How Psychiatrists Can Address Sleep-Wake Disorders Effectively

No two patients are the same, except in one regard: all patients (and practitioners) sleep.

Psychiatry and Behavioral Health Learning Network connected with Thomas L. Schwartz, MD, distinguished teaching professor, Department of Psychiatry and Behavioral Sciences, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY, ahead of his session, “Wake Me Up Before You Go-Go: Strategies for Improving Sleep-Wake Issues” presented at the 2024 NEI Fall Congress.

In this exclusive Q&A, Dr Schwartz provides a peek into the major takeaways from his session, including the importance of paying attention to wakefulness issues as well as insomnia, explains how psychiatrists can become “a little bit of a neurologist” to reinforce their clinical toolboxes, and details some of the exciting developments in neuroscience that are expanding the psychopharmacological options for treating sleep-wake issues in psychiatric patients.

For more news and insights from the 2024 NEI Fall Congress, visit our newsroom right here on PBHLN.

Psychiatry and Behavioral Health Learning Network (PBHLN): What are a couple of the important takeaways from your NEI session on sleep/wake issues?

Thomas L. Schwartz, MD: I think NEI over the years has done a lot of work on insomnia. So we see a lot of insomnia in psychiatry. It's a cross-cutting symptom in depression, anxiety, bipolarity, and addictions. I think we've done a good job discussing insomnia, how to diagnose, how to treat it, and we certainly have had more medications available to us.

Over the last few years we've started to talk about narcolepsy and idiopathic hypersomnia, or hypersomnolence disorders as we psychiatrists call it in the DSM system. We've been adding more and more about some "neurological" conditions that many psychiatrists are going to see during the daytime.

What has been really nice with this talk and those at NEI Fall Congresses past is that we're covering both sides. If you're excessively tired during the day and having a problem, we have treatments. If you're not sleeping at night, we have treatments. We've adopted a more well-rounded approach, I think.

PBHLN: In your experience and practice, are neurologists a part of your care team. If not, where do they fit into the treatment paradigm for sleep-wake issues?

Dr Schwartz: It's always good to have a solid neurologist that you can refer to. I don't have a neurologist specifically on my team or my clinic, but I'm spoiled at an academic medical center where we have lots of different people around.

But I would think even if you're in a community somewhere and you don't have access to academic medical centers, find yourself a good neurologist, or any sleep specialist, because pulmonologists can do this and some psychiatrists are sleep-qualified. I think it's always good to have somebody else around.

I've learned as a psychiatrist, that it's okay to be a little bit of a neurologist if you can get training. I grew up in the era where every patient with schizophrenia had nervous system problems. We gave them side effects like tardive dyskinesia and Parkinsonism. I'm not a neurologist, but somehow I got trained to treat these movements.

So, I think if you approach narcolepsy or idiopathic hypersomnia as a "neurology condition," you can kind of be an amateur neurologist. Get yourself trained, learn how to make the diagnosis, learn how to use the meds, which what we teach here at NEI Congress. You can dabble in it once you get training, but if training isn't available, find a neurologist that you can work with.

PBHLN: Could you share some practical tips with our audience of psychiatry clinicians on how to create a initial treatment strategy for patients with sleep-wake issues?

Dr Schwartz: As a psychiatrist, I'm usually treating depression and/or anxiety that have insomnia and fatigue as part of their symptomatology. I think the first step is to use FDA-approved meds to treat the baseline condition. Then, if you're still left with fatigue or insomnia, you have to scratch your head a little bit. Is that a side effect I gave my patient? Is that the residual depression or anxiety symptom I failed to treat? Do they actually have a separate condition like narcolepsy, insomnia, et cetera? Do they have some kind of a pain condition or breathing condition like apnea at night? Is there something I missed that's creating this?

From a psychiatric perspective, we probably need to look at those kind of comorbidity things, take a pause, and ask, "why is this leftover?" The more it looks like it's a standalone symptom, they have narcolepsy. Again, make that referral or, if you're trained in it, get the sleep studies you need, and then go ahead and start treating.

I think that's the way I would view it in practice: make the diagnosis as a psychiatrist on the psychiatric things, and then if there's stuff left over, reevaluation and go from there.

PBHLN: Which recent developments in the neuroscience for sleep-wake issues are you most excited about and why?

