Archive for February 14th, 2008

I apologize as I need to cut and past this entire interview/discussion as only some of you may have access to it? It’s from Medscape on this little microsite, almost. Here’s the link anyway.

It might be a little long but skip over the parts that bore you. Or feel free to skip over this entire post if it bores you. I shall interject with a few comments as always. This article may not be that thrilling, but it interested me somewhat.

The Impact of Insomnia on Sleep: An Expert Interview with Daniel Buysee, MD
By Suma Jacob, MD, PhD

Dr. Jacob is the 2006 American Association for Technology in Psychiatry Fellow, sponsored by GlaxoSmithkline.

Introduction: Daniel Buysse, MD, is Professor of Psychiatry, at Western Psychiatric Institute and Clinic University of Pittsburgh, Pittsburgh, PA. Dr. Buysse is an internationally renowned psychiatrist and sleep expert, who discussed the interaction of depression and insomnia with Suma Jacob, MD, PhD in the Fall of 2006.

Dr. Jacob: Dr. Buysse, in addition to insomnia being a medical disorder, it has often been a prominent symptom or comorbid with other disorders, especially depression and anxiety. How common are these co-occurrences?

Alright, insomnia is a “medical disorder.” Yes. This is true. Can it occur as well with psych stuff?

Dr. Buysse: They are very common. If you looked at people who have chronic insomnia, approximately 50% of those will have comorbid depression. So depending on how you diagnose people, one can easily come to the conclusion that comorbid insomnia, particularly insomnia that is comorbid with depression is the most common type.

Why sure! The first words out of his mouth are “chronic insomnia!” If that doesn’t speak to “medical disorder…?”

50% too. That’s a fair figure as well. I know I sure fall into that number! If I don’t have my meds I can’t sleep at all! I think if you took me off them I might never sleep again! Well I might sleep at some point for brief intervals, but I would still have insomnia.

Dr. Jacob: 2005 National Institute of Health (NIH) Consensus Conference made a point about the concept of comorbidity in insomnia. What are the consequences of considering insomnia to be a symptom as opposed to a disorder?

I’m sorry. I can’t find the NIH Consensus Conference information, but it’s important. They didn’t link to it or anything.

Dr. Buysse: Considering insomnia to be a symptom only could lead to under treatment and it could influence general treatment outcomes. If we consider the specific case of insomnia comorbid with depression, it is a fairly common occurrence that insomnia persists after depression is treated. We know that when insomnia persists it leads to a reduced rate of remission in the depression itself and increased risk for relapse and recurrence of depression. So there are consequences for not treating insomnia.

Oooh. This is getting exciting now. Insomnia as a symptom only. We’re heading back to the issue of perhaps a (chronic) medical condition too? If not (or even if so) the point about “under treatment” is very important here.

Think about it. How many of us with any of our illnesses have “comorbid” insomnia? How much has it messed us up? It is absolutely possible that we might experience a shift in mood, we might feel better, but our sleep is still completely disastrous. Then our moods get completely out of whack again. This guy is making some sense, don’t you think?

Dr. Jacob: Do you believe that there is a common mechanism or pathway in the brain that can explain such a common co-occurrence with depression?

Dr. Buysse: We don’t really know the answer to that. There are data to suggest that the biology of insomnia and the biology of depression are related to one another. One potential key is that both disorders, depression and insomnia, involve dysregulation of the HPA axis and in particular, elevated corticotropin-releasing hormone.

Okay, the “HPA axis” is the “Hypothalamic-pituitary-adrenal axis.” It’s a major hormonal “hub,” if you will, between your brain (the first two parts in the name) and the the adrenals that sit atop your kidneys. Obviously because of that there’s a whole whack of stuff going on.

However, for the sleep business the CRH mentioned above comes from the Hypothalamus. What gets me more excited, even though it’s not mentioned here, is that Cortisol is also involved! I am always fighting for my Cortisol to get more “press,” and research done with it as far as all of our head crap!

I did find this under the Psychopharmacy section in Wiki that doesn’t get me so excited. Changes in CRH in cerebrospinal fluid have been noted in suicide victims. Better get that insomnia treated! I’m kidding. That’s not funny.

