus control improved 1 or 2 sleep outcomes (low-strength evidence). Evidence for other comparisons and for harms was insufficient to permit conclusions. LIMITATIONS: A wide variety of comparisons limited the ability to pool data. Trials did not always report global outcomes and infrequently conducted remitter or responder analysis. Comparisons were often information or waitlist groups, and publication bias was possible. CONCLUSION: Use of CBT-I improves most outcomes compared with inactive controls. Multicomponent behavioral therapy and stimulus control may improve some sleep outcomes. Evidence on other outcomes, comparisons, and long-term efficacy were limited. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. ( PROSPERO: CRD42014009908).

Urdu translation of the Hamilton Rating Scale for Depression: Results of a validation study.

OBJECTIVE: To develop a standardized validated version of the Hamilton Rating Scale for Depression (HAM-D) in Urdu. METHODS: After translation of the HAM-D into the Urdu language following standard guidelines, the final Urdu version (HAM-D-U) was administered to 160 depressed outpatients. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation between HAM-D-U scores at baseline and after a 2-week interval was evaluated for test-retest reliability. Moreover, scores of two clinicians on HAM-D-U were compared for inter-rater reliability. For establishing concurrent validity, scores of HAM-D-U and BDI-U were compared by using Spearman correlation coefficient. The study was conducted at Mayo Hospital, Lahore, from May to December 2014. RESULTS: The Cronbach alpha for HAM-D-U was 0.71. Composite scores for HAM-D-U at baseline and after a 2-week interval were also highly correlated with each other (Spearman correlation coefficient 0.83, p-value < 0.01) indicating good test-retest reliability. Composite scores for HAM-D-U and BDI-U were positively correlated with each other (Spearman correlation coefficient 0.85, p < 0.01) indicating good concurrent validity. Scores of two clinicians for HAM-D-U were also positively correlated (Spearman correlation coefficient 0.82, p-value < 0.01) indicated good inter-rater reliability. CONCLUSION: The HAM-D-U is a valid and reliable instrument for the assessment of Depression. It shows good inter-rater and test-retest reliability. The HAM-D-U can be a tool either for clinical management or research.

Can primary care sleep medicine integration work?

Sleep disorders are common in the veteran population. There is an increasing need for sleep medicine services in returning veterans. Primary care providers are uncomfortable diagnosing and treating sleep disorders. Patients often have to wait several days before they can be seen by a sleep clinician. This pilot project evaluated the feasibility of providing sleep medicine services to patients in a primary care setting. Primary care providers were involved in decision-making, resulting in improved satisfaction with sleep medicine services among primary care clinicians.

Nocturnal Awakening & Sleep Duration in Veterans with PTSD: An Actigraphic Study.

OBJECTIVE: To assess whether awakenings from sleep and sleep duration in Post Traumatic Stress Disorder (PTSD) were related to demography, posttraumatic or depressive symptoms, subjective sleep quality, and daytime sleepiness. METHODS: Sample consisted of 23 veterans with lifetime PTSD and current sleep disturbance not due to apnea or other diagnosable conditions. Data collection included demography, two weeks of actigraphy, Beck Depression Inventory, Posttraumatic Checklist, Clinical Assessment of Posttraumatic Symptoms, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. RESULTS: The study revealed that awakenings increased with younger age. Variability in awakenings also increased with younger age (p = 0.002). More awakenings were associated with shorter sleep duration. CONCLUSIONS: These paradoxical observations regarding younger age and more awakening may be related to increased sleep symptoms early in the course and then gradual waning of posttraumatic symptoms over time, since awakenings tend to increase with age in normals (rather than decrease, as we observed).