Sleep and Suicidal Risks - The sleep professional's role in early intervention

The following article was featured in the July/August 2011 edition of Sleep Review: The Journal for Sleep Specialists and we thought we would pass the information along to you. The article was written by Barry Krakow MD.

   More than 30,000 individuals die by suicide each year in the United States. For every death by suicide, there are 10 - 25 nonlethal attempts. Lifetime prevalence indicates 5% of the population reports a suicide attempt, 4% a plan, and 14% ideation. Although suicide is the 11th leading cause of death in the United States, recent research reveals a number of risk factors that may be targeted to prevent fatalities.
   In our field of sleep medicine, research points to sleep disturbances as significant risk factors for suicidal ideation and behaviors. Deverity of global insomnia has been identified as a significant - and, importantly, modifiable - short-term risk factor for suicide. Hypersomnia and poor sleep quality have both been predictive of eventual death by suicide. Suicidal individuals report significantly higher rates of nightmares, especially when the patient is suffering from depression. Other sleep disturbances have been implicated as potential suicide risk factors, including lower sleep efficiency, longer sleep latency and sleep-disordered breathing.
   The knowledge that sleep problems may provoke or worsen suicidal thoughts creates a clinically important opportunity for sleep physicians, because patients with both sleep problems and suicidal ideation may seek treatment at sleep centers, particularly if their experiences with psychiatrists or other therapists have not fully resolved their mental health concerns. In such circumstances, mental health patients may suffer from lingering insomnia or nonrestorative sleep due to ineffective psychotherapy or psychotropic medications. If insomnia persists, they may turn their attention toward solving their sleep problems by seeking help from a sleep specialist. And sleep centers and providers would then have the change to detect and provide early intervention for these patients before their suicidal ideation progresses to suicidal behaviors or completed suicides.
   Until recently, research had not been conducted on the prevalence of suicidal ideation in patients seeking treatment at sleep medical centers. In 2010, we collaborated with experts in the field of suicide research at Florida State University (Drs Thomas Joiner and Jessica Ribeiro) to evaluate a large database of sleep patients who sought treatment at Maimondies Sleep Arts & Sciences, a community-based sleep center that specializes in the treatment of mental health patients with sleep disorders. Our results were published in the Journal of Affective Disorders in January 2011.
   From our database of 1,584 patients, we discovered that 13% (n = 211) of the entire sample reported suicidal ideation; and more than a third of these patients or 4.5% of the total sample reported a degree of suicidal ideation consistent with apparent clinical risk.
   Statistically, a very large number of common sleep factors were associated significantly with suicidal ideation including:

• Poor sleep quality
• Lighter sleep
• Insomnia severity
• Awakenings at night
• Sleep onset latency
• Prolonged time in bed
• Wake time after sleep onset
• Lower sleep efficiency
• Daytime fatigue and sleepiness

   Additonal interesting associations were parasomnias such as nightmares, acting out dreams and disruptive sleep behaviors. Also, psychophysiological conditioning such as excessive time monitoring behavior or "losing sleep over losing sleep" was associated with the severity of suicidal ideation. Even something as simple as a poor sleep environment was associated with suicidal ideation.
   To further analyze all these factors, we then controlled for depressive symptoms in our sample, because suicidal ideation is so strongly linked to depression. With this analysis, a number of sleep factors still correlated significantly with suicidal ideation or showed a trend toward significance, including greater chronicity of sleep problems, poor sleep quality, daytime fatigue, lighter sleep, prolonged time in bed and nightmares. So, even though the effects of depressive symptoms were removed from the analysis, these sleep symptoms remained in association with suicidal ideation.
   Now, this type of research cannot prove these sleep factors cause suicidal ideation or lead to completed suicides. However, the pervasiveness of these associations strongly suggests that intervention research is needed to learn whether treatment of these sleep problems would result in a decrease in suicidal ideation. Research programs are currently in the proposal stages to the Military Suicide Research Consortium to investigate whether sleep treatments such as cognitive-behavioral therapy for insomnia (CBT-I) or imagery rehearsal therapy (IRT) for nightmares can be effectively administered to military personnel who suffer from suicidal ideation.
   At Maimonides Sleep Arts & Sciences, we use Dr. Joiner's DSI-SS scale (Depression Severity Index - Suicide Subscale) of four brief questions on suicidal thoughts and behaviors. If patients are identified with elevated scores, we contact them to find out whether they are currently undergoing counseling. If not, we help them make arrangements to begin work with a therapist. In rare instances in the clinic, we have also helped suicidal patients initiate preliminary actions (eg, removal of a gun from the home; third-party monitoring of medications) in conjunction with their therapists. Most importantly, we aggressively treat their sleep problems in the belief that enhanced sleep quality will improve mental health symptoms.
  In summary, suicidal ideation appears to be fairly common in treatment-seeking sleep patients. Prevalence rates will likely vary depending on the type of sleep medical center and the population it serves. It seems plausible that evidence-based treatments of sleep disorders would lower suicidal risks, mostly in the area of decreased suicidal ideation. In fact, a recent case study showed that auto-CPAP treatment in an elderly sleep apnea patient dramatically eliminated suicidal ideation. Thus, the sleep center may prove to be an important research venue or early intervention site for this deadly and common mental health problem.

