Sleep And Mental Health Continued

Sleep disorders can also be due to another mental disorder:

Insomnia can be present in:

• Panic disorder: paroxysmal awakening with entering stage 3 & 4 sleep

• Major depressive disorder: difficulty falling asleep or early morning awakening

• Bipolar II, manic episodes: short sleepers, difficulty falling asleep but don’t complain of sleep problems. They awaken refreshed after 2-4 hours of sleep, true decreased need for sleep.

• Schizophrenia: decreased total sleep time, slow-wave sleep, REM sleep is reduced early during an exacerbation

• PTSD: nightmares

• OCD: Rituals

• ADHD: difficulty falling asleep (worsened by stimulants if taken at night)

• Substance abuse/ dependence: Opioids (Heroin), Benzodiazepines (Valium/ Diazepam), Stimulants (Khat/Miraa).

Hypersomnia can be present in

• Mood disorder: depressive phase of Bipolar I

• Mild depression: excess daytime sleepiness in initial stages

• Uncomplicated grief

Management of sleeping disorders depends on the type and cause:

Treating the underlying cause of the sleep disturbance may be most effective.

Management of sleeping too much:

• Use of stimulants (amphetamines) in the morning or evening

• Use of non-sedating antidepressants (SSRIs)

Management of sleeping too little: These are psychological and medical;

Psychological treatments such as Cognitive Behavioral Therapy (CBT) can help by changing unhelpful ways of thinking that can make one anxious and stop them from sleeping.

When the conditioned component is prominent, stimulus control by using de-conditioning technique may help, such as;

· strengthening the link of being in bed with sleeping, by getting to bed only when one feels tired, and only using the bed for sleeping and sex.

· weakening the link of being in bed with doing things that are likely to keep you awake, like watching exciting TV programmes, doing work or organising things.

· weakening the link of being in bed with anxious worrying; if not asleep after 5 minutes in bed, get up and do something else instead of lying in bed worrying.

When somatized tension/muscle tension is prominent, practice;

• biofeedback

• relaxation response; progressive muscle relaxation helps one to relax their muscles deeply. One by one, you tense and then release your body muscles working up from your legs, arms, shoulders, face and neck.

Satisfying sexual experience promotes sleep, in men more than women.

Sleep hygiene can be practised:

· Do not go without sleep for a long time. Go to bed when you are tired and maintain a routine of waking up at the same time daily, whether you still feel tired or not.

· If you have had a bad night, do not sleep in the next day as it will make it harder to fall asleep the following night.

· Avoid daytime naps except when the sleep chart indicates.

· Maintain physical fitness; do graded program of vigorous exercise early in the day. Late afternoon or early evening can also work if the exercise is mild. Regular swimming or walking can be helpful.

· Eat at regular times daily; try to have your supper earlier in the evening and avoid large meals near bedtime.

· Very hot, 20 minute body temperature raising bath soaks near bedtime can be helpful.

· Evening relaxation routines before going to bed may help; progressive muscle relaxation or aromatherapy.

• Maintain comfortable sleep positions and ensure your bedroom, bed and mattress are comfortable. Generally, you need to replace your mattress every 10 years to get the best support and comfort.

• If you have troubling thoughts and you cannot do anything about it right away, write it down before bedtime and tell yourself to deal with it the next day.

· Avoid evening stimulation; substitute TV with radio or relaxed reading

· If you cannot sleep, get up and do something relaxing like reading a book or listening to quiet music. After a while you should feel tired enough to return to bed.

· Discontinue central nervous system acting drugs (caffeine, nicotine, alcohol, stimulants); stop drinking tea or coffee by mid-afternoon because caffeine hangs around in your body many hours after your last drink. If you need a hot drink in the evening, try something milky or herbal that does not contain caffeine.

Do not drink a lot of alcohol. It may help you fall asleep, but you will almost certainly wake up during the night.

• Do not use street drugs like ecstasy, cocaine and amphetamines. They are stimulants, and like caffeine, the will keep you awake.

• Avoid slimming tablets as they will tend to keep you awake.

Medical treatment can also be given;

Benzodiazepines can be used for short term management of insomnia and must be prescribed by the Doctor. They should be used with care, for not more than 2 weeks, to prevent tolerance and addiction/ dependence. If one has been on sleeping pills for a long time, it is best to gradually reduce the dose under the guidance of the doctor.

In some case, antidepressant tablets can be helpful.

Dietary supplements such as melatonin (endogenous hormone produced by pineal gland, link to sleep regulation) and L-tryptophan can be useful.

References

Managing excessive daytime sleepiness in adults. Drug and Therapeutics Bulletin 2004;42:52-56; doi:10.1136/dtb.2004.42752

Sleep Disorders (1988) Williams R.L., Karacan I. & Moore C.A. John Wiley & Sons ISBN 0471837210.

Behavioural and pharmacological therapies for late-life insomniacs (1999) Norin C.M. et al JAMA, 281: 991-999.

Management of insomnia (1997) Kupfer D.J. & Reynolds C.F. New England Journal of Medicine, 336: 341-346.

Impact of sleep debt on metabolic and endocrine function (1999) Spiegel, K., Leproult, R & Van Cauter, E. The Lancet, 354, 1435-1439.

Non-pharmacological interventions for insomnia: a meta-analysis of treatment efficacy (1994) American Journal of Psychiatry, 151, 1172-1180.