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Sleep Medicine: Can We Regain Lost Ground? Angelos Halaris, M.D., Ph.D. Professor and Chairman and Sinan Baran, M.D. Medical Director, Sleep Disorders Center Department of Psychiatry and Human Behavior University of Mississippi Medical Center Sleep Medicine Subspecialty of: Psychiatry

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Sleep medicine can we regain lost ground l.jpg

Sleep Medicine: Can We Regain Lost Ground?

Angelos Halaris, M.D., Ph.D.

Professor and Chairman

and

Sinan Baran, M.D.

Medical Director, Sleep Disorders Center

Department of Psychiatry and Human Behavior

University of Mississippi Medical Center


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Sleep MedicineSubspecialty of:

  • Psychiatry

  • Neurology

  • Pulmonary Medicine

  • Internal Medicine

  • Pediatrics

  • Psychology

  • Other


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Historical Perspective

Psychiatrists were drawn to sleep research in the past because of interest in REM sleep and dreaming.



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New Diplomates of the American Board of Sleep Medicine in 2001:

Pulmonologists 135

Neurologists 39

Other 18

Internists 6

Psychologists 2

Psychiatrists 0


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Total Diplomates of the American Board of Sleep Medicine 2001:

# %

  • Pulmonologists 901 53.0

  • Neurologists 433 25.5

  • Psychologists 112 6.6

  • Psychiatrists 110 6.5

  • Internists 44 2.6

  • Other 99 5.8

    1699


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Possible Reasons for Decreased Interest in Sleep Medicine by Psychiatrists

  • Sleep Medicine has become more general medical and less psychiatric:

    • Current emphasis on sleep-disordered breathing

    • Domination of field by pulmonologists

  • Perception of isolation or detachment from

  • mainstream psychiatry?


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Why Should Psychiatrists Consider Subspecializing in Sleep Medicine?

  • Professional diversity

  • Psychiatric training of great value in the evaluation of all patients with sleep complaints

    • more comprehensive approach

    • increased sensitivity to contributing psychiatric factors including medication effects

  • Insomnia: the most difficult presenting complaint

  • Circadian rhythms


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Obstructive Sleep Apnea Medicine?

  • Should not discourage psychiatrists from becoming involved with sleep medicine

  • Upper airway obstruction during sleep

  • CPAP acts as a splint to “prop open” the upper airway

  • A relatively “fun” and easy problem (for the appropriately trained physician) to diagnose and treat, though there are subtleties

  • CPAP compliance issues well suited for psychiatrists


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Obstructive Sleep Apnea Medicine?

  • “Meat and potatoes” of sleep medicine

  • Majority of cases referred to a sleep center

    BUT

  • There are many other interesting cases sprinkled in to spice things up


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Domination of Sleep Medicine by Pulmonologists is Without Scientific Basis

  • OSA is not a pulmonary disorder

  • Pulmonologists are not inherently more qualified to treat OSA

  • CPAP/BiPAP treatment of OSA does not require a pulmonologist


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Comorbidity of Sleep and Psychiatric Disorders Scientific Basis

  • Mood d/o can present with insomnia as chief complaint

  • Primary sleep d/o can have psychiatric symptoms:

    • affective

    • pseudo-psychotic

    • anxiety

  • Coincidental concurrence of sleep and psychiatric disorders:

    • special patient needs


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PSG Patients taking Psychotropic Medications at UMMC Scientific Basis

25.86% of 1106 patients:

Antidepressants 22.97 %

Mood stabilizers 1.45 %

Antipsychotics 4.50 %

Buspirone 1.27 %

Clomipramine 0.18 %

(4.89% on more than one class of medication)


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Practical Matters Scientific Basis

  • Typical Practice of Sleep Medicine

  • Training

  • Board Certification

  • Developing a Sleep Disorders Center

  • Developing a Sleep Medicine Fellowship

  • Referrals

  • Reimbursement


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Typical Practice of Sleep Medicine Scientific Basis

  • History and (focused) physical exam

  • Interpretation of PSG

    • visual pattern recognition skills


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Training in Sleep Medicine Scientific Basis

  • Formal 1-2 year fellowship following residency

    • accredited by AASM

    • non-accredited

  • Formal training + Clinical experience


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Board Certification by American Academy of Sleep Medicine Scientific Basis

  • ABSM not recognized by ABMS

  • AMA self-designated medical specialty

  • Candidate for subspecialty of ABPN?