Sleep Apnea Linked to Dementia in Older Women

An article featured in the Denver Post this summer addressed the link between sleep apnea and dementia. Here's what the article had to say:

   Older women with sleep apnea have twice the risk of developing dementia as those without the breathing disorder, according to a study published Tuesday, but the data weren't conclusive as to why.

   The findings indicate that people with sleep apnea should be screened for cognitive problems, said Kristine Yaffe, an author of the study in JAMA: the Journal of the American Medical Association.

   Potential cognitive decline "is another reason why you want to be medically followed carefully and possibly treated" for sleep apnea, said Dr. Yaffe, who is a professor of psychiatry, neurology and epidemiology at the University of California, San Francisco.

   Sleep apnea, in which sufferers stop breathing as many as hundreds of times a night, commonly results from a blockage of the airway during sleep. The disorder is estimated to affect 10% to 20% of middle-aged and older adults, according to a recent report by the federal Agency for Healthcare Research and Quality.

   The study published Tuesday followed 298 older women who all started off testing cognitively normal. They had a mean age of 82 and were followed for an average of five years. Over that time, the women who had sleep apnea were twice as likely to develop memory decline or other symptoms of dementia.

   When a person stops breathing during sleep, blood-oxygenation levels fall. When it reaches a certain low, the body wakes itself and begins breathing again. To get a diagnosis of sleep apnea, such episodes must occur five or more times per hour. Typically a person with sleep apnea isn't aware this is happening but feels tired upon waking despite getting many hours of sleep.

   The increased risk of dementia appeared linked to the amount of time the women experienced decreased oxygen, not the total amount of sleep or the number of interruptions to their sleep. It isn't definitive from the data, however, whether oxygen deprivation caused the dementia symptoms or some other pathology was responsible for both the sleep problems and the cognitive decline. The results would likely apply to men as well but need to be replicated in that population, Dr. Yaffe said.

   The study examined women with moderate sleep apnea - 15 or more breathing stoppages per hour - so the cognitive impact among those with milder sleep apnea wasn't clear, said Amy Aronsky, medical director for the Center for Sleep Disorders in Longview, Wash., who wasn't involved with the study. However, the finding "gives further proof to the idea that untreated sleep apnea has a lot of unintended consequences", Dr. Aronsky said.

This article was written by Shirley S. Wang

Now Participating with CIGNA!

We are happy to announce that we have now been accepted as a participating provider with CIGNA Healthcare to provide oral appliances for sleep apnea. Contact our office today to find out what coverage might be available with your CIGNA plan and start sleeping better tonight!

Now Accepting Medicare!

We are pleased to announce that we are now participating with Medicare as a durable medical equipment supplier for oral appliances!

Late last year Medicare determined that they will cover sleep apnea appliances when medically necessary. In order to establish medical necessity, the patient must have an overnight sleep study performed that documents an apnea-hypopnea index (AHI) of 15 or greater. If less than 15 but more than 5, must have documentation of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia or hypertension, ischemic heart disease or history of stroke. If the AHI is greater than 30, must have documentation of CPAP trial and reason of non-compliance.

Medicare also requires a prescription to be written by the primary care physician sent to our office describing the need for an oral appliance.

Our staff can assist you in gathering all documentation required by Medicare prior to your appointment. Why not give us a call today and start sleeping better!

Welcome to Our Blog

Thank you for checking out our blog! Our goal is to keep you up to date with the world of sleep apnea and to provide informative and helpful information. The following came to us from the American Academy of Dental Sleep Medicine:

A study done by the University of Texas Health Science Center at San Antonio published 1/14/2009 shows that dental appliances are successful in treatment of patient with severe sleep apnea.  The study used the Thornton Adjustable Positioner (TAP) and according to assistant professor Paul McLornan B.D.S in the Department of Prosthodontics, "We saw patients who began the study with severe sleep apnea end the study with very mild or no sleep apnea. They reported sleeping better, feeling more rested in the morning and altogether healthier."

Dr. McLornan said this research is vital to both the medical and dental communities.

"What we found was that many of our patients with moderate to severe sleep apnea were not adhering to standard treatment with Continuous Positive Airway Pressure (CPAP). Although the CPAP is considered to be the gold standard in treating sleep apnea and is very effective, compliance by patients is well below 50 percent. Sleep apnea is a growing and serious problem for people of all ages and all ethnic groups. If left untreated, it becomes progressively worse. People suffering from sleep apnea are at increased risk for high blood pressure, heart attacks, strokes, obesity and diabetes. It takes both dentists and medical professionals working together to control this potentially deadly disorder. The TAP gives patients another viable treatment alternative."

The American Academy of Sleep Medicine, the professional society that sets the standards for and promotes excellence in sleep medicine, now recommends that oral appliances can be the first line of treatment for people with mild to moderate sleep apnea. Dr. McLornan's study demonstrates it can be used for patients with severe problems as well.