Dr Schwartz: I think we've entered the era for insomnia--it's not all about GABAA anymore. GABAA is the inhibitory neurotransmitter where it makes us sleepy at night. The true older school benzodiazepines work here, the BZRA- and Z-drugs, zopiclone, and zolpidem all kind of in GABAA as well. That's great! These drugs are highly effective. They get people to sleep. The downside is that they can be addictive. They can disrupt breathing at night. Some of them may hurt sleep architecture. They're not perfect, but boy, they can make your patients go to sleep. They can wake up tired, groggy, hungover the next day, but we've used this strategy for decades.

In the world of insomnia, the orexin antagonists are unique. They're controlled substances, but they don't seem to do the damage on sleep architecture or result in patients waking up as hungover. There's three of them out now: suvorexant, lemborexant, and daridorexant. So, I think that's an exciting new class of insomnia treatments. The antihistamines have got their due. We always use them off-label. But low-dose doxepin is a great strategy that has FDA-approval. So, I think the GABAA-facilitating drugs are tried and true, but it's also nice to see we're manipulating different neurotransmitters and receptors now, and helping people get better sleep.

On the wakefulness side of things, if you just think about narcolepsy, idiopathic hypersomnia, if you translate that into terrible daytime fatigue and sleepiness in psychiatric practice, we are really good at the stimulants, the methylphenidates, the amphetamines. We know how to wake people up because we know these drugs, we're comfortable using them, monitoring them, but I'm not sure they're the greatest for these conditions we're talking about. There's no off-switch: they stop, they start, they stop again. Modafinil, armodafinil, is different kind of stimulant with longer half-life. I'm not sure we're as good at using that class of drugs, we just never incorporated them into regular practice. They were approved for things like narcolepsy, which we don't view ourselves as psychiatrists as being good at managing. We also have histamine three (H3) receptor antagonists, and that wakes people up so we can play with the histamine system. Instead of blocking H1 as we do with some patients, other people wake up. We have 3 different versions of oxybate we can use at night, which are somewhat oddballs. They're sedative and they really knock people out, but they also somehow keep you awake during the day. I think they provide some of the best deep sleep out of any product we have. So if you sleep great during the night, get good restorative sleep, you're less tired during the day.

I think these are great things to look at in the world of psychiatry, but we haven't yet delved into the wakefullness side of things because we're really stuck on narcolepsy and idiopathic hypersomnia. So, hopefully there are future studies just down the line.

As a final note, and these are off-label areas, but I wonder could these things be good antidepressants and fix our depressed patients' circadian clocks? It's really cool stuff--there are a lot of different brain areas, neurotransmitters, neuroreceptors, that we're able to manipulate now to try to help people.

PBHLN: What's the most important takeaway on this topic you'd like to share with our audience?

Dr Schwartz: I think on one level, insomnia clearly exists, particularly in psychiatric practice. I do think it's a harder cell to convince the average psychiatrist that they're going to see narcolepsy every day. It's a pretty rare condition, but it is out there. And an idiopathic hypersomnia, I bet we see a lot of, and we just assume it's side effect. We assume it's part of the depression, but it might be its own condition. So I do think we need to get better at sorting through the comorbidities and making accurate diagnoses. And then certainly if we see either of these things make a good referral and get patients the care that they need or get yourself trained and you could start treating directly. I think that is the baseline message for my talk.

Thomas L. Schwartz, MD, received his medical degree from and completed his residency in adult psychiatry at the State University of New York (SUNY) Upstate Medical University in Syracuse, New York. Now a Distinguished Teaching Professor, Department of Psychiatry and Behavioral Sciences, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY, Dr Schwartz active on many teaching, administrative and curriculum committees at SUNY.

Dr Schwartz’s abilities as a medical educator have been recognized with the Marc H. Hollander, MD, Psychiatry Award, Teacher of the Year, and Mentor of the Year awards from SUNY Upstate Medical University, Nancy Roeske, MD, Irma Bland, Certificates of Recognition for Excellence in Medical Student and Resident Education from the American Psychiatric Association, the SUNY Upstate President’s and the SUNY Chancellor’s Award for Teaching.

Dr Schwartz is the author of Practical Psychopharmacology: Basic to Advanced Principles, "Stahl’s Essential Psychopharmacology” Case Studies Volume 2, Integrating Psychotherapy and Pharmacotherapy, Antipsychotic Drugs: Pharmacology, Side Effects and Abuse Prevention, Second and Third Generation Antipsychotics.  He is the editor of Depression: Treatment Strategies and Management, 1st and 2nd Eds. and is the Deputy Editor for the journal CNS Spectrums.