Effective Telehealth Sleep Disorder Treatment Strategies

In this final installment of a video series on sleep disorder treatment through telehealth, Rachel E. Salas, MD, MEd, FAAN, FANA, professor, department of Neurology, John Hopkins Medicine, describes her approach to treating insomnia via telehealth, including screening for other possible sleep disorders and monitoring patient response to treatment plans.

Missed Parts 1 and 2 of this series? Find them in our Telehealth Excellence Forum.

Read the Transcript:

Psych Congress Network: What challenges or considerations arise when titrating or adjusting insomnia medications remotely via telehealth? How do you monitor the effectiveness and potential side effects?

Rachel E. Salas, MD, Med, FAAN, FANA: Thinking about disadvantages for patients with insomnia, I would say the first thing to mention would be that most of the time when patients show up with symptoms of insomnia is that it's my job to first determine is this primary insomnia, or is there something else that you know may have initiated this insomnia? It could be another sleep disorder like obstructive sleep abnormal, restless leg, syndrome, circadian rhythm, whatever the other sleep disorder may be. Once I diagnose the patient with insomnia, then I get them on board with the frontline treatment strategy for insomnia, which is cognitive behavioral therapy. I have them see my colleague, one of the sleep behavioral psychologist, to  come up with the personalized plan. Incorporating strategies from cognitive behavioral therapy is really where I want to be, and most of the time, many of the patients presenting with insomnia have not tried or met with a sleep behavioral psychologist to undergo therapy.

So, I would say that is the first step after making sure that the patient doesn't have another undiagnosed primary sleep disorder and nowadays, the sleep behavioral psychologists are also able to meet with patients via telemedicine, which has really increased access for patients. Because before you know, meeting with the sleep behavioral psychologists, maybe you know 4 to 6, sometimes longer sessions. It's hard to miss work. So now, by doing it telemedicine patient could maybe schedule their session during lunchtime, or maybe at the end of the day, where they're not losing time for travel to have those visits.

Once a patient undergoes cognitive behavioral therapy and is still having issues, then at that point I may try using medications. I would say, if not necessarily had drawbacks on on, on treating these patients via telehealth or tele-sleep. I tell them the medication choice that we were going to move forward with, review potential side effects, like I would have done in person. They would be initiated on the medication, and then usually what I tell them, in a couple of weeks, send me a message through the electronic medical record and let me know if things are improving, any side effects experienced, and we go from there.

PCN: How do you monitor the effectiveness and potential side effects?

Dr Salas: I would say that I have my patients follow up pretty quickly and like, I said, because I'm able to see more patients during a given clinical schedule. Then I'm more likely able to get them in a little bit sooner. Getting things done in the same way goes for the patients with insomnia, who might be at risk for things like obstructive sleep apnea, now I'm able to get that sleep study a lot sooner, especially if it's being done at their home—a home sleep apnea test is available. Then I read it, and follow up with them pretty regularly. I'm trying to think about a disadvantage of seeing a patient with insomnia via tele-sleep, and I'm having a hard time finding a disadvantage. Frankly, I have more insight now to their sleep environment and their work environment. I may have recommendations on things they can do in their environments to optimize their sleep, some sleep hygiene recommendations that may be helpful. Obviously, that's not a treatment alone, but these are all things that people can enhance in their environment. I personally believe that sleep can be impacted with the things around you. So if you have things in your bedroom that are triggering stress or worry, or bills that haven't been paid, or you know you haven't had time to do laundry—these kind of negative things can affect people's sleep onset and their time to sleep. Additionally, patients’ bedrooms that might have a lot of carpet or heavy curtains or heavy bedding and pillows. These kinds of things can trap allergens, and things like that could be impacting the patient's sleep without them even knowing. So, making recommendations, I think, has really been positively affected via telehealth.

PCN: Where do you see the future of ‘telesleep’ headed?

Dr Salas: I think we're going to see more and more sleep specialists engaging in tele-sleep, because I think that there are far more advantages. Now, you could argue back and say, “Well, there are some patients that really absolutely prefer to have a in-person clinical visit,” and I acknowledge that. I've certainly had, in my own clinical practice, patients make that request.

But for me now, having a hundred percent tally sleep practice, the advantages are that I get to see more patients. In fact, I have a license in other states aside from Maryland, so I actually see patients in Texas and Florida, and some other States that have loosened their licensure requirements during the pandemic. But I think that more and more sleep specialists are going to see the advantages here. With cultural shift, more and more patients are going to be more comfortable with that. But certainly I understand that some people really want to have an in person visit, and there are certainly some of my colleagues that are still going to see patients in person as well. So, it’s really just about finding the clinician that you connect with but for me think I'm I've been able to reach more patients, not only in in the State that I work in, but the other states that I have a license in.

My hope is that the United States government will work with medical organizations to really make licensure more universal, so that we don't have to have different state regulations on our license, and this would help us reach even more patients.

Rachel E. Salas, MD, MEd, is a professor in the Department of Neurology at Johns Hopkins Medicine, with a joint appointment in the School of Nursing. She earned her medical degree from the University of Texas Medical Branch at Galveston and completed her internship in Internal Medicine and residency in Neurology. After her chief year, she pursued a two-year sleep medicine fellowship in Baltimore before joining the Department of Neurology at Johns Hopkins in 2008. She is board-certified in Sleep Medicine and Neurology. Dr. Salas holds the positions of Assistant Medical Director and Director of Ambulatory Sleep Services at the Johns Hopkins Center for Sleep and Wellness.