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Sleep medicine expert addresses clinical challenges, treatment options

David Neubauer

ORLANDO, Fla. — In a session here, David Neubauer, MD, associate professor of psychiatry and behavioral sciences at Johns Hopkins University, answered key questions submitted by clinicians prior to the presentation to help health care professionals address clinical challenges in sleep disorders.

“If you’re not getting enough sleep then you’re cheating yourself,” Neubauer said.

Diagnosing, screening

Screening depends upon what you want to know, what you want to screen for and the patient population, according to Neubauer.

“In general settings, ‘Do you sleep well at nighttime?’ and ‘Do you feel alert during the daytime?’ — there’s your screening,” he said. “It takes 5 seconds and you can move on to other issues unless you find there’s something positive; then you’re going to want to explore it further.”

He also recommended the following sleep-related questionnaires:

• Patient Health Questionnaire-9;
• Pittsburgh Sleep Quality Index;
• Insomnia Severity Index;
• Epworth Sleepiness Scale; and
• STOP-BANG.

Clinicians should also take comprehensive sleep histories from patients, assess possible comorbid conditions that may affect sleep and go over current medications, Neubauer said.

He also noted it is important to diagnose and treat both depression and insomnia in patients who have both disorders.

“There’s a whole lot of interaction between sleep and mood in good ways and potentially bad ways,” Neubauer said. “Looking at how mood affects sleep, we know that when people are experiencing depressive episodes, there’s a good chance they’re going to have bad sleep.”

Pharmacologic treatments

It is critical to educate about sleep hygiene in combination with medication intervention, according to Neubauer. He recommended promoting healthy sleep habits — like regulating sleep-wake timing and discussing an environment conducive for sleep — and employing cognitive-behavioral strategies along with pharmacologic treatments when necessary.

“If people aren’t following sleep-healthy habits, no matter how hard you try with medication or a behavioral approach, it’s not going to work very well,” he said. “You have to start with the foundation — making sure people are following good, healthy sleep habits.”

Although Neubauer expressed some concern over using benzodiazepines for treatment of chronic insomnia, he felt comfortable prescribing them for selected patients who are carefully monitored and functioning well. If a patient taking benzodiazepines experiences rebound insomnia when they try to stop using them, he said tapering the dose in small increments and considering alternative pharmacodynamic approaches can help minimize hypnotic discontinuation problems.

When treating patients with zolpidem who experience hypnotic tolerance, Neubauer told attendees they can increase the dose, explore circadian problems and/or consider an alternative pharmacodynamic approach.

He also discussed a new medication, Belsomra (suvorexant, Merck), which is a dual orexin receptor antagonist. Clinical trials have shown that it was beneficial, but it was typically used at higher doses. The FDA approved up to 20 mg at bedtime, but the studies were done at 30 mg or 40 mg, and there was much greater efficacy at those doses, Neubauer explained.

“From a theoretical point of view, it makes a whole lot of sense why suvorexant would be beneficial for sleep. It’s been discovered that orexin has a really important role in stabilizing and promoting wakefulness,” he said. “Yes, it is potentially beneficial, but some people find that it doesn’t do much for them at all.”

When patients with mood disorders experience problems waking up in the morning despite good sleep quality, Neubauer asked attendees to consider sleep quality and quantity, circadian rhythm phase delay, mood/motivation, medication effects and whether they may have an unrecognized sleep disorder.

Non-pharmacologic treatments

Neubauer emphasized the importance of encouraging sleep hygiene practices for patients with any sleep disorder as well as for healthy individuals. However, it depends on the person and the individual situation, he said. Some sleep hygiene recommendations included:

• promoting healthy sleep habits;
• avoiding caffeine, alcohol and nicotine products in the evening;
• maintaining a regular bedtime and out-of-bed time;
• designating enough time for sleep (ie, 8 hours);
• avoiding bright light exposure around bedtime;
• getting plenty of light exposure and being active during the day;
• keeping the bedroom cool and dark;
• avoiding naps for long periods; and
• not spending too much wakeful time in bed or watching the clock throughout the night.

He also supplied resources on sleep hygiene habits for patients: www.sleepeducation.org and www.sleepfoundation.org.

Evidence-based research also supports cognitive behavioral therapy for insomnia (CBT-I), though he noted that CBT-I is “not always one-size-fits-all.”

Neubauer described a brief behavioral treatment that targets the behavioral end more than the cognitive end, as an alternative treatment for insomnia. Some features of brief behavioral treatment include sleep education, reducing time in bed, getting up at the same time every day and not going to bed unless sleepy.

“Practical take-aways from my [session]: focus on the fundamentals like healthy sleep habits. Prioritize sleep and don’t compromise it by doing other things. Regularize sleep timing; really enforce the circadian sleep regulation,” Neubauer said. “Consider the effects of medication for all patients you’re evaluating for sleep problems. Optimize the management of comorbid conditions. Rethink insomnia causation when treatment is suboptimal. Employ cognitive-behavioral therapies whenever possible. Personalize medication selection and discuss potential adverse effects and monitor throughout therapy.” – by Savannah Demko

Disclosures: Neubauer reports no relevant financial disclosures.