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Board Certification by American Academy of Sleep Medicine Scientific Basis

  • Must 1st complete ACGME accredited residency or its equivalent prior to sleep training

  • Currently, several options and waivers to qualify

  • 2005: training must be in AASM accredited fellowship program to qualify for exam


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Components of a Sleep Disorders Center Scientific Basis

  • Sleep specialist

  • Technical staff

    • Chief technologist

    • maximum 2:1 patient to technologist ratio

    • mainly night shift work

  • Secretarial staff

    • key issue: booking/maintaining PSG schedule

  • Facility/Hardware

    • Rooms

    • Computerized (“paperless”) systems

    • Infrastructure


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Accreditation of Center Scientific Basis

  • ABSM certified or “eligible” physician

  • PSG technologists

  • Chief technologist preferably certified by BPSGT

  • 3rd party reimbursement implications


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Accreditation of Fellowship Scientific Basis

  • Accredited Center

  • Clinical exposure:

    • volume

    • breadth

  • Formal academic curriculum


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Referrals Scientific Basis

  • Initial office evaluation prior to consideration of PSG for most patients

  • Direct PSG referral only available to physicians with some experience with sleep disorders

    • report must be reviewed and approved by sleep specialist prior to PSG


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Reimbursement for Sleep Procedures in MS: Professional Fee Scientific Basis

Procedure BC/BS Medicare Medicaid

PSG 164.00 124.53 164.88

PSG/CPAP 175.00 133.69 176.64

MSLT 71.20 69.76 73.63


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Reimbursement for Sleep Procedures in MS: Technical Fee Scientific Basis

Procedure BC/BS Medicare Medicaid

PSG 531.00 484.35 528.94

PSG/CPAP 533.00 490.39 547.81

MSLT 309.00 165.15 280.67


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Relations with Neurology and Pulmonary Medicine Scientific Basis

  • Appropriate referral (not for sleep disorders)

    • seizures during sleep

    • intrinsic lung disease

  • In multidisciplinary sleep centers:

    • psychiatrists should maintain exposure to all sleep disorders

    • avoid pitfall of receiving only psychiatric referrals


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Additional Information Scientific Basis

  • American Board of Sleep Medicine: www.absm.org

  • American Academy of Sleep Medicine: www.aasmnet.org

  • Board of Registered Polysomnographic Technologists: www.brpt.org

  • Association of Polysomnographic Technologists: www.aptweb.org


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www.aasmnet.org Scientific Basis


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www.aasmnet.org Scientific Basis


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Conclusions Scientific Basis

  • Sleep medicine is not just about OSA, but OSA can be satisfying for psychiatrists to diagnose and treat

  • Psychiatrists can practice the full spectrum of Sleep Medicine and are particularly well suited for cases of psychiatric comorbidity

  • An active, full-service sleep disorders center can function well within and enhance a department of psychiatry


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Recommendations Scientific Basis

  • Educate psychiatrists about sleep medicine and the need for psychiatry to increase its visibility and involvement (through APA)

    • increase activity at psychiatric conferences

    • increase sleep-related publications in psychiatric journals (rather than focus on Sleep Medicine journals)

  • Mandate a rotation in sleep medicine for general psychiatry residents (off-site if in-house sleep lab not present)


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Recommendations (cont.) Scientific Basis

  • Consider sleep medicine a subspecialty of ABPN

  • AACDP to develop a consulting mechanism to assist departments of psychiatry in developing sleep laboratories and fellowships

  • Provide community education about sleep disorders spearheaded by psychiatrists with expertise in sleep medicine


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Sleep Medicine at the University of Mississippi Medical Center(UMMC)

  • A full-service center that diagnoses and treats all sleep disorders

  • Established 1980’s in the Department of Psychiatry

  • Currently on staff:

    • 4 physicians (1 full-time) certified by ABPN and ABSM

    • 5 polysomnographic technologists


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UMMC Sleep Disorders Center: Credentials Center

  • One of 368 Sleep Disorders Centers accredited by the American Academy of Sleep Medicine

  • One of 21 Sleep Medicine training programs accredited by the American Academy of Sleep Medicine


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Sleep Studies in 2001 Academic Year Center

  • Nocturnal Polysomnogram 687

  • Multiple Sleep Latency Test* 8

  • indicated in evaluation of narcolepsy or when quantification of daytime sleepiness is required


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Referral Patterns Center

  • Internal Medicine

  • Family Medicine

  • Pulmonary Medicine

  • Pediatrics

  • Otolaryngology

  • Psychiatry


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Training Center

  • Full-time fellowship position (1-2 year)

  • 1-2 month elective rotations for residents/fellows from following departments:

    • Psychiatry

    • Neurology

    • Pulmonology

    • Internal Medicine


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Patient Population Center

  • Adult 76 %

  • Pediatric 24 %


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Patient Distribution Center

68% Sleep-disordered Breathing

11% Periodic Limb Movement Disorder/Restless Legs Syndrome

10% Insomnia

7% Narcolepsy

2% Parasomnias


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Obstructive Sleep Apnea Center

  • Should not discourage psychiatrists from becoming involved with sleep medicine

  • Upper airway obstruction during sleep

  • CPAP acts as a splint to “prop open” the upper airway

  • A relatively “fun” and easy problem (for the appropriately trained physician) to diagnose and treat, though there are subtleties

