Are Psychiatrists Paying Attention to Sleep?

Adeel Meraj

Cite this article as: BJMP 2012;5(3):a525
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Abstract

Sleep medicine is a relatively new medical discipline since the 1970’s. It has developed tremendously and has come across as an independent discipline in the United States over the last thirty years. The US has a well-developed and respected sleep medicine training structure which allows specialists from various disciplines, including psychiatry, to acquire specialty training in sleep and become certified sleep specialists. This is not the case in Europe and the United Kingdom where there is no structured training and the practice of sleep medicine is limited to respiratory physicians (such as pulmonologists). In the last decade there has been an increased interest among US psychiatry residents in pursuing further training in sleep medicine. This article gives a brief overview of the development of sleep medicine in the US in the past 30 years and the current structure of training in the US compared to several European countries. It highlights the value of sleep medicine as a career choice for psychiatrists and the advantage psychiatrists have in treating sleep disorders.

Introduction:

Sleep is a fundamental part of our lives and about one-third of it is spent sleeping. Sleep deprivation has been linked with such high profile public disasters, as Chernobyl, the Challenger shuttle disaster and the nuclear meltdown at Three Mile Island. According to the US Highway Traffic Safety Administration, approx. 100,000 motor vehicle accidents are the result of driver’s drowsiness and fatigue1. There is an association of sleep disorders with anxiety and depression which may be bidirectional. Patients with insomnia for 2 weeks or longer, without current depression are at increased risk of developing major depression. Both insomnia and hypersomnia are considered independent predictors of depression and anxiety2.

Key Milestones in the Development of American Sleep Medicine:

The history of treatment of sleep disorders dates back to at least the use of opium as a hypnotic reported in ancient Egyptian text. Sleep medicine, however did not emerge as a distinct discipline until the 1970’s. Drs. Kleitman and Dement were significant early contributors to this field in the United States. In 1957 they first described Non Rapid Eye Movement (NREM) sleep and Rapid Eye Movement (REM) sleep and proposed the 4 stages of NREM sleep. In 1972 Dr. Dement, a Professor of Psychiatry and Behavioural Sciences at Stanford University School of Medicine, contributed to the establishment of the first sleep disorder centre in Stanford. After Stanford, other centres in New York, Texas, Ohio and Pennsylvania started providing sleep evaluations for which patients stayed in the centre overnight. The Association of Sleep Disorders Centre (ASDC) was established in 1975 and Dr. Dement served as its first president for12 years. In 1999 ASDC was renamed American Academy of Sleep Medicine (AASM). The first textbook of sleep medicine “Principles and Practice of Sleep Medicine” was published in 80’s. The journal SLEEP started in 1978. In 1998 the AASM commissioned the fellowship training committee to develop guidelines for sleep medicine fellowship training. The first two programmes to be granted formal accreditation were Stanford University in California and the Centre for Sleep and Wake in Montefiore Medical Centre, New York. The American Medical Association recognized sleep medicine as a specialty in 1996. In 2004 the Accreditation Council on Graduate Medical Education (ACGME) took over the fellowship accreditation process and approved a one year training programme 1,3,4,5.

Sleep Medicine training in Europe:

Unlike United States, there are no formal sleep medicine training programmes or qualification in the United Kingdom or Europe. Sleep medicine is restricted to a small group of respiratory physicians with a special interest in sleep medicine. Psychiatry trainees are exposed to very little formal teaching in sleep medicine. However in the last 3 years the neuropsychiatry section of the Royal College of Psychiatrists of the United Kingdom has formed the “sleep working group” under the leadership of Dr. Hugh Selsick, this group is responsible for increasing awareness of sleep medicine among British psychiatrists, by emphasizing the importance of sleep medicine in psychiatric practice and encouraging psychiatrists to contribute to the field of sleep medicine. This group has developed a competency based curriculum that incorporates the training of sleep medicine into the psychiatry curriculum, to organize sleep medicine symposia at annual conferences of the Royal College and to develop professional training (CPD) modules for psychiatrists. British Sleep Society is another forum that brings together physicians from various backgrounds interested in sleep medicine. Royal Society of Medicine also has a sleep medicine section which organizes various conferences. There are two, week long courses on sleep medicine, the Edinburgh and Cambridge courses. Recently the University of Glasgow started a Master’s of Science (MSc) in behavioural sleep medicine program for healthcare providers working in Scotland, the rest of the United Kingdom and Europe 6, 7, 8, 9. There is a trans-European move to start a formal sleep medicine certification similar to what we have in the United States. European Sleep Research Society (ESRC), a professional body of sleep scientists in Europe responsible for promoting sleep research and sleep medicine is starting its “first ESRS certification examination” in sleep medicine; this examination is scheduled to take place on September 4th, 2012 at the 21st Congress of the European Sleep Research Society in Paris. Since there are no formal training programmes this will be for those without formal training 10.

