Let's all make a point to get better at sleep medicine

[DD214_DOC]

Even if we are NOT sleep specialists. Just this week I have caught 3 or 4 kids I'm pretty certain have sleep disorders that have been missed and untreated for at least a year or more, or several years in one case. I hope many of us realize how huge this blindspot is for most of us and how little of it we get in our training, and make a point to better ourselves and fill in the gap. It's infinitely useful!

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[birchswing]

DSPS is misdiagnosed as many things (insomnia, ADHD, depression, anxiety). In the community I belong to, I see a number of people placed on Ambien who don't sleep on Ambien but then finally sleep later in the early morning. Ambien can't fix a sleep cycle disorder.

Read the research on melatonin (from MIT).

More=worse!

300 mcg is about the maximum useful dose of melatonin--not the 5 or 10 mg commonly sold.

 

[Shikima]

Good insight. One of the reasons why I did the fellowship. Helps with the Gero patients too because of the parasomnia behaviors are diagnostic.

 

[PistolPete]

Agree completely. I enjoy sleep medicine, just not enough to do ICU months in sleep fellowship!

 

[FlowRate]

Agree completely. I enjoy sleep medicine, just not enough to do ICU months in sleep fellowship!

Not that I'm practicing yet, but I enjoy sleep medicine (did a neuro month that was 1/3 sleep med) minus OSA. I think it's great that there are people willing to treat OSA, it's a huge lifestyle improvement and has benefits for mental health disorders, cardiovascular health, and migraines, but it's just kinda boring to me. I didn't know the fellowship did time on the ICU, though.

 

[DD214_DOC]

OSA isn't very interesting and is pretty straightforward. It's all that other stuff.

 

[Doctor Bagel]

On that note, good (free) resources? I dislike dealing with sleep issues but agree that I should do better at it.

 

[WisNeuro]

Yes please. I would love to get patients whose sleep problems were well managed, instead of just being put on maintenance zolpidem or trazadone for who knows how many years.

 

[Shikima]

There aren't really any free resources. Picking up ICSD-3, which is the DSM equiv for sleep, will be helpful in diagnostic criteria. This then helps to further break down the disorders presented and then you'll know if you need a pulmonologist and/or a neurologist. Or just bite the bullet in referring to a comprehensive sleep specialist.

For now, just start with some basic questions - how are you sleeping? How much sleep do you get? What's your sleep schedule? Is it good quality of sleep? If you could make you sleep better, how would you? Check for RLS symptoms (uncontrollable urges to walk, move, stretch, and kick your legs at night, especially before bedtime). Ask about parasomnia behaviors. You've pretty much got 80% of the information there.

 

[AcronymAllergy]

Somewhat related, I try to review basic sleep hygiene concepts during feedback with all patients who report just about any type of sleep disturbance (they've usually already been referred for sleep studies and/or to other specialists by the time they get to me). I personalize the feedback whenever possible to specific habits they've reported that would likely be detrimental to obtaining quality sleep, and almost always suggest they talk with their primary MH provider about psychotherapy for insomnia if it seems appropriate.

 

[Dharma]

Bust out those blue-blocking sunglasses for late night computer, tv, and phone action kids!

 

[WisNeuro]

Bust out those blue-blocking sunglasses for late night computer, tv, and phone action kids!

In my patients, it's less of that, and usually more trying to dispel the myth that several drinks before bed leads to better sleep. Also, having a cigarette after waking in the middle of the night, while maybe psychologically calming, is not actually physiologically calming.

 

[Shikima]

Sleep diaries are you friends. I'm still ticked that actigraphy is not a reimbursable activity.

 

[MLT2MT2DO]

Even if we are NOT sleep specialists. Just this week I have caught 3 or 4 kids I'm pretty certain have sleep disorders that have been missed and untreated for at least a year or more, or several years in one case. I hope many of us realize how huge this blindspot is for most of us and how little of it we get in our training, and make a point to better ourselves and fill in the gap. It's infinitely useful!

Curious, what disorders in these kids did you catch where they are that prevelant but easily overlooked.

 

[Shikima]

Curious, what disorders in these kids did you catch where they are that prevelant but easily overlooked.

Circadian misalignments, insufficient sleep, limit setting insomnia, and snoring (which then requires a PSG).

 

[Doctor Bagel]

So this is where I hate sleep. I hate sleep hygiene conversations with a burning passion. I feel like I get nowhere -- I'm guessing this is how our primary care colleagues feel about smoking cessation. At the VA, we had this really wondering CBT for insomnia program, and on one (not even once) accepted a referral option for this. They were hopeless. I was hopeless. It was a bad scene. Argh, so maybe I'll send my sleep people to someone with more tolerance for having these converations. You can send me your addicts and otherwise struggling with compliance with treatment folks.

 

[birchswing]

I'm going to see a neurologist/sleep specialist (the person I found is both apparently). I just saw my psychiatrist and she didn't think she could help with my sleep. Which is actually fine IMO, because she does have a lot of other stuff to keep track of with me in terms of meds, and I'm not sure exactly what she could do. She doesn't have testing equipment or anything like that.

I have a completely different problem than frank insomnia. I can choose between insomnia and a semi-normal sleep schedule or heavenly, wonderful sleep and sleeping during business hours. I've already done blue-light, orange glasses at night, going out in the sun and exercising early in the day--every sleep hygiene thing I can think of. And I still do them in spite of it not seeming to work. Only thing I haven't tried is melatonin because I already have so many meds on board and don't want to add anything that could interact. My psychiatrist thought melatonin was OK to add but wouldn't say so definitively, so I'll wait till I see the neurologist/sleep specialist.

I feel guilty every time I let myself get good sleep because I know I'm getting away from a normal schedule. But when I stick to a normal schedule, I never get used to it and feel miserable.

It's a frustrating problem. People think that if I just wake up earlier I'll fall asleep earlier. But in truth I suffer through the fog of insomnia all day and then my brain clears out in the middle of the night and I'm finally awake. I've actually been curious if I were to move to the time zone I'm in sync with whether I would be "normal"--not that I would do that, but just wondering hypothetically.

 

[PistolPete]

Bust out those blue-blocking sunglasses for late night computer, tv, and phone action kids!

I've recommend the f.lux app which blocks blue light on your computer based on your geographic location (you input your zip) and the screen turns a different color when the sun sets. Great app for people who work a lot on the computer in the evening before bedtime!

 

[Dharma]

I've recommend the f.lux app which blocks blue light on your computer based on your geographic location (you input your zip) and the screen turns a different color when the sun sets. Great app for people who work a lot on the computer in the evening before bedtime!

I like that app too! We all wear the glasses around the house at night still. Crazy cheap too (although we do look slightly goofy) : Amazon product

 

[birchswing]

I like that app too! We all wear the glasses around the house at night still. Crazy cheap too (although we do look slightly goofy) : Amazon product

I use both the orange glasses and F.lux, too.

The iPhone is getting something equivalent with the iOS 9.3 release called Night Shift, which appears to be a copy of F.lux pretty much. F.lux tried getting an app on the iPhone before but was turned down because to be a system-wide resource it required permissions Apple wouldn't give to a third party developer. I'm glad the iPhone is getting it but dislike the way Apple "borrows" ideas from developers.

 

[F0nzie]

So this is where I hate sleep. I hate sleep hygiene conversations with a burning passion. I feel like I get nowhere -- I'm guessing this is how our primary care colleagues feel about smoking cessation. At the VA, we had this really wondering CBT for insomnia program, and on one (not even once) accepted a referral option for this. They were hopeless. I was hopeless. It was a bad scene. Argh, so maybe I'll send my sleep people to someone with more tolerance for having these converations. You can send me your addicts and otherwise struggling with compliance with treatment folks.

lol best sleep hygiene post.

 

[hamstergang]

I'm going to see a neurologist/sleep specialist (the person I found is both apparently). I just saw my psychiatrist and she didn't think she could help with my sleep. Which is actually fine IMO, because she does have a lot of other stuff to keep track of with me in terms of meds, and I'm not sure exactly what she could do. She doesn't have testing equipment or anything like that.

I have a completely different problem than frank insomnia. I can choose between insomnia and a semi-normal sleep schedule or heavenly, wonderful sleep and sleeping during business hours. I've already done blue-light, orange glasses at night, going out in the sun and exercising early in the day--every sleep hygiene thing I can think of. And I still do them in spite of it not seeming to work. Only thing I haven't tried is melatonin because I already have so many meds on board and don't want to add anything that could interact. My psychiatrist thought melatonin was OK to add but wouldn't say so definitively, so I'll wait till I see the neurologist/sleep specialist.

I feel guilty every time I let myself get good sleep because I know I'm getting away from a normal schedule. But when I stick to a normal schedule, I never get used to it and feel miserable.

It's a frustrating problem. People think that if I just wake up earlier I'll fall asleep earlier. But in truth I suffer through the fog of insomnia all day and then my brain clears out in the middle of the night and I'm finally awake. I've actually been curious if I were to move to the time zone I'm in sync with whether I would be "normal"--not that I would do that, but just wondering hypothetically.

This site still isn't a place for patients to bring their medical issues. We've all heard your problems multiple times and it doesn't really add to the discussion.

 

[Shikima]

So this is where I hate sleep. I hate sleep hygiene conversations with a burning passion. I feel like I get nowhere -- I'm guessing this is how our primary care colleagues feel about smoking cessation. At the VA, we had this really wondering CBT for insomnia program, and on one (not even once) accepted a referral option for this. They were hopeless. I was hopeless. It was a bad scene. Argh, so maybe I'll send my sleep people to someone with more tolerance for having these converations. You can send me your addicts and otherwise struggling with compliance with treatment folks.

Too bad you're not closer to send your referrals on over to me.

 

[birchswing]

This site still isn't a place for patients to bring their medical issues. We've all heard your problems multiple times and it doesn't really add to the discussion.

I just saw my psychiatrist this week for a regular follow-up and my intended purpose was to address sleep head-on. She couldn't help me, which I accepted. I'm scheduled to see a neurologist. I know I haven't discussed that before because it just happened yesterday.

It's anecdotal, but it's relevant and adds a real-life scenario that people interested in psychiatry can take a look at when considering how and by whom sleep disorders are treated. Psychiatrists and neurologists are board certified by the same organization. Discussing who treats what is interesting to me. I think this is an interesting thread. Sleep is a huge part of health, but a lot of times it's ignored.

 

[Doctor Bagel]

lol best sleep hygiene post.

I think my typos probably speak to my sleep deprived state, which just might be secondary to my own poor sleep hygiene.

 

[sunlioness]

So this is where I hate sleep. I hate sleep hygiene conversations with a burning passion.

ME TOO.

And I find myself endlessly frustrated by the ones who can't sleep entirely because they're worried they won't be able to sleep. Or the ones who think X thing that is actually fairly normal is a total insurmountable problem.

There was this one guy once who'd gone to sleep medicine. Had the study, nothing remarkable. But he didn't like their recommendations (basically for sleep hygiene type stuff and CBT). So he kept coming to me wanting meds to zonk him. And I wouldn't do it. You need to follow with Sleep Medicine, I said. And he said, "No, I want to follow with you. They didn't help me."

And I'm like . . . Those guys are boarded in this. That's what they do. GO THERE.

Sigh.

 

[Shikima]

ME TOO.

And I find myself endlessly frustrated by the ones who can't sleep entirely because they're worried they won't be able to sleep. Or the ones who think X thing that is actually fairly normal is a total insurmountable problem.

There was this one guy once who'd gone to sleep medicine. Had the study, nothing remarkable. But he didn't like their recommendations (basically for sleep hygiene type stuff and CBT). So he kept coming to me wanting meds to zonk him. And I wouldn't do it. You need to follow with Sleep Medicine, I said. And he said, "No, I want to follow with you. They didn't help me."

And I'm like . . . Those guys are boarded in this. That's what they do. GO THERE.

Sigh.

It was likely pulmonologists who have said this.

 

[sunlioness]

It was.


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[Shikima]

Frankly, they are good for one thing only, managing breathing. Anything else related to sleep medicine, they're not that good.

 

[sunlioness]

How do you become good? If I had a clue, I might like it. But gaining a clue in this area was never part of, well, anything. I screen for sleep apnea in everyone presenting for depression and refer to sleep studies a lot more than most people do. Or at least I did. But beyond that and the basic sleep hygiene pep talk that everyone hates hearing just as much as I hate giving it, I don't know what to do.


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[Shikima]

How do you become good? If I had a clue, I might like it. But gaining a clue in this area was never part of, well, anything. I screen for sleep apnea in everyone presenting for depression and refer to sleep studies a lot more than most people do. Or at least I did. But beyond that and the basic sleep hygiene pep talk that everyone hates hearing just as much as I hate giving it, I don't know what to do.


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To become good, you have to want to and have an interest. Most people are in PP, which means anything that is complicated will be dealt with superficially because it doesn't pay. Typically in my practice I'm looking for other causes than just emotional dysregulation as the cause for insomnia and other complaints. I like being a diagnostician.