  • CPAP compliance issues well suited for psychiatrists


Obstructive sleep apnea44 l.jpg
Obstructive Sleep Apnea Center

  • “Meat and potatoes” of sleep medicine

  • Majority of cases referred to a sleep center

    BUT

  • There are many other types of interesting cases sprinkled in to spice things up

    • narcolepsy

    • parasomnias

    • insomnia


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Domination of Sleep Medicine by Pulmonologists is Without Scientific Basis

  • OSA is not a pulmonary disorder

  • Pulmonologists are not inherently more qualified to treat OSA

  • CPAP/BiPAP treatment of OSA does not require a pulmonologist


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Conclusions Scientific Basis

  • Sleep medicine is not just about OSA, but OSA can be satisfying for psychiatrists to diagnose and treat

  • Psychiatrists can practice the full spectrum of Sleep Medicine and are particularly well suited for cases of psychiatric comorbidity

  • An active, full-service sleep disorders center can function well within and enhance a department of psychiatry


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Recommendations Scientific Basis

  • Educate psychiatrists about sleep medicine and the need for psychiatry to increase its visibility and involvement (through APA)

    • increase activity at psychiatric conferences

    • increase sleep-related publications in psychiatric journals (rather than focus on Sleep Medicine journals)

  • Mandate a rotation in sleep medicine for general psychiatry residents (off-site if in-house sleep lab not present)


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Recommendations (cont.) Scientific Basis

  • Declare sleep medicine a subspecialty of ABPN

  • AACDP to develop a consulting mechanism to assist departments of psychiatry in developing sleep laboratories and fellowships

  • Provide community education about sleep disorders spearheaded by psychiatrists with expertise in sleep medicine


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Results Scientific Basis


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Comorbidity of Sleep and Psychiatric Disorders Scientific Basis

Angelos Halaris, M.D., Ph.D.

Professor and Chairman

University of Mississippi Medical Center


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Purpose Scientific Basis

To determine the prevalence of psychiatric disorders in our patient population over the past 3 years.

The majority of our patients are referred by non-psychiatrists for the evaluation of primary sleep disorders other than insomnia.


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Methods Scientific Basis

  • Our PSG database was reviewed to identify patients who were taking psychotropic medications.

  • Presence of psychiatric disorders was presumed on the basis of patients’ medications, and chart review was conducted to clarify ambiguous cases.


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OSA patients on Antidepressant Medication Scientific Basis

Of 254 patients on antidepressants, 207 had OSA (81.50 %)

(True depression?)


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Conclusions Scientific Basis

The prevalence of psychiatric disorders is high in a typical sleep disorders center patient population, and may be even higher than these numbers suggest, since patients were not evaluated psychiatrically by us and may have had psychiatric symptoms that were not formally identified by referring physicians.


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Discussion Scientific Basis


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Does OSA Cause MDD? Scientific Basis

  • OSA patients with depressive symptoms can be misdiagnosed as having MDD.

  • In our experience,

    • Depressive symptoms due to OSA resolve with treatment of OSA and do not require separate treatment

    • Antidepressants are sometimes discontinued by referring MD after CPAP treatment


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Overlap of OSA and MDD Sx Scientific Basis

  • Fatigue/anergia

  • Sleep disturbance

  • Amotivation

  • Decreased concentration

  • Decreased libido


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Depressive Sx Not Typically Seen in OSA Scientific Basis

  • Crying

  • Hopelessness

  • Decreased appetite

  • Weight loss

  • Suicidal ideation


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Reversal of Depression With CPAP Scientific Basis

  • 55 patients with OSA completed Zung Self-Rating Depression Scale (SDS)

  • 45% had score > 50

  • All 11 patients with elevated scores showed improvement with CPAP (60.5+1.9 to 44.4+2.6 [p<0.001])

    Millman RP, Fogel BS, McNamara ME, Carlisle CC: Depression as a manifestation of obstructive sleep apnea: reversal with nasal continuous positive airway pressure. J Clin Psychiatry. 1989 Sep;50(9):348-51.


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Advantages of Psychiatrist Sleep Specialist: Scientific Basis

  • Increased sensitivity to needs of psychiatric patients with sleep disorders

    • e.g., compliance with CPAP

  • Ability to differentiate major depressive disorder from depressive symptoms due to OSA.

  • Increased familiarity with effects of psychotropic medications on sleep


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Polysomnograms Currently Performed Scientific Basis

  • 3 studies/night

  • 5 nights/week


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Concurrent Psychiatric Disorders in 1999 Scientific Basis

  • Affective Disorders 12 %

  • Psychotic Disorders 3 %

    (typically not the reason for referral)


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Sleep Diagnoses of Sample Population Scientific Basis

1106 Patients: %

Obstructive sleep apnea 82.10

Upper airway resistance syndrome 11.23

Periodic leg movement disorder 2.72

Narcolepsy 0.45

Parasomnias 0.18

Sleep-related GERD 0.36

Other 2.90


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