Another way of getting at the similar pathways involved in insomnia and depression is through functional neuroimaging studies during sleep and wake. Similar patterns have been observed in depression and insomnia using positron emission tomography. Both depression and insomnia show a relative persistence of brain activation in the frontal brain regions during non-REM sleep.

Huh. That’s kind of cool too. There’s a bit more on that later.

Dr. Jacob: When both insomnia and depression are present, are there any data that describe which came first?

Dr. Buysse: In the last 5 years or so, a variety of data have suggested that the usual expectation that insomnia is due to depression may actually be the incorrect sequence. There are now several epidemiologic studies that show that having insomnia independent of depression, there is a risk for later developing depression. Insomnia is one of the stronger risk factors identified for development of depression.

In recurrent depression, there are additional data suggesting that insomnia typically appears first and depression appears later. A study by Ohayon and Roth suggests that the particular sequence of insomnia preceding depression is a more common one than insomnia appearing at the same time as depression or depression coming first and insomnia showing up later. Therefore, the data suggests that insomnia commonly precedes depression.

Oh, yes indeedy over here! I know my insomnia hit like a freight train before I became depressed. Shall we take a poll? Who else out there experienced sleepy problems prior to moody problems? Again, let’s “wake up” to this people!

Dr. Jacob: If assessment for sleeping difficulties is a part of a usual mental status exam, why is insomnia often missed?

Dr. Buysse: I am not sure that it is necessarily missed, but rather underplayed. We know that sleep difficulties are part of the diagnostic criteria of depression, anxiety disorders, and bipolar disorder. I think that clinicians are assessing for sleep difficulties. However, when sleep difficulties are present, they are seen as another symptom of a depressive or anxiety disorder and the assumption is that treating the depression or anxiety disorder is sufficient for dealing with insomnia. As we previously discussed, this can lead to under treatment.

Yes, yes…please can we keep hammering it home?

Dr. Jacob: Would sleep patterns present differently with comorbid insomnia and depression (i.e. falling asleep, staying asleep, early morning awakening, and overall length of sleep)?

I can answer this one before Buysse! Completely not! I’m still leaning to my “chronic insomnia”/medical condition presenting along with psych illnesses opinion. See above with his 50% statistic?

Dr. Buysse: In general, people who have comorbid insomnia and depression have more severe difficulties than people who have insomnia alone. The specific type of difficulty is not very different than in people with primary insomnia. Patients with primary and comorbid insomnia have about equal degrees of difficulty falling asleep, difficulty staying asleep or early morning awakening. The usual assumption is that early morning awakening is more of a sign of depression, but there is not really great data supporting that.

Dr. Jacob: Does age play a factor in these two disorders presenting comorbidly?

Dr. Buysse: Younger patients with depression more often have hypersomnia, whereas older adults with depression more often have insomnia. There is evidence from sleep laboratory studies that depression and age interact. That is, older adults have disproportionately worse sleep when they are depressed than younger adults.

This may be true. Although I will say as a caveat that adolescents’ sleep is completely screwed up because of their hormones anyway. It has been proven that they need more sleep–depressed or not. The depression may just exacerbate this, however.

Dr. Jacob: How does anxiety fit into this?

Dr. Buysse: In general, older adults with depression will have more anxiety symptoms than younger adults. Older adults can have a more activated or anxious depression and have greater insomnia symptoms as part of the picture.

Hmmm. Well we all are different. When I was depressed as a kid…well, I was anxious since birth. However, I do know that my anxiety increased with depressive episodes as an adult.

Dr. Jacob: Which disorder would you treat first in comorbid insomnia and depression?

Dr. Buysse: We shouldn’t necessarily think of treating either one first or second, but of treating both conditions adequately. If a patient has significant insomnia as well as depression, he/she should be treated promptly, for both problems. If you look at overall morbidity, there is more danger in not treating for depression than missing the treatment of insomnia. Depression, if untreated, can result in greater negative outcomes. The key is to diagnose and treat both conditions appropriately.

