In this issue of Psychiatric Annals, we examine the relationships between psychiatric illness and sleep disorders. Long before sleep-disordered breathing became a predominant focus of sleep medicine, many psychiatrists and psychologists were establishing the basis for the field as a clinical discipline. People including Drs. Mary Carskadon, Rosalind Cartwright, William Dement, Peter Hauri, Max Hirshkowitz, Allan Hobson, Anthony Kales, Ismet Karacan, Milton Kramer, David Kupfer, Robert McCarley, Wallace Mendelson, Charles Reynolds III, Howard Roffwarg, Robert Williams, and many others were pioneers of this development. As the field has matured, we can now explore the importance of recognizing and treating sleep disturbances to optimize treatment and prevention of psychiatric disorders.
Drs. Daniel D. Herrick and Michael J. Sateia review the relationships between sleep and mood disorders. They are academic descendants of the late Peter Hauri, PhD, who began the sleep research program at the Geisel School of Medicine at Dartmouth (Hanover, NH) in 1972. His first laboratory was in the inpatient psychiatry unit, where he began his major contributions to our understanding of insomnia and was a progenitor of what has become modern behavioral sleep medicine. We now recognize insomnia as both a symptom of mood disorder as well as a comorbid disorder, which affects the course of depression as well as predicting its occurrence and severity. Treatment of insomnia is an important component of therapy for depression.
Drs. Erin Koffel, Imran S. Khawaja, and Anne Germain examine the relationships between sleep and posttraumatic stress disorder (PTSD), also citing the influence of sleep on the presentation and treatment of that illness. Our contemporary understanding of this ancient disorder was influenced by Matthew Friedman's description of the “Post Vietnam Syndrome” during the aftermath of that war.1 Working at the White River Junction VA Medical Center and also a member of the Dartmouth faculty, he described features of the soon-to-be-designated PTSD with sleep disturbed by nightmares as a prominent feature. We now recognize that nightmares, as well as insomnia, can be treated directly with specific psychotherapeutic and pharmacologic modalities to improve therapy for PTSD.
Drs. Wilfred R. Pigeon, Todd M. Bishop, and Caitlin E. Titus address the interaction of sleep disorder and suicide, providing an extensive examination of the literature to document the importance of this relationship. They provide a strong suggestion that sleep disturbance is an independent risk factor for suicidal ideation, attempts, and completions. This is particularly important to our veteran population and the authors emphasize the need for further meta-analytic study to clarify these risks. We lack documentation of the protective benefits to be anticipated with treatment of sleep disorders, although it is compelling to hope for this in view of the points made by our other contributing authors.
Dr. Khawaja and colleagues address obstructive sleep apnea (OSA), the highly prevalent disorder of sleep, which has well-documented effects on cardiovascular, metabolic, and cognitive functioning, including maintenance of psychomotor vigilance. This disorder adds the pathophysiologic influence of intermittent hypoxemia to the fragmentation and overall diminution of sleep that occur in the various other sleep disorders. Animal models indicate the deleterious effect of this on brain structures including the hippocampus. OSA also stimulates liberation of inflammatory mediators, which may also contribute to psychopathology. Thus, even a distinctly respiratory disturbance of sleep can have an association with psychiatric disorder. This is also bidirectional, because the obesity often associated with psychiatric illness and its therapies can produce or confound OSA.
Dr. Richard C. Holbert and colleagues review the relationship of schizophrenia and sleep problems. Sleep disorders are often missed in these patients. Insomnia, a common complaint in these patients, is considered to be a risk factor for impending relapse of psychosis. Moreover, antipsychotic mediations may worsen restless legs syndrome. They are also known to cause weight gain, increasing the propensity for these patients to develop OSA. The authors emphasize the importance of screening for sleep disorders in this patient population.
We are thankful to the contributing authors for this issue; all are prominent educators, researchers, and clinicians. We are hopeful that you will find these articles informative and relevant to your clinical practice.
- Friedman MJ. Post-Vietnam syndrome: recognition and management. Psychsomatics.1981;22(112):931–943. doi:10.1016/S0033-3182(81)73455-8 [CrossRef]