Psychiatry and Sleep:

Asking about the patient’s sleep is an integral part of a psychiatric consultation. Almost all the medication that psychiatrists prescribe has an effect on sleep architecture. Some psychiatric medications are used to treat sleep disorders and others can cause sleep disorders like Restless Legs Syndrome and PMLD. Understanding sleep can help us understand the mechanism of psychiatric illness. Many psychiatric disorders have comorbid sleep disorders and several behavioural therapies have been used successfully for the treatment of sleep disorders. There is bidirectional association between sleep disorders and psychiatric disorders. With the growing population of military soldiers returning from Iraq and Afghanistan with post-traumatic stress disorder, sleep problems and depression, there is an increased need for psychiatrists who possess knowledge in both sleep disorders and comorbid psychiatric illness. Psychiatrists have a distinct advantage dealing with sleep disorders and can bring those skills to sleep medicine.

Are psychiatrists attracted towards sleep medicine? The answer is yes. In the recent years we have seen an increased interest among psychiatry trainees for a sleep fellowship in United States. In recognition of behavioural consequences of sleep problems and multidisciplinary approach in sleep disorders, fellowship programmes are increasingly taking applicants from various backgrounds and not just pulmonology and neurology. Many psychiatry trainees are choosing a sleep medicine elective earlier in residency. Currently there are more than 710 accredited sleep centres in the United States. Many major university medical centres have a one year fellowship programme accepting applications from physicians from various backgrounds including Psychiatry, Neurology, Internal Medicine, Pulmonology, Paediatrics, ENT and Anaesthesia 1. There are more than 24 AGME approved sleep medicine fellowship programmes in the United States 11. New fellowship programmes are being opened at the University of Kansas Medical Centre and the University of Texas Health Sciences Centre, San Antonio.

Conclusion:

Sleep medicine is a new and exciting field of medicine with potential to grow in future. It’s a multidisciplinary field. American sleep medicine has evolved greatly over the last 30 years and there appears to be much to learn from the American model. There is a need for the psychiatry training programs both in the United States and the Europe to encourage and prepare their trainees to consider training in sleep medicine. Psychiatry trainees in the United States interested in sleep medicine should speak with their programme directors early in their residency training to register their interest and residents should also contact the local sleep centre for more advice. Each year American Academy of Sleep Medicine (AASM) accepts 10 international physicians for its 4 week mini-fellowship programme. Three weeks of the fellowship are spent at an AASM-accredited U.S sleep centre with their last week of the fellowship spent at the annual SLEEP conference. A certificate of training is issued at the end of the mini fellowship 12.

Acknowledgements
Barry I. Liskow MD, Professor of Psychiatry and Residency Program Director, Department of Psychiatry and Behavioural Sciences, University of Kansas Medical Centre.
Competing Interests
None disclosed
Author Details
Adeel Meraj, MD, Resident Physician, University of Kansas Medical Centre, Kansas, USA
CORRESPONDENCE: Adeel Meraj, MD, Resident Physician, University of Kansas Medical Centre, Department of Psychiatry and Behavioural Sciences, 3901 Rainbow Blvd, MS 4015, Kansas City, Kansas, USA
Email: adeel_shamse@yahoo.co.uk

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