Upcoming Webinar

When to Prescribe Advanced PAP Therapies for Patients Struggling with CPAP

  • Date: Tuesday, May 29, 2018
  • Time: 12:15 PM Pacific Daylight Time
  • Duration: 1 hour, 30 minutes

When obstructive sleep apnea patients fail or can't adhere to the continuous form of positive airway pressure therapy (commonly known as CPAP), there are other options that clinicians should explore to get patients to adherence. In some cases, these other options include advanced positive airway pressure modes such as bilevel devices and adaptive servo-ventilation (ASV), which take into account such parameters as expiratory pressure intolerance. Learn what the literature says about these "rescue" devices as well as real-world approaches to switching patients to advanced therapies when indicated.

For more information and to register for the event, CLICK HERE


Mental Health and Sleep

Do Sleeping Pills Work?

Posted in Mental Health and Sleep

Warrning: Eliminating sleep medications is often a prudent step to enhance sleep quality. But, timing is everything, and SDT does not suggest, recommend or require that you change your medication in any way without first consulting your prescribing physician.

Sleeping Pills How can sedatives be so highly touted when so many people who use them still wake up in the middle of the night or report minimal improvement in sleep quality, even after having "slept all through the night?"

The answer is that something else degrades your sleep, which the drug does not address. Either the drug cannot prevent you from waking in the middle of the night, because it doesn't prevent the cause of such awakenings, or the drug does not improve sleep quality, because it does not remove the sleep quality problem you suffer from. All of which raises the interesting question of whether or not sleeping pills or antidepressants just give you more sleep that's not worth getting, which leads us back to an old mantra "all sleep is not the same."

Nearly all the older brands of sedatives clearly worsen sleep quality since they clearly speed up brain waves. Some of the newer agents appear to enhance sleep quality some of the time, but these gains are often less than what you can achieve by uncovering and resolving the mental and physical elements causing your sleep quality problems.

If sedatives do not consistently improve sleep quality or do not improve it to a high level, how do they make you "sleep" more?

The short answer is that sleeping pills may increase clock hours while decreasing or having no change in solid hours of sleep. Most sedatives also affect your memory, so you are less likely to remember waking up as much during the night, and therefore, it seems you have slept more. Most importantly, it is common knowledge that most sleeping pills and other psychiatric drugs speed up brain waves at times, and many prevent you from entering into deeper, more restorative sleep stages.

All of which raises the following question: "If certain sleeping pills give you more sleep but of a lighter quality, then are you really getting that much more sleep, or is it possible you might actually be getting less sleep?"

If someone offered you one ounce of gold or 25 ounces of silver, which would you take?

I trust you took the gold, one ounce of which wuold be worth nearly three times the value of 25 ounces of silver. Golden slumbers means deeper sleep; its benefits are more noticeable and valuable than obtaining more sleep of lighter (lesser) quality.

Are you struggling to get a good night's sleep? There are safe and effective methods to help. However, some turn to alternative methods such as pills or alcohol. Don't wait to seek help from a drug or alcohol rehab if you are experiencing this type of addiction.

Depression and Insomnia

Posted in Mental Health and Sleep

Depression and Insomnia Emerging scientific research clearly shows that the relationships between depression and insomnia are far more complex than originally understood. The current model as expressed in the psychiatric terminology of the DSM-IV-TR (the diagnostic manual used by psychiatrists and psychologists to define mental health disorders) emphasizes insomnia as a common symptom of depression. Some patients with depression show the symptom of hypersomnia (sleeping too much), but most depressed patients who report sleep problems emphasize insomnia over hypersomnia.

The newer model emerging from a sleep medicine perspective indicates a much more bi-directional relationship between insomnia and depression. In many instances, the insomnia may occur first, which then seems to lead to the depression. Above all, what's most important from the research of others and the research and clinical experience of our centers is that insomnia takes on a life of its own among depressed patients.

When we say "a life of its own," we mean that insomnia is no longer just a symptom of depression. It is a co-occurring sleep disorder that is aggravating the depression condition. This critical distinction, therefore, means that it is imperative to treat the insomnia instead of waiting around to see what happens to the insomnia when the depression is treated.

Some evidence already points to the potential to improve depression simply by treating the insomnia. Other evidence suggests that treating insomnia early might prevent depression from developing or might lessen the depression that still develops.

Last, our experience tells us that even this degree of complexity is insufficient to explain the full relationship between insomnia and depression. We believe that an enormously large number of patients with both depression and insomnia also suffer from sleep-disordered breathing (SDB). We also believe that SDB goes largely unnoticed, undetected, and undiagnosed in these patients and therefore it obviously goes untreated.

The bottom line is that if SDB persists in a patient with insomnia and depression, then we would expect this patient to have difficulty fully resolving either the insomnia or depression, and usually both. Clinically, we think that any depressed patient with insomnia who is not responding well to antidepressants would be well served by completing an overnight sleep test to check for SDB.

Anxiety and Insomnia

Posted in Mental Health and Sleep

We have proposed two theories that may explain why anxious insomnia patients might develop sleep breathing problems.

First, an enormous number of patients with mental disorders suffer from unwanted bouts of sleeplessness that plague them for years. As it turns out, insomnia itself seems to increase your risk for sleep breathing difficulties, because insomnia causes you to spend too much time in lighter stages of sleep. In these lighter stages, your breathing is more susceptible to disruption from abnormal breathing events. Thus, while the mental health patient might start out with insomnia and no sleep-disordered breathing (SDB), it's possible SDB can develop over a period of persistently fragmented sleep.

Anxiety We also speculate that emotional distress, particularly anxiety, directly impacts the human airway, causing some type of tension or restriction. In other words, we wonder whether a person can develop SDB just by being nervous for so long that it adversely influences breathing.

Eventually, changes caused by insomnia and emotional distress may foster the clinical emergence of sleep-disordered breathing, particularly in a less apparent form known as upper airway resistance syndrome (UARS). We have worked with many trauma survivors who reported no sleep problems prior to a traumatic event. Then post-trauma, they developed anxiety, nightmares and insomnia, which were never fully treated. As their sleep got progressively worse, they were eventually tested and found to have SDB. It would be very interesting to find out how early in the course of their sleep problems they actually developed the first signs of SDB. For these reasons, we are now much more aggressive in recommending sleep testing for insomnia as early as possible.

Trauma and Insomnia

Posted in Mental Health and Sleep

We have been among the leading research groups studying post-traumatic sleep disturbance, both in terms of evaluating the nature of these sleep problems and in treating them. This area actually represents the initial pathway of research for me and my research groups as we began treating nightmares in patients with or without a history of trauma.

The more we studied nightmare patients, the more we realized that insomnia almost always emerged as another and sometimes more serious sleep complaint. Whether they had difficulty falling asleep or staying asleep, early morning awakenings, or nonrestorative slumber, we were impressed with how nearly universal it was for treatment-seeking trauma patients to complain about their sleep. Regrettably, it was almost equally universal that these trauma survivors rarely found someone interested in exploring their sleep problems in depth.

Instead of discussing sleep problems or attempting to evaluate them as a sleep medicine physician might, most patients reported receiving prescription after prescription of various sleep aids or hypnotics, antidepressants, or mood stabilizers. Some received a smattering of sleep hygiene instructions, but few were provided advanced cognitive-behavioral instructions for insomnia, and almost no one was sent to a sleep center for sleep testing to check for breathing or movement disorders.

What we found over the course of the past decade is that post-traumatic sleep disturbance frequently comprises physical or physiological components as well as the psychological components. Many trauma survivors do appear to respond to cognitive-behavioral treatments, and many responded to our use of the imagery techniques for their nightmares, but once these treatments were completed, these patients often showed residual sleep symptoms, especially daytime fatigue or sleepiness. Some were still very aware of unrefreshing sleep upon awakening in the morning.

Trauma and Insomnia One thing led to another, and we discovered that most of these patients were also suffering from sleep-disordered breathing or from sleep movement problems such as restless legs syndrome or periodic limb movement disorder. Once we began to treat these conditions, the patients reported further improvements in their sleep. In 2003 we opened our community-based sleep medical center  -  Maimonides Sleep Arts & Sciences in Albuquerque, New Mexico - to specialize in helping patients with sleep and mental health problems. Since that time, we continue to see how mental health patients, especially those with anxiety, depression or PTSD, make important treatment gains when they also work to improve all aspects of their sleep disorders in addition to the treatments they use for their mental health disorders.

Sleep medicine truly has much to offer to mental health patients!

Nightmares and Insomnia

Posted in Mental Health and Sleep

Nightmares Nightmares and disturbing dreams are some of the most troubling forms of mental imagery, and these unwelcome visitors feel utterly uncontrollable. Nightmares are a common cause of poor sleep, because they provoke troubled dreamers to put off their bedtimes until later at night to avoid dreaming. Worse, if awakened at night by troubling images, they may find it difficult if not impossible to return to sleep.

In our work, we routinely hear from nightmare patients that their sleep is compromised, but what's most remarkable is that most nightmare patients do not connect the bad dreams with bad sleep. In our work with groups, we were surprised at how often nightmare patients were surprised at the connection between insomnia and disturbing dreams. Yet, once they saw the connection, it resonated deeply and made them more aware of the harmful impact of nightmares on sleep.

Our research team specializes in treating nightmares in all sufferers, including individuals exposed to sexual assault, other criminal assaults, disasters, 9/11 survivors, and war veterans as well as those without any mental health concerns. From our work, we have shown a high likelihood that the overwhelming majority of chronic nightmares become entrenched as unavoidable learned behaviors. This insight is critical, because it explains a very interesting outcome in research and in clinical work.

Most nightmare patients report that their sleep improves when they successfully treat the condition. In other words, there's a good chance your insomnia will be reduced or eliminated if you find a way to reduce or eliminate disturbing dreams. In fact, in all of our research on nightmares dating back almost 20 years, the potential to sleep better was one if not the strongest motivating influences on nightmare patients choosing to move forward with our non-drug treatments for disturbing dreams.

In an article our group published in the Journal of the American Medical Association in 2001, a randomized controlled study showed that an imagery exercise "imagery rehearsal therapy (IRT)" reduces disturbing dreams without any additional therapy or medication. You can learn much more about our work at our sister site Nightmare Treatment, where we also offer an audio series and treatment workbook, Turning Nightmares Into Dreams, to teach you how to conquer your bad dreams and nightmares.