Hallelujah! This is what we need! Treat them both! Don’t just focus on the psych illnesses! Those are important as well, especially if the patient is in imminent danger, but TREAT THE SLEEP PROBLEMS! *laughing*

Dr. Jacob: What impact does insomnia have on quality of life? What impact on quality of life does comorbidity with depression have?

Dr. Buysse: Insomnia, both as a primary disorder and as a comorbid condition, has a negative impact on quality of life. Insomnia has its own independent negative impact on quality of life, even when it occurs with disorders such as arthritis, cardiovascular disorders or cancer.

Perhaps I should have deleted this. It’s a very dumb question.

Dr. Jacob: Are there functional MRI changes seen with patients who have insomnia compared with those who don’t?

Dr. Buysse: I’m not aware of fMRI data. However, using positive emission tomography during sleep and wakefulness, we found that in people with insomnia actually appear different in both sleep and wake time compared with good sleepers. Patients with insomnia have relative brain activation. That is, when they appear to be asleep by polysomnographic criteria, their brains show excessive metabolic rate in the frontal cortex and in the brain arousal structures. During wakefulness, their brain is more metabolically active than good sleepers but insomnia patients have a relative decrease in areas such as the frontal lobe which are important for executive function and higher order cognitive function.

I find this a bit more interesting than the brief mention above about the PET scans, and non-REM sleep. However it doesn’t distinguish between those with primary insomnia, and those who have psych illnesses either with, or without primary insomnia. Maybe it doesn’t matter *PA raises eyebrows*

As far as the latter, there have been many studies done with PET scans, and fMRIs (not mentioned as being done above for insomnia) for those with psych illnesses, and measuring frontal lobe activity. I am not sure, but many seem to have been done regarding Schizophrenia–at least from what I have read. There may be more regarding other illnesses.

So is it illness related that your cognitive, and higher order functions are compromised, or is it because of lack of sleep? At the very worst (or “best” for the scan results) could it be that after building up a massive sleep deficit, your cognitive functions are completely screwed up?

However, I think what is more interesting, is that being measured while the insomniacs are asleep: the fact that they have a higher metabolic activity than the “good sleepers.” So what are we doing when we’re sleeping? Rather, what are our brains doing?

If we go back to the HPA axis, and try look at what Buysse is trying to say about the change in the CRH…well? Release of CRH is moderated in part by my good old friend Cortisol! Also by “stress,” but Cortisol is also known as “the stress hormone.” So it’s all a bit tricky. Circadian cycles get linked in there too…well, gee! That’s just going to screw things up, and not really help right? If you’re already thrown off because of your Circadian Rhythms, you’re probably not sleeping!

Like everything else in the big, wide, wonderful world of (brain) science, we require some more research here.

Dr. Jacob: What are potential consequences of not treating a patient who suffers from insomnia?

Dr. Buysse: Not treating insomnia results in poor quality of life and poor functional outcomes. Evidence suggests an increased risk for subsequent depression and anxiety disorders and there is some evidence for cardiovascular and other health outcomes as well.

Again, apologies. Dumb question. Of course there are other consequences as well. We can all think of some.

Dr. Jacob: How can we create better awareness about insomnia among physicians and patients? Do you believe that the new NIH Consensus Statement will help change clinical practice? If so, how?

Dr. Buysse: The NIH State of the Science Conference may help change medical practice. It really comes down to education and awareness. The practicing physician had very little sleep education during medical school or in post-graduate education. There is a great need to educate physicians about insomnia.

Hallelujah Part II!!! Are you listening doctors???

Dr. Jacob: How extensive is the economic burden of insomnia? Direct and Indirect?

Dr. Buysse: Insomnia is associated with decreased productivity and increased costs for individuals, employers and society. The financial impact is difficult to estimate but one study suggests that in the United States, the costs of insomnia are $77 billion to $92 billion annually, including lost productivity and accidents. The direct and indirect costs of depression are equally costly and estimated to be at least $44 billion annually for the US economy.

Stats, stats…bottom line you don’t perform when you can’t sleep, indeed work productivity plummets, people screw up, and it’s bad, bad, bad!

Dr. Jacob: Dr. Buysse, thank you for your time, I’ve enjoyed our discussion today!

Hopefully you’ll thank PA for her post and her time–and you won’t think this sucks *laughing*