While there are plenty of excessively complicated classifications of sleep disorders in this world, TCR, in the midst of a sleep-deprived delirium, has decided that psychiatrists should become most familiar with the following four common problems:

1. Obstructive Sleep Apnea


2. Restless Leg Syndrome.


3. Circadian sleep disorders (mainly jet lag and shift work problems).


4. Chronic, primary insomnia

Obstructive sleep apnea (OSA).
The typical patient with OSA is an overweight man in his 50s, although people of any age, gender, or body type may be afflicted. Ask patients if they snore (patients with OSA almost always snore, though not all snorers have OSA), and ask if they are sleepy during the day even when they think that they have slept through the night, a common paradoxical complaint in OSA. Refer patients who answer "yes" to both of these questions to a sleep specialist, since the only way to reliably diagnose OSA is by an overnight sleep study. Scare them into not procrastinating by pointing out that untreated sleep apnea can cause cardiac problems because of chronically low levels of oxygen during the night.

Restless Leg Syndrome (RLS).
RLS is more common than you think (it affects 2-5% of the population), and is eminently diagnosable and treatable by psychiatrists. Learn about it, and you will soon have some very grateful patients in your practice. Ask, "Do your legs often feel restless, and do you get a creepy-crawly sensation in them that makes you want to get up and walk around to relieve it?" RLS symptoms are usually worse in the evenings, and most patients with RLS also have PLMS (periodic limb movements of sleep), which is what causes the presenting complaint of insomnia and daytime sleepiness. Oddly enough, you should order a serum ferritin in these patients, since iron deficiency can cause RLS. No medications are currently approved for RLS treatment, but based on positive controlled trials, dopamine agonists are used most frequently. . Many start with Mirapex (pramipexole) 0.25 mg - 0.5 mg QHS, which often does the trick (Neurology 1999; 52:938- 43). Requip (ropinirole) is a newer option. Sinemet (carbidopa-levodopa) also works, but has more side effects. Klonopin (clonazepam) can be helpful if the above don't work.

Circadian Sleep Disorders.
Both shift work insomnia and jet lag will often respond to a combination of a hypnotic and Provigil (modafinil, recently FDA approved shift work disorder); each medication must be timed appropriately, and may only need to be used temporarily, until the rhythm has been normalized. There continues to be a buzz about melatonin offering something specifically valuable for the insomnia of jet lag, but results of clinical trials have been inconsistent.

Chronic Insomnia.
Sure, we've all read the perfunctory spiels on "sleep hygiene" and many of us are good doobies and go over the list with our patients, but if it helps one out of 10 patients we're happy. "Sleep hygiene," however, is actually a pale subcategory of a sophisticated batch of behavioral and cognitive therapy techniques that work very well for patients with the kind of insomnia that is so chronic that it has become a way of life. According to a recent meta-analysis of 21 clinical trials, behavior therapy and pharmacotherapy work equally well for chronic insomnia, though behavior therapy probably helps initial insomnia more (Am J Psychiatry 2002; 159:5-11). Pharmacological approaches are discussed elsewhere in this issue ("Sleeping Pills: An Update"). Helpful behavioral remedies include avoiding naps and waking up at the same early time each day, both of which increase the amount of wakefulness prior to bedtime, thus promoting sleepiness. Cognitive restructuring tips include educating your patient that it's no catastrophe to sleep only five or so hours, since this "core sleep" includes all of our deep sleep and allows us to function reasonably well. This often helps prevent the middle of the night clockwatching that plagues chronic insomniacs. An excellent book to recommend to patients is Say Goodnight to Insomnia, Gregg D. Jacobs, 1999, Owl Books (NY).

TCR VERDICT
Insomnia: Rule out sleep disorders before pulling out the pad.