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A quels aspects du sommeil faut-il prêter le plus d’attention lors de la prise en charge du patient psychiatrique ? ANPSSSM 15/6/2011 Xavier A. Preud’homme, M.D. Duke University Sleep Laboratory [email protected] – Tel. 1-919-681-87442- Fax 1-919-681-8744
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A quels aspects du sommeil faut-il prêter le plus d’attention
lors de la prise en charge du patient psychiatrique ?
ANPSSSM 15/6/2011Xavier A. Preud’homme, M.D.
Duke University Sleep [email protected] – Tel. 1-919-681-87442- Fax 1-919-681-8744
Xavier Preud’homme: Disclosure1) Investigateur principal – Bourse d’étude de Pfizer
Analyse de la variabilité du segment RR afin de comparer déterminer l’équilibre sympathovagal chez le sujet présentant une hyperactivité de la vessie et chez le sujet sain
2) Investigateur secondaire – NIH-NIDDKEtude des mécanismes des mictions nocturnes y compris de l’énurésie
3) Investigateur secondaire – AstellasEtude de l’instabilité du muscle detrusor pendant le sommeil chez la femme
4) Investigateur principal – Bourse d’étude du CFAR Duke/NIHEst-il possible d’améliorer l’adhérence à la trithérapie du SIDA en traitant l’insomnie par thérapie cognitivo-comportementale?
Objectifs pédagogiques Survol de la physiologie et physiopathologie du
sommeil chez l’humainTisser les liens avec les pathologies
psychiatriques Insister sur le potentiel d’interactions Organiser la présentation en fonction des
approches diagnostiques des problematiques du sommeil Présenter les actualités thérapeutiques Questions - Réponses
L’impact de la privation du sommeilaprès 24 hr. d’éveil = Ethanol of 80
Thomas M et al. J Sleep Res. 2000;9:335-352.
18FDG PET Study of Healthy, Sleep-Deprived Adults, Showing Decreased Metabolism in the Thalamus, Prefrontal Cortex, and Inferior Parietal Cortex
FDG, fluorodeoxyglucose; PET, positron emission tomography
Prefrontalcortex
Inferior parietalcortex
Occipitalcortex
Thalamus
Presenter
Presentation Notes
OPTIONAL
Mean (+SE) Number of Attentional Failures among the 20 Interns as a Group and Individually while Working Overnight (11 p.m. to 7 a.m.) during the Traditional Schedule and the
Intervention Schedule
Lockley, S. et al. N Engl J Med 2004;351:1829-1837
2004 Annals of Internal Medicine4 hr de sommeil => - 18% leptine, +28% ghreline, + 24% appétit
Paradigme de la privation de sommeil
Privationde sommeil
5% =>hypomanie6% => manie33% => ok> 1 nuit(BZD)
Wake Therapy: “Thérapie par l’eveil”
Dark Therapy: “L’anti-lumière”
American Psychiatric Association. DSM-IV TR. 2000.
Difficulty falling asleep
Difficulty staying asleep
Non-restorative
sleep
Significant Distress or Impairment in Function for 1 month
and/or and/or
AND
Critères du diagnostic de l’insomnieprimaire selon le DSM-IV
Presenter
Presentation Notes
Slide 2: Definition of Insomnia Insomnia may be primary—with no known underlying etiology—or secondary—related to a psychiatric disorder, a general medical condition, or substance induced.1 Regardless of its etiology, insomnia is always associated with next-day consequences and is defined by one or more of the following sleep complaints1-3: Difficulty falling asleep Difficulty staying asleep Nonrestorative sleep Next-day consequences include impaired concentration, impaired memory, decreased ability to accomplish daily tasks, and decreased enjoyment of interpersonal relationships.3 These consequences and the ubiquity of disturbed sleep constitute a “national sleep alert.”2
L’agenda du sommeilDate 10/08/08 10/09/08 10/11/08 10/12/08 10/13/08
Nighttime Medications
Alcohol
Bed Time
Wake Time
Time Out of Bed in a.m.
Awakenings and Time Awake for Each One
Quality of Sleep (0-5)
Feeling of Restoration in the a.m. (0-5)
Roth T, et al. Sleep Med. 2005;6:487-95.
Latence de sommeil (subjective): 6 & 12 moissous eszopiclone
PBO-ESZ
ESZ-ESZ
Base 1 2 3 4 5 6 7 8 9 10 11 12
45
30
15
60
75
0
Med
ian
Slee
p La
tenc
y (m
inut
es)
Months of Study
Double-blind period Open-label period
* * *
† † † †† †
Eszopiclone Reduces Sleep-Onset Latency to <30 Minutes for up to 12 Months of Use
Presenter
Presentation Notes
[Graph to be redrawn]
Indications pour une aproche non pharmacologique
• Hygiène du sommeil• Thérapie cognitivo-comportementale
=> Succès = celui des hypmotiques• Approche cognitive• Approche comportementale:
Diminuer le stimulusRestreindre le temps de sommeil
Wohlgemuth and Krystal, 2005; Krystal et al., 1998
0
5
10
15
20
Major Depression Any Anxiety Disorder Alcohol Abuse/Dependence
New
Cas
es a
t 3.
5-Ye
ar F
ollo
w-U
p (%
) 15.9%
4.6%
13.7%
7.1% 7.1%
4.7%
Prior History of InsomniaNo Insomnia
Insomnie = risque de développerd’autres maladies mentales
Breslau N, et al. Biol Psychiatry. 1996;39:411-418. NIH. Sleep. 2005;28:1049-1057.
Presenter
Presentation Notes
Slide IV-5. Insomnia as a Risk Factor for Later Emergence of �Psychiatric Disorders In a longitudinal, epidemiologic health maintenance organization (HMO) study by Breslau and colleagues of 1,007 adults (aged 21 to 30 years), 167 respondents (16.6%) reported insomnia alone lasting for at least 2 weeks. Of these individuals, 70.7% were found to have a psychiatric disorder and 31.1% had major depression. In the follow-up interview of 979 persons 3.5 years later, the incidence of new cases of major depression �in those with a history of insomnia was 15.9%. Reference Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39:411-418.
Treated with fluoxetine 20 mg for 8 weeks
Symptoms résiduels chez les patients déprimés en rémission
%
05
101520253035404550
Nierenberg AA, et al. J Clin Psychiatry. 1999;60:221-225.
8 Week Double-Blind, Randomized Trial-N=545Fluoxetine+Eszopiclone vs. Fluoxetine+Placebo
** * * * *
240
270
300
330
360
390
420
-1 0 1 2 3 4 5 6 7 8
Placebo+FluoxetineEszopiclone+FluoxetineTo
tal S
leep
Tim
e (M
in)
Weeks
Fava M, McCall WV, Krystal A, Rubens R, Caron J, Wessel T, Amato T, Roth T. Biological Psychiatry. 2007.
Insomnia Efficacy
*P<0.0001
Significant Effect on Depression Response
Improvement in HAM-D 17 Excluding Insomnia Items
9.5
11.1
0
2
4
6
8
10
12
End of Study
P<0.001
ESZ+Flu
Pcbo+Flu
43
55
0
10
20
30
40
50
60
End of Study
Pcbo+Flu
ESZ+Flu
% Remitters(HAM-D17≤ 7)
P<0.01
Melatonine
Principes de la chronothérapie
Luminothérapie
Paradigme du DLMO
Morningness-EveningnessQuestionnaire (MEQ)
Demence
Cauchemards & Troubles du sommeil paradoxal (REM)
• CauchemardsCrise d’épilepsie ? => PSG avec videoEtat de stress post-traumatique => PrasozineATTENTION prédit le mieux le suicide (surtout chez la femme)
• Pathologie du sommeil REMCrise d’épilepsie ? => PSG avec videoApnées? => PSGSuivi du patient >50% avec Parkinson 10 ans plus tardDémence avec Lewy bodies & sensibilité aux neuroleptiques
PMLS & RLS
• PLMS = 5% des causes d’hypersomnie• Urémie• Anémia => Manque de fer• Grossesse• Manque d’acide folique• Diabete• Arthrite rheumatoide• ATD surtout les SSRIs• Etats de manque
Upper Airway Sites Contributing to OSA
Cardiovascular Effects of Sleep Apnea
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Presenter
Presentation Notes
Pathophysiologic effects of sleep apnea. Pleural pressure (Ppl) is a used to measure the pressure around the heart and its vascular structures. The consequences include vascular inflammation and remodleing, similar to CAD; the ↑ in sympathetic activity and inflammation cytokines, actives wbcs, oxidative stress, and hypercoagulopathy. These alterations can be reversed using CPAP.
Dx of OSA :Mallampati Classification
Trend Analysis for the Relationship between Increased Severity of the Obstructive Sleep Apnea Syndrome and the Composite Outcome of Stroke or Death from Any Cause (N=1022)
Yaggi, H. et al. N Engl J Med 2005;353:2034-2041
Treatment-CPAP treatment–Positive pressure keeps airway open–most effective
CPAP therapy
Treatment of OSA with: GOLD STANDARD: CPAP
Heart Rate and Blood Pressure
Kaneko, Y. et al. N Engl J Med 2003;348:1233-1241
Individual Values for the Left Ventricular Ejection Fraction in All Patients
Kaneko, Y. et al. N Engl J Med 2003;348:1233-1241
PSG of OSA vs. CSA
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Presenter
Presentation Notes
The top illustration of a PSG clip of OSA shows lack of Airflow with ventilatory effort; this is in contrast to the bottom slide of CSA where there is no Airflow and no ventilatory drive
L’ échelle de somnolence de Epworth
Normal
Insomnia
Sleep Apnea
Residents
Narcolepsy
0
5
10
15
20
Mean 5.90 2.20 11.70 14.70 17.50
Normal Insomnia Sleep Apnea Residents Narcolepsy
Papp et al. Sleep, 2002.
Epworth
Sleepiness
Scale
© American Academy of Sleep Medicine
American Academy of Sleep Medicine
0
5
10
15
20
1000 1200 1400 1600 1800
Time of Day (24-hr clock)
MSL
T Sc
ore (
min
)
Post-call Baseline ExtendedTi
me
to fa
ll as
leep
on M
SLT
(min
)
Sleepiness level post-call vs on a normal (baseline)schedule was equivalent in anesthesia residents.
A period of extended sleep (over 4 nights) normalized post-call sleepiness levels.
Howard 2002
A quels aspects du sommeil faut-il prêter le plus d’attention lors de la prise en charge du patient
psychiatrique ?
• 1) Durée (n’aggravons pas ce qui est déjà fait)• 2) Qualité (insomnie <=> dépression)• 3) Régularité (aspects circadiens & luminothérapie)• 4) Cauchemards / troubles REM (suicide – Parkinson+)
• