TCPR: What are some of the basic questions that we should be asking our patients who complain of sleep problems?

Dr. Rosenberg: First, I always urge my psychiatrist friends to look at the medications they are prescribing because many of the medications used for depression and anxiety actually cause the insomnia. Both the SNRIs and the SSRIs not uncommonly cause insomnia. Then, you should try to get some kind of a sleep history. Anybody who comes to see me fills out a week of a sleep diary. If you can get a patient to fill out a sleep diary before they come to see you for at least five nights, that can be extremely helpful. Because so many of the psychiatric disorders involve sleep deprivation or insomnia, and those—if they are not dealt with—tend to promulgate and worsen the psychiatric disorder. In asking about insomnia, you want to ask, do you have trouble falling asleep? Do you have trouble staying asleep? Do you wake up in the middle of the night or early morning hours and can’t get back to sleep? Does the problem go on at least three days a week? Has it been going on for more than a month? If there is no psychiatric problem we call that a primary insomnia, but about 40% of all people with insomnia suffer from depression or anxiety. 

TCPR: What are some other questions besides those pertaining to insomnia?

Dr. Rosenberg: Ask people about the quality of their sleep. Do you snore? It turns out that a lot of people who wake up in the middle of the night and are diagnosed with insomnia really don’t have insomnia; they have sleep apnea. And that is frequently missed. And then the other thing you want to talk about to your patients is their sleep hygiene. How much caffeine do you consume? Do you smoke right up until bedtime? Do you have your computer on? Is your TV on? Are you exposing yourself to a lot of blue light within 90 minutes of bedtime, because if you are—iPads, cell phones, texting—that is going to make it very difficult to fall asleep. And in a patient with anxiety—and many of my patients have comorbid generalized anxiety disorder or social anxiety—sometimes just correcting their sleep hygiene goes a long way to getting them to improve their sleep. And when we get them to sleep longer, their psychiatrists report that there is an improvement in their ability to treat their anxiety and of course also to treat their depression.

TCPR: Going back to sleep apnea, what should we be asking our patients to assess for that?

Dr. Rosenberg: Ask, “do you snore?” If they say no, ask if anyone has ever commented that they do—many times people don’t know or are embarrassed to admit that they snore. Do you wake up feeling that your sleep is nonrestorative? Are you sleepy during the day? Those are the standard questions, but there are other things that a physician can ask that are a little more nuanced, and which can be very helpful. Do you wake up with headaches? People with sleep apnea tend to have headaches in the morning—about 30% or 40%—probably due to low oxygen and high blood pressure during sleep. They tend to get up and urinate a lot. When one breathes against a closed airway it stretches the heart, and the heart puts out a polypeptide hormone that causes you to urinate. I don’t know how many of my male patients have said to me they have already been to the urologist, they are on tamsulosin, they are on all these drugs for their prostate, and in the end it was sleep apnea that caused their frequent urination. Ask about abnormal behaviors in sleep. In a lot of patients diagnosed with REM behavior disorder, which is acting out their dreams, it turns out that they actually have agitated arousals out of REM sleep due to sleep apnea.

TCPR: And what should we ask to ascertain restless leg syndrome (RLS)?

Dr. Rosenberg: First, it’s important to distinguish RLS from periodic limb movement disorder (PLMD), which, while it is more common in restless leg syndrome, it is a different condition characterized by moving the legs around a lot throughout the night. Restless leg syndrome is when you either can’t fall asleep or you wake up in the middle of the night and you have a subjective sensation of discomfort in your legs. It can even be in your upper extremities or in the thorax. But it is a subjective sensation of discomfort with an urge to move and is relieved by movement. So if a person is just kicking during their sleep, that may not mean anything. That is probably periodic limb movement. We see that in older people. We see that in people who are on antidepressants and in people with sleep apnea. But if a person says, “I wake up and my legs are driving me nuts and I can’t go to sleep. I get up and I walk or I massage them or I take a hot bath to try to relieve it”—that is restless leg syndrome. Restless leg syndrome is very commonly precipitated by psychiatric drugs, particularly the SSRIs and the SNRIs. The only antidepressant that does not cause RLS is Wellbutrin. Of course, the antipsychotics, especially the first-generation antipsychotics, have a high incidence of restless legs.

TCPR: So we talked about the possibility of medications causing insomnia, sleep apnea, restless leg syndrome. We talked about some basic sleep hygiene things. What else should we be asking about?

Dr. Rosenberg: Another one is aches and pains, and there may be a relationship with low vitamin D levels. And of course your environment: Is your bedroom too hot? Does your bed partner snore and keep you awake? A lot of times we talk about bedroom divorces, which can save a person’s marriage and also can save their health. I frequently tell my patients, “Well, how about a 4 or 5 day trial or a weekend trial where you sleep in a separate bedroom and let’s see what happens?” Sometimes they will come back and tell me, “It’s the best sleep I’ve had in years.”

TCPR: At what point in your experience is it appropriate for a psychiatrist to say, “Okay, it’s time for you to see a sleep specialist?”

Dr. Rosenberg: Certainly if a patient has restless leg syndrome and you are not well versed in treating that, then you want to send him to a sleep specialist. If a patient has suspected sleep apnea, undoubtedly you are going to send them to us, and it is important because we do need to test. And by treating the sleep apnea, it is going to make it so much easier to treat the psychiatric disorder. Or if you have people with abnormal behaviors in sleep and you are stumped because you are not used to dealing with sleepwalking or REM behavior disorder—I mean, this is not something that many people have been trained in. You really should send them to see a sleep specialist who can help you and work with you in diagnosing and treating it.

TCPR: Interesting. So your typical sleep specialist does not just treat sleep apnea?

Dr. Rosenberg: I hope not. A lot of us are, unfortunately. But a good sleep specialist, someone who is really into it, will do a lot more than test for sleep apnea. Make sure they are board certified in sleep medicine, and that they are not just a pulmonologist who has a sleep lab. 

TCPR: Do physicians learn about CBT for insomnia in sleep medicine fellowships?

Dr. Rosenberg: Yes, absolutely. They learn stimulus control; sleep restriction therapy. We also use imagery rehearsal therapy for PTSD. I’d like to see more psychiatrists involved in that.

TCPR: What is that?

Dr. Rosenberg: Imagery rehearsal therapy is the treatment of choice for recurrent nightmares. When combined with cognitive behavioral therapy, it is actually superior to prazosin in most studies (Seda G, J Clin Sleep Med 2015;11(1):11–22). You basically go through the traumatic event and you have the patient rewrite a script. They write it down and they change the ending or they change the content in some way. It stays close enough to the original, but they change it enough so that it has a happy ending or a pleasant connotation. They rehearse it in their mind for 10 or 15 minutes a day. This goes on for a couple of weeks and it is extremely successful in eliminating the nightmares.

TCPR: Interesting, so we need to learn more about that.

Dr. Rosenberg: Yes. Sometimes I’m shocked that even at the local VA, some of the psychiatrists are not familiar with imagery rehearsal therapy; they tend to rely on drugs like Seroquel or prazosin.

TCPR: When we refer a patient to a sleep specialist, what can they expect? What will happen?

Dr. Rosenberg: When they come to see us, even in advance of the appointment, I have them fill out various forms: a week of sleep logs, a generalized anxiety disorder scale, a Beck Depression Inventory, and a very thorough 5-page sleep history. And we also have the spouse fill out what we call the “Mayo Spouse Sleep Questionnaire,” which covers things that the bed partner might note, such as acting out dreams or snoring. So I’ve got a lot of information before you walk in the door. And then I am going to take a good thorough history on them beginning with when their sleep problem began, when any comorbid psychiatric problem began, and the temporal relationship between the two. I want to go over their drugs very carefully to see if there is a medication that could be causing their insomnia or could be causing their hypersomnolence—two of the more common causes are mirtazapine (Remeron) and trazodone.

TCPR: Under what circumstances will you do a sleep study?

Dr. Rosenberg: Most sleep specialists will do a sleep study if we suspect sleep apnea or if there is an abnormal behavior during sleep. If your trouble is falling asleep, I’m probably not going to do a sleep study, but if the problem is staying asleep, some type of diagnostic polysomnogram will make sure we are not missing a primary sleep disorder, such as sleep apnea.

TCPR: So what is a sleep study?

Dr. Rosenberg: Basically with the sleep study, the polysomnogram pretty much monitors everything physiological that is going on during sleep. We are going to be monitoring your brainwaves: frontal, central, and occipital. We are monitoring breathing with a thermistor through the nasal pressure transducer so we can pick up any air movement coming through the nose and mouth. We monitor effort to breathe with belts over the chest and abdomen. We have an oximeter. We know what position you are in. We are monitoring movements of legs with sensors on the legs, and sometimes we put sensors on the upper extremities if we suspect you might be acting out your dreams. And all this is being recorded with a camera and a microphone with a board-certified technician watching it throughout the night looking to see if there are any abnormalities. Now if we pick up sleep apnea, we will come right in, stop the test, and put you on continuous positive airway pressure therapy (CPAP) to immediately see how well that treatment will work. In depression, we often pick up an early onset in REM sleep, and an increase in total REM sleep, which is classic for depression. 

TCPR: Many of our patients are on benzodiazepines. How do these drugs affect sleep architecture?

Dr. Rosenberg: Benzodiazepines do a couple of things. Number one, they suppress deep sleep (slow wave sleep), and you get mostly stage II sleep. They also suppress REM sleep. Another effect is that benzos can worsen sleep apnea. 

TCPR: Do you think we are overusing benzos?

Dr. Rosenberg: Yes, and I try to get most of my patients off of benzos if I can. Recent studies have associated benzo use with an increased risk of Alzheimer’s disease. There are also many studies showing that benzodiazepines may inhibit the ability to achieve fear extinction in PTSD patients. Meaning that when these patients have a benzo on board, they are far more likely to remember and upregulate negative emotions as opposed to positive emotions. And then you’ve got the issue of residual daytime somnolence; you’ve got the issue of falling in the middle of the night; you’ve got the issue of sleepwalking; eating in your sleep. I mean, I’m not saying I don’t ever use them, but I would say my usage of them has dropped precipitously.

TCPR: How are you getting patients off benzos?

Dr Rosenberg: Based on some recent studies, I am using pregabalin (Lyrica) and finding that it is an excellent way to wean people off of benzodiazepines. We normally start them on Lyrica anywhere from 50–75 mg and begin to taper the benzo by about 50% every week or two. If they have problems tolerating the taper, we’ll double the Lyrica to 150. Once the patient is off the benzos, we’ll try tapering off the Lyrica over a week or so, but some patients want to stay on it, which is probably fine, because it’s safe (Bobes J et al, Eur Psychiatry 2012;27(4):301–307).

TCPR: Tell me about some of the treatments. What’s the latest for sleep apnea?

Dr. Rosenberg: For sleep apnea, we go with CPAP, and if a patient cannot wear a CPAP or they are intolerant or they’re claustrophobic, we will do what is called a “positive airway pressure nap session.” They come into my facility; I have a skilled technician who is trained in desensitization, and we work with them so they can learn to tolerate wearing the CPAP. If that fails, then we usually send them to a skilled dentist who knows how to make an oral appliance called a mandibular advancement device. These devices don’t always work, but when they do work—and we have ways of predicting whether or not they will work—they are just as effective and just as good. For insomnia on the other hand, I’m a big user of mirtazapine at 15 mg. If I have a patient who has severe anxiety or depression, with insomnia, and they are already on an antidepressant, and I don’t want to use Lunesta or Ambien, I will often talk to the psychiatrist and ask, “Do you have any problem with my putting him on a low dose of mirtazapine”—usually 15 mg. The lower the dose the more sedating it is. I have had great luck, and I haven’t had much weight gain, by the way. I’d rather do that than put them on Lunesta or Ambien and they are left hanging for the next five years on that drug.

TCPR: Among the whole spectrum of the benzos and the non-benzos are there any out there that you prefer over any others?

Dr. Rosenberg: I generally would go with the non-benzos over the benzos. So we are talking about the so-called Z drugs: zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta). Sonata is a very short-acting drug that can be used in the middle of the night or it can be used for sleep-onset insomnia because it works quickly and it is gone in two hours. So if you have a truck driver or somebody who needs to be sharp in the morning that might be the drug, so I will use that occasionally. I shy away from Ambien because of the parasomnias. I see these behaviors way more with Ambien than with Lunesta or Sonata—although nobody has really done a good head-to-head study, that’s my clinical impression. And I am not saying I never ever give anybody a benzo. Occasionally I’ve used temazepam (Restoril) in an anxiety patient when nothing else works. 

TCPR: What about Silenor?

Dr. Rosenberg: Silenor is low-dose doxepin 3 to 6 mg. All the studies showed that after 8 hours nobody was drunk or left sleepy. It is the only drug that really works for improving the last 2–3 hours of sleep. So if you have your classic depressed patient whose insomnia is early morning awakenings, Silenor is probably the drug of choice for keeping them asleep.

TCPR: Given that it is brand name and expensive, can we use versions of generic doxepin?

Dr. Rosenberg: Yes, most of my patients find it too expensive, so I’ll prescribe liquid doxepin—there’s a pediatric form that is 5 mg per ml. 

TCPR: Thank you, Dr. Rosenberg.