Incidentally, you are correct in that it is sleep medicine's job to talk about circadian misalignment's, actively engaging with some basic tenets of stimulus reduction, as well as utilizing medications to help with insomnia. There are many tools that the sleep physician has been given to help with these. Most choose to ignore it and with the brush of a hand declare "It's Psychiatry's problem!" -- case in point, how many times has Psychiatry been consulted for social problems and other nonsense that we cannot help out with, or just the mere appearance of "looking sad" derives a consult for depression.

 

[thoffen]

I like this thread a lot. Probably we should all do some CBT-Insomnia just to know the principles. And I've found that managing expectations for sleep and sleep medicines goes a long way, even if we're not finding a primary sleep disorder. Really hard to build an alliance with a patient if you keep giving them trazodone/benadryl/seroquel/ambien/etc. long after they've built up tolerance, and the reaction you get for trying to take it away isn't entirely the patient's fault.

 

[Doctor Bagel]

I like this thread a lot. Probably we should all do some CBT-Insomnia just to know the principles. And I've found that managing expectations for sleep and sleep medicines goes a long way, even if we're not finding a primary sleep disorder. Really hard to build an alliance with a patient if you keep giving them trazodone/benadryl/seroquel/ambien/etc. long after they've built up tolerance, and the reaction you get for trying to take it away isn't entirely the patient's fault.

I pretty much frame starting sleep medications with a "these medications don't work in the long run" type of spiel.

Speaking of missed diagnostic issue -- I had a patient in the inpatient unit who was just plain not sleeping even after taking a pretty decent dose of an antipsychotic, depakote and zolpidem at night. People in the outpatient setting had also been throwing all sorts of medications at him. I got pulled into this increase medications thing that seemed to work for a little bit, so I kept on going with it. It turned out, though, that he wasn't sleeping because he had this delusion around sleeping so he was forcing himself to stay awake. Lesson for me that I really shouldn't have gotten pulled into the whole sleep thing which turned out to be a bit of a distraction from his general treatment needs.

OK, on that note -- thoughts about short term sleep treatments for mania either in the inpatient setting or directed at avoiding a hospitalization? I'd like to have a more sophisticated response to this.

 

[sunlioness]

I'd like to be better at sleep stuff. I do find it interesting. Not interesting enough to do a fellowship, but interested enough to try to get good at it. Or at least have a clue.


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[Shikima]

I pretty much frame starting sleep medications with a "these medications don't work in the long run" type of spiel.

Speaking of missed diagnostic issue -- I had a patient in the inpatient unit who was just plain not sleeping even after taking a pretty decent dose of an antipsychotic, depakote and zolpidem at night. People in the outpatient setting had also been throwing all sorts of medications at him. I got pulled into this increase medications thing that seemed to work for a little bit, so I kept on going with it. It turned out, though, that he wasn't sleeping because he had this delusion around sleeping so he was forcing himself to stay awake. Lesson for me that I really shouldn't have gotten pulled into the whole sleep thing which turned out to be a bit of a distraction from his general treatment needs.

OK, on that note -- thoughts about short term sleep treatments for mania either in the inpatient setting or directed at avoiding a hospitalization? I'd like to have a more sophisticated response to this.

Anxiety is a real (enter your favorite word). It will create sleep state misperceptions as well as override medications to work on emotions. In short, look at michael jackson - it's the phenomenon which draws a person into a long battle. This is where actigraphy and sleep diaries is very helpful.

I had one in clinic where the same thing was happening. All kinds of medications, until his wife came in exasperated. Evidently he'd sleep whenever, and wherever. There was absolutely no regulation. Additionally, what made it hard to treat, I think he is a short sleeper too - one who truly does not need the 8 hours and can do fine with less. These people are rare but do exist contrary to the popular belief "No, I don't need to sleep 8 hours" macho man randy savage statement. After sleep restriction, his wife watching him like a hawk, he was starting to consolidate his sleep and finally understood and kind of napping sabotaged the process. He's now getting 6 hours per night regularly with lunesta 3mg and is doing quite well. Even mood regulation is much better for him with the regular sleep.

Fortunately, I was billing sessions at 99214 due to the work being put in and seeing him weekly or biweekly for about 3 months before we had everything corrected.

For this reason, a lot of people who say they do sleep are more minded for procedures when the real money is in frequent clinic visits. And these visits are only for 15 mins each.

 

[birchswing]

Anxiety is a real (enter your favorite word). It will create sleep state misperceptions as well as override medications to work on emotions. In short, look at michael jackson - it's the phenomenon which draws a person into a long battle. This is where actigraphy and sleep diaries is very helpful.

