Relevant Psychiatry for the Outline Neurologist Sleep Focus on sleep, light Light Therapy therapy, bipolar Bipolar Disorder disorder Prior RAIN talks: Descartes Li, M.D. 2017- MDD v grief, antidepressant selection, AD Clinical Professor side effects University of California, San 2018 – SSRD, including conversion Jean-Jacques d’Ortous de Mairan, Francisco engraved portrait (Smithsonian Institution 2020 – Sleep, Light therapy, and Bipolar disorder descartes.li@ucsf.edu Libraries) https://www.lindahall.org/jean-jacques-dortous-de-mairan/ 1 2 Outline Sleep Sleep • Introduction Light Therapy • Epidemiology Bipolar Disorder • Foundational concepts • Diagnosis and assessment of sleep • Treatment 3 4 1
Industrialization and Hours of Sleep Sleep • Introduction • Society sleeps 1.5 hours less per hour per night compared to 100 years ago • Epidemiology 1942: average 7.9 hours per night • Foundational concepts 2001: 6.7 hours per night • Diagnosis and assessment of sleep • The increase in work performance demanded by our 24 hour economy • Treatment has effectively added a 13th month of work compared to the last century 5 6 Effect of technology on sleep “microsleeps” Thirty-one percent (31%) of drivers will fall asleep while driving at least once in their lifetime. 100,000 accidents a year happen because of tiredness. Gradisar M, Wolfson AR, Harvey AG, Hale L, Rosenberg R, Czeisler CA. The Sleep and Technology Use of Americans: Findings from the National Sleep Foundation’s 2011 Sleep in America Poll. J Clin Sleep Med. 2013;9(12):1291-1299. doi:10.5664/jcsm.3272 7 8 2
Opponent Process (or Two Process) Sleep Model of Sleep • Introduction • Sleep Debt and • Epidemiology • Foundational concepts • Alerting Force work at the • Diagnosis and assessment of sleep same time • Treatment • But they fluctuate independently At any given time, the sum is called sleep propensity 9 10 What is the Alerting Force? What is Sleep Debt? (aka Circadian rhythm) (aka homeostatic drive or pressure) 11 12 3
Sleep tip#1: Melatonin Blue Light blocking glasses 13 14 Sleep tip#2: Raise body temperature (early in the day) Which leads to a compensatory decrease in core body temperature that night see also www.Tuck.com However, raising skin temperature may also be helpful Raymann RJEM, Swaab DF, Van Someren EJW. Skin deep: enhanced sleep depth by cutaneous temperature manipulation. Brain. 2008;131(Pt 2):500- 513. doi:10.1093/brain/awm315 15 16 4
Summary: Opponent Process Sleep Model of Sleep • Introduction • Sleep Debt and • Epidemiology • Foundational concepts • Alerting Force work at the • Diagnosis and assessment of same time sleep • Treatment • But they fluctuate independently 17 18 Four questions Key Rule outs Question comment 1) How long does it Normal sleep latency is about usually take you to fall 10 minutes; Be aware of • Obstructive sleep apnea asleep? patients with short latencies, • Narcolepsy such as 2 minutes • Restless leg syndrome 2) How many times a Ask this of the patient's sleep night do you wake up? partner as well. • Nocturnal myoclonus • Caffeinism 3) After each awakening, Combined with question #2 how long does it take to gives how much sleep is fall back asleep? being lost 4) Do you feel refreshed Most important question upon awakening in the morning? How much coffee do you drink? 19 20 5
Case Vignette Caffeine 54-year-old physician reports that she (and educational tangent) awakens every morning at 4am no matter Can you drink what time he goes to sleep. Extremely coffee and then tired/sleepy mid-afternoon which makes it sleep? difficult to work productively. Drinks about three cups of coffee Overuse can lead to restlessness, anxiety, throughout the day to stay awake, but this cardiac arrhythmias, gi seems to interfere with going to bed at a distress, irritability, etc reasonable time How much caffeine does she have in her by the time she goes to bed? Caffeine has fascinating pharmacology, see: What is the FDA recommended maximum? https://www.psychiatrictimes.com/cme/caffeine- neurobiological-and-psychiatric-implications 21 22 How much caffeine in the How Much Caffeine? following products? (Starbucks Featured Dark Roast) 110mg 80mg 227mg https://www.caffeinei 195mg 260mg 340mg (per ounce, nformer.com/the- 20-50mg = 20 beans) caffeine-database (but some up to 95mg per cup) 23 24 6
How much caffeine is too How Much Caffeine? much? (assorted energy drinks and shots) 260mg /2 oz 400mg 300mg 422mg/1.93 oz 125mg https://www.fda.gov/food/dietary-supplement-products-ingredients/pure-and-highly-concentrated-caffeine (222mg, the 200mg over 6 hours) https://www.fda.gov/consumers/consumer-updates/spilling-beans-how-much-caffeine-too-much 25 26 How Much Caffeine? (tablets OTC) 27 28 7
What is the half-life of Assume ½ life = 5hours caffeine? Time amount Question: If you take 240mg of 12noon 240mg caffeine at 12noon, how much is still 5pm 120mg in your body at 10pm? 10pm 60mg Half-life of caffeine = 3 to 7 hours (in healthy active individuals) What about another cup of coffee (133mg) at 3pm? using formula above, that gives another 50mg at 10pm Answer: 60mg (which is the equivalent of 16oz of Diet Coke) Total = 60mg+50mg = 110mg 29 30 Test Question Sleep 62yo woman with sleep maintenance insomnia for the past six months. Self- • Introduction prescribed trial of Unisom not helpful. No • Epidemiology other medical or psychiatric morbidities. Which of the following is true*: • Foundational concepts A. Moderate evidence for temazepam • Diagnosis and assessment of sleep B. Strong evidence for doxepin+suvorexant • Treatment C. Sufficient evidence for CBT-I as first line – CBT-I treatment D. Moderate evidence that pharmacotherapy – Pharmacotherapy decisions should be independent of CBT-I *Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine . 2017;13(02):307-349. doi:10.5664/jcsm.6470 31 32 8
Test Question Nonpharmacologic Treatment Strategies: Sleep Hygiene 62yo woman with sleep maintenance insomnia for the past six months. Self- • Maintain regular bedtime and awakening time 1-3 prescribed trial of Unisom not helpful. No • Exercise regularly, but not before bedtime 1,2 other medical or psychiatric morbidities. • Avoid naps 1,3 Which of the following is true*: • Avoid caffeine intake after noon and alcohol A. Moderate evidence for temazepam and nicotine in the evening 1,2 B. Strong evidence for doxepin+suvorexant • Make bedroom comfortable: dark, quiet, not too hot or too cold 1,2 C. Sufficient evidence for CBT-I as first line treatment • If hungry, have only a light snack before bedtime 2 D. Moderate evidence that pharmacotherapy 1. Lippmann S et al. Insomnia: therapeutic approach. South Med J. 2001;94:866-873. 2. National Heart, Lung, and Blood Institute Working Group on Insomnia. Insomnia: Assessment and Management decisions should be independent of CBT-I in Primary Care. Bethesda, Md: National Heart, Lung, and Blood Institute; September 1998. NIH Publication No. 98- 4088. 3. Kupfer DJ, Reynolds CF. Management of insomnia. N Engl J Med. 1997;336:341-346. *Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for Working Group on Insomnia. 1998. NIH Publication 98-4088. the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine . 2017;13(02):307-349. doi:10.5664/jcsm.6470 33 34 Minimal evidence for sleep Sleep Hygiene hygiene If it worked, then the patient probably “…the direct effects of individual wouldn’t be coming to see you. recommendations on sleep remains largely untested in the general population.” From Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The Role of Sleep Hygiene in Promoting Public Health: A Review of Empirical Evidence. Sleep Med Rev . 2015;22:23-36. doi:10.1016/j.smrv.2014.10.001 Sleep Hygiene is different from stimulus control and sleep restriction https://www.originsrecovery.com/addiction- recovery-sleep/ 35 36 9
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