Sleep Issues: An Opportunity for Integrated Care

Who should take the lead when issues of sleep problems come up? Is the sleep problem a physical or a behavioral health issue? If a client only has diabetes, there is no question that the lead in the integrated team needs to be the primary care provider (PCP) or endocrinologist. If a person only has bipolar disorder, no one questions that the psychiatric provider should be leading treatment. But when sleep issues occur, it is not always clear if it is a physical or a behavioral health disorder. It may fall in between and, as a result, risks getting lost.

Up to 80% of patients in psychiatric settings report chronic sleep problems. Up to 90% of people with depression report sleep problems. Three-quarters of people with bipolar disorder experience insomnia or reduced need for sleep, and in direct contrast, 50% of those with bipolar depression experience excessive sleeping. Compare this to 10-18% of people in the general population experiencing sleep problems. Many people assume that the behavioral health problem is the cause. But this is not always the case. People with sleep problems are up to four times more likely to develop depression and sleep problems pre-date anxiety disorders 25% of the time. (“Sleep and Mental Health” Harvard Mental Health Letter (July 2009): Vol. 26, No. 1, pp. 1-3).

The interaction between sleep and behavioral health is a complex one. We know that even when mental illness is not present, sleep deprivation can cause hallucinations, irritability and difficulty concentrating. When mental illness is present the effects of sleep deprivation can multiply. Many antipsychotic medications leave people feeling sedated, and some anti-depressants have the opposite effect, and keep people awake.

Sleep issues are also prevalent among people with substance use disorders. In fact, sleep problems are 5-10 times higher in people with substance use disorders than in the general population (Vimont, Celia. “Sleep Problems and Substance Use Disorders: An Often Overlooked Link” Partnership for Drug Free Kids 26 July 2013. Web 3 July 2014). For many, “nodding off” can be a symptom of substance use, and many people use alcohol and/or other drugs as a sleep aid. But while alcohol helps people fall asleep, it interrupts the sleep cycle and many people wake up just a few hours later. For the newly abstinent, sleep can be disrupted for weeks; long after other initial withdrawal symptoms have subsided.

Sleep problems can take several forms, and neither too much sleep, nor too little, is healthy. The brain requires an appropriate amount of sleep to rest, refresh, and reorganize. Not enough sleep can result in memory problems, a weakened immune system, dysfunction in social settings, and of course, low energy.

When there is a problem, the first step is an evaluation. Whether the complaints are first heard by the behavioral health specialist or the medical provider, it is likely that primary care physicians and psychiatric providers will be involved. Depending on the initial findings, in addition to consulting with the behavioral health team, other specialists such as sleep medicine experts, neurologists, pulmonologists, and pain management specialists may be involved to help rule out medical problems. If a medical disorder is identified, such as sleep apnea, restless leg syndrome, or a circadian rhythm disorder, it should be treated by the medical team, keeping the behavioral health providers apprised and involved. Similarly, if the cause is psychiatric, substance use, or other behaviorally derived issues, these should be addressed by the behavioral health team, keeping the medical providers in the loop.

One of the first responses to sleep issues, whether the problem is medical or behavioral, is sleep hygiene education, a preventive tool and treatment strategy. Sleep hygiene (or habits) refers to a set of practices that contribute to a restful night’s sleep. At their most basic, these “healthy” sleep habits are common knowledge: establish and follow a regular bedtime routine, minimize use of drugs and alcohol, maintain a healthy diet and exercise regularly. Other practices are less intuitive such as ensuring adequate exposure to natural light to help balance the sleep-wake cycle, isolating the sleep environment to ensure it’s primarily associated with sleep, and establishing a pleasant and relaxing sleep environment.

A more involved behavioral response to sleep is Cognitive Behavioral Therapy for Insomnia, or CBT-I. CBT-I focuses on helping people avoid anxiety about not falling asleep by building confidence that a good night’s sleep is possible. CBT-I participants maintain sleep diaries, and may be placed on sleep restriction (where they are not allowed to go to bed earlier initially to recover from exhaustion). The practice involves sleep hygiene education and incorporating cognitive changes such as identifying and challenging irrational thoughts that cause or worsen sleep problems. It also stresses providing education to reframe or replace problematic thoughts and/or feelings related to sleep. Many people report that initially, CBT-I participants get even less sleep than before starting, but after several weeks, they are able to resume normal sleep habits. (“Cognitive-Behavioral Treatment of Insomnia” Penn Sleep Centers Newsletter (Winter 2006): Web 5 March 2014.)

For some people, resolving sleep issues requires medication. There are a number of medications that prescribers may use to promote sleep. These include zolpidem, eszopiclone, ramelteon, zaleplon, doxepine, quetiapine, trazadone, mirtazapine, and benzodiazepines such as clonazepam or temazepam. Additionally, some people use over the counter medications such as diphenhydramine or other non-prescription strength anti-histamines for sleep. Many can have potentially dangerous side effects when used with other medications. Moreover, some of these medications can be habit forming, and therefore need to be carefully monitored when prescribed. This underscores the importance of information sharing between the medical and behavioral health teams: while doctors routinely ask about other medications, many patients do not consistently report all medications they are using. Providers who share this information (with consent) can help avert future problems.

On top of other behavioral health issues, there are other risk factors that can result in elevated risk for sleep issues. Teens, the elderly, and menopausal women are three age cohorts that often don’t get enough sleep. Menopausal women in particular may not be aware that insomnia is associated with changing hormones and may blame sleep problems on an escalation of pre-existing conditions.

However, being “sleep aware” with vulnerable groups is no different from being sleep aware with other populations. Everyone on the team should be alert for sleep concerns. Specific questions about sleep should be a part of assessments, and medical and psychiatric evaluations, work-ups, and histories. Groups focused on health and well-being should include discussions about sleep. Sleep hygiene education can be offered. Brochures and posters providing information about sleep can be displayed. And programs should routinely ask clients to sign HIPAA or other confidentiality waivers allowing the behavioral health team to communicate with medical providers to facilitate information sharing and collaboration. Finally, information on local sleep resources, including sleep labs and other sleep specialists should be kept on hand.

FEGS has taken significant steps to become more “sleep aware.” In looking into the sleep habits of clients, it was learned that many clients had sleep disturbances but were unaware of all the tools available to help them. So FEGS launched a comprehensive campaign in some of its programs, providing education, treatment and referrals for sleep problems. As a result of this campaign, prescribers began to initiate conversations about sleep issues more with their clients. The offering of comprehensive treatment brought together the entire team to work with the client for the best outcomes possible.

To best address sleep problems, physical and mental health providers need to share information and coordinate interventions. Yet despite the need for integrated, coordinated care, providers continue to operate in silos. After all, confidentiality waivers fail to get signed, it is difficult to find time to talk, and providers don’t consistently speak the same language. But when done right, like diabetes and hypertension, sleep problems benefit most from collaboration between physical and behavioral health. The interventions may be simple, but the payoffs are great.

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