Wasn't he sort of like a one-off case? From what I read he had used benzodiazepines and they stopped working--not atypical. But using propofol outside of a hospital is probably the domain of a very, very small population. I would guess his case was more one of asking, "Isn't there something else that can be done?" And a doctor not unlike Dr. Spaceman from 30 Rock saying, "Well actually I might have something."

 

[Shikima]

Wasn't he sort of like a one-off case? From what I read he had used benzodiazepines and they stopped working--not atypical. But using propofol outside of a hospital is probably the domain of a very, very small population. I would guess his case was more one of asking, "Isn't there something else that can be done?" And a doctor not unlike Dr. Spaceman from 30 Rock saying, "Well actually I might have something."

No, it's quite common when treating people with insomnia. The problem is that the brain, with the emotional intensity, can override any medication pretty much. The counterpoint to this is demonstrated by the power of suggestion through the placebo effect.

 

[sunlioness]

Wait ... Propofol is quite common in treating patients with insomnia?


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[Shikima]

It's all the rage.

 

[birchswing]

It's all the rage.

Your sarcasm is too subtle for me.

 

[doctorpilgrim]

One more thing to make patients angry along with, benzodiazepines are not good for your anxiety;narcotics are not good for your chronic pain; benzodiazepines are not good for sleep; stimulants are not good for your attention problems, antipsychotics are not good for your anger/sleep. No wonder many patients say that I sound like their high school principal.

Vistaril in his other posts has asked some interesting questions,which makes me think, whether I should focus more and more on my inability to sell these ideas to patients.

Now only if the corporation that bought us would ignore production and patient satisfaction I can practice.

 

[DD214_DOC]

How do you become good? If I had a clue, I might like it. But gaining a clue in this area was never part of, well, anything. I screen for sleep apnea in everyone presenting for depression and refer to sleep studies a lot more than most people do. Or at least I did. But beyond that and the basic sleep hygiene pep talk that everyone hates hearing just as much as I hate giving it, I don't know what to do.


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All I did was get a sleep medicine book and read it. Then I started to integrate what I read into my evaluations. It's not hard to do. I mean that's basically all you do during fellowship, or any other kind of medical training.

 

[sunlioness]

All I did was get a sleep medicine book and read it. Then I started to integrate what I read into my evaluations. It's not hard to do. I mean that's basically all you do during fellowship, or any other kind of medical training.

Is there one you'd recommend? That preferably doesn't cost $200 like the one I saw on Amazon last night.


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[Shikima]

Is there one you'd recommend? That preferably doesn't cost $200 like the one I saw on Amazon last night.


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You know, this is a good enough version/volume to read. The diagnostic stuff will have changed and it won't be relavent to your current practice. But the information hasn't changed all that much.
http://www.amazon.com/gp/offer-list...ie=UTF8&condition=used&qid=1453050051&sr=8-58

Also, if you want the most current diagnostic criteria for sleep disorders, pick up the most recent edition for ICSD-3.
http://www.amazon.com/gp/offer-list...ie=UTF8&qid=1453050159&sr=8-1&keywords=icsd-3

$100 total between the 2 books. Let me know if you need any other suggestions or help.

 

[sunlioness]

Thank you!

 

[F0nzie]

Getting a pt that does their CBTi, sleep hygiene, and sleep diary is like trying to win the powerball. I'm still playing. I just may quit from pure satisfaction if I win this one.

If you do child psych parents really listen though, which is nice. Except I don't see kids.

 

[Shikima]

I get pretty good compliance. Depends on why you're doing it and selling it. Those who don't do it aren't invested in their care to begin with.

 

[Ceke2002]

Just out of curiosity, at what point do you say to a patient 'okay, you're just gonna have to learn to live with this', and then the focus of treatment shifts to acceptance rather than treatment?

 

[Shikima]

Just out of curiosity, at what point do you say to a patient 'okay, you're just gonna have to learn to live with this', and then the focus of treatment shifts to acceptance rather than treatment?

I just remind them that they decided to seek out care and ask what are they willing to do to get better?
I certainly do not have the legs to create drive-by business by standing on the corner.

 

[Wilf]

This site still isn't a place for patients to bring their medical issues. We've all heard your problems multiple times and it doesn't really add to the discussion.

Psychiatry is one of the few physician forums where patients are common posters. I am not sure why the moderators allow it, especially since they are both also trolls. Come on, psychiatry.

Birchswing's recent post in the "is med school worth it?" forum should be the last straw. Steve Harvey is an absolute ***** and yet he or she still posts a ridiculous video from him and insults him in ways that are pseudo intellectual at best.