International Review of Psychiatry, April 2014; 26(2): 137–138
EDITORIAL
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Auckland on 11/02/14 For personal use only.
The Nexus of Sleep Psychology, Psychiatry, and Neurology in Health Clinical sleep medicine is evolving into a truly integrated, inter-professional health discipline. Although the field has always enjoyed the cross fertilization of multiple scientific disciplines, in the past decade, sleep-disordered breathing came to be the dominant clinical professional identity in the USA. Although the public health relevance of sleep-disordered breathing, with its associated risk of cardiovascular and metabolic diseases, is firmly established, the predominant focus on sleep apnoea in clinical sleep medicine was also undoubtedly shaped, in part, by economic forces within the US healthcare system. The relatively high third party reimbursement rates garnered for attended polysomnography procedures to diagnose and treat sleep-disordered breathing expanded the field with a distinct emphasis on sleep apnoea. In recent years, however, relatively inexpensive home sleep testing procedures to diagnose uncomplicated sleep apnoea are becoming normative, and the field finds itself rushing to develop new models of integrated, comprehensive care for the full range of sleep disorders. There is renewed energy on prevention and the critical role that insomnia, circadian dysrhythmia, and other common sleep disturbances play in the management of chronic medical and psychiatric disorders. The burgeoning recognition of the importance of sleep to overall health and well-being is a critical opportunity for psychology, psychiatry, neurology and associated fields to play a more broad and integrated role in healthcare. This special edition emphasizes the emerging prominence of sleep psychology, psychiatry, and neurology in clinical sleep medicine/healthcare. These three subspecialist professions share some common ground in their focus on sleep and the central nervous system, but each also provides uniquely valuable perspectives on the role of brain and behaviour in sleep health. Unfortunately, standard medical and psychological training programmes in these specialities generally provide minimal education in sleep, and consequently evidence-based treatments for sleep disorders such as insomnia, nightmare disorder, restless legs syndrome, are largely confined to specialized academic medical centres. The majority of patients with sleep disturbances seeking neurological, psychiatric and psychological care for related
ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.914651
disorders are rarely screened or treated for sleep disorders according to evidence-based practices. This edition highlights a variety, but by no means exhaustive range of common sleep disorders that often require targeted, specialized treatment, even when they occur within the context of contributing medical and psychiatric disorders. It also emphasizes the broad mental and physical health implications of deficient sleep that may not rise to the level of a specific sleep disorder, but which should be attended to by healthcare professionals with the same import as facilitating tobacco cessation or decreasing problem drinking behaviour. Clinicians treating patients with chronic medical and psychiatric disease need to flexibly and sometimes simultaneously conceptualize sleep as a behaviour, a disorder, and a symptom of another disorder. As a symptom, emergent sleep disruption is often prodromal, signalling pending relapse of major depression or the onset of mania. Severe insomnia can also be a marker of disease severity, heightening risk for suicidal behaviour. Insomnia too can be evidence of partial remission, predisposing to future relapse if untreated. Conceptualizing and intervening on these dimensions of sleep in the clinical context can be challenging, but has great potential to dramatically improve patient outcomes. This edition starts with Baron and Reid highlighting the independent role of circadian misalignment in both physical and mental health, a topic that is rarely covered in most curriculums, but which has several empirically derived and practical interventions, including melatonin supplementation, bright light therapy, and behavioural scheduling of daytime activities. Grandner nicely clarifies some of the sleeprelated jargon that sometimes creates an unfortunate barrier between the sleep field and other professions, and raises the important concept of sleep as a health behaviour. Promoting sleep health must not focus narrowly on sleep-related disorders, but also on helping patients obtain sufficient quantity and quality to meet their personal needs. Coughlin and Smith accentuate this conceptualization, reviewing evidence strongly suggesting that deficient sleep may contribute to the world-wide obesity epidemic. Tang and Winsper highlight the robust and under-recognized relationship between sleep disturbance and suicidal
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Auckland on 11/02/14 For personal use only.
138
M. T. Smith
behaviour, knowledge which might be used daily by mental health professionals to sharpen risk assessment of their suicidal patients and which has yet to be translated into suicide prevention programmes. Taylor and Pruiksma provide a meta-analytic review demonstrating the strong evidence base for the efficacy of cognitive behaviour therapy for insomnia occurring in the context of psychiatric disorders. Neubauer provides an excellent overview of pharmacological approaches to insomnia, touching on problems with off-label approaches that largely lack empirical support, but which are widely utilized. Nadorff et al. describe both pharmacological and behavioural treatments for nightmare disorder, an important topic that is further elaborated upon in Vandrey et al.’s work describing interactions
between disordered sleep, post-traumatic stress disorder and substance use disorders. Finally, Allen concludes with a definitive piece on restless legs syndrome, a sleep-interfering movement disorder, most typically the domain of sleep neurology. This insightful overview highlights common diagnostic pitfalls, important associations with psychopathology and psychotropic medications that exacerbate this under-detected and misdiagnosed condition. Michael T. Smith, Ph.D., Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioural Sciences, Baltimore, MD USA. E-mail: [email protected]
EDITORIAL
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Auckland on 11/02/14 For personal use only.
The Nexus of Sleep Psychology, Psychiatry, and Neurology in Health Clinical sleep medicine is evolving into a truly integrated, inter-professional health discipline. Although the field has always enjoyed the cross fertilization of multiple scientific disciplines, in the past decade, sleep-disordered breathing came to be the dominant clinical professional identity in the USA. Although the public health relevance of sleep-disordered breathing, with its associated risk of cardiovascular and metabolic diseases, is firmly established, the predominant focus on sleep apnoea in clinical sleep medicine was also undoubtedly shaped, in part, by economic forces within the US healthcare system. The relatively high third party reimbursement rates garnered for attended polysomnography procedures to diagnose and treat sleep-disordered breathing expanded the field with a distinct emphasis on sleep apnoea. In recent years, however, relatively inexpensive home sleep testing procedures to diagnose uncomplicated sleep apnoea are becoming normative, and the field finds itself rushing to develop new models of integrated, comprehensive care for the full range of sleep disorders. There is renewed energy on prevention and the critical role that insomnia, circadian dysrhythmia, and other common sleep disturbances play in the management of chronic medical and psychiatric disorders. The burgeoning recognition of the importance of sleep to overall health and well-being is a critical opportunity for psychology, psychiatry, neurology and associated fields to play a more broad and integrated role in healthcare. This special edition emphasizes the emerging prominence of sleep psychology, psychiatry, and neurology in clinical sleep medicine/healthcare. These three subspecialist professions share some common ground in their focus on sleep and the central nervous system, but each also provides uniquely valuable perspectives on the role of brain and behaviour in sleep health. Unfortunately, standard medical and psychological training programmes in these specialities generally provide minimal education in sleep, and consequently evidence-based treatments for sleep disorders such as insomnia, nightmare disorder, restless legs syndrome, are largely confined to specialized academic medical centres. The majority of patients with sleep disturbances seeking neurological, psychiatric and psychological care for related
ISSN 0954–0261 print/ISSN 1369–1627 online © 2014 Institute of Psychiatry DOI: 10.3109/09540261.2014.914651
disorders are rarely screened or treated for sleep disorders according to evidence-based practices. This edition highlights a variety, but by no means exhaustive range of common sleep disorders that often require targeted, specialized treatment, even when they occur within the context of contributing medical and psychiatric disorders. It also emphasizes the broad mental and physical health implications of deficient sleep that may not rise to the level of a specific sleep disorder, but which should be attended to by healthcare professionals with the same import as facilitating tobacco cessation or decreasing problem drinking behaviour. Clinicians treating patients with chronic medical and psychiatric disease need to flexibly and sometimes simultaneously conceptualize sleep as a behaviour, a disorder, and a symptom of another disorder. As a symptom, emergent sleep disruption is often prodromal, signalling pending relapse of major depression or the onset of mania. Severe insomnia can also be a marker of disease severity, heightening risk for suicidal behaviour. Insomnia too can be evidence of partial remission, predisposing to future relapse if untreated. Conceptualizing and intervening on these dimensions of sleep in the clinical context can be challenging, but has great potential to dramatically improve patient outcomes. This edition starts with Baron and Reid highlighting the independent role of circadian misalignment in both physical and mental health, a topic that is rarely covered in most curriculums, but which has several empirically derived and practical interventions, including melatonin supplementation, bright light therapy, and behavioural scheduling of daytime activities. Grandner nicely clarifies some of the sleeprelated jargon that sometimes creates an unfortunate barrier between the sleep field and other professions, and raises the important concept of sleep as a health behaviour. Promoting sleep health must not focus narrowly on sleep-related disorders, but also on helping patients obtain sufficient quantity and quality to meet their personal needs. Coughlin and Smith accentuate this conceptualization, reviewing evidence strongly suggesting that deficient sleep may contribute to the world-wide obesity epidemic. Tang and Winsper highlight the robust and under-recognized relationship between sleep disturbance and suicidal
Int Rev Psychiatry Downloaded from informahealthcare.com by University of Auckland on 11/02/14 For personal use only.
138
M. T. Smith
behaviour, knowledge which might be used daily by mental health professionals to sharpen risk assessment of their suicidal patients and which has yet to be translated into suicide prevention programmes. Taylor and Pruiksma provide a meta-analytic review demonstrating the strong evidence base for the efficacy of cognitive behaviour therapy for insomnia occurring in the context of psychiatric disorders. Neubauer provides an excellent overview of pharmacological approaches to insomnia, touching on problems with off-label approaches that largely lack empirical support, but which are widely utilized. Nadorff et al. describe both pharmacological and behavioural treatments for nightmare disorder, an important topic that is further elaborated upon in Vandrey et al.’s work describing interactions
between disordered sleep, post-traumatic stress disorder and substance use disorders. Finally, Allen concludes with a definitive piece on restless legs syndrome, a sleep-interfering movement disorder, most typically the domain of sleep neurology. This insightful overview highlights common diagnostic pitfalls, important associations with psychopathology and psychotropic medications that exacerbate this under-detected and misdiagnosed condition. Michael T. Smith, Ph.D., Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioural Sciences, Baltimore, MD USA. E-mail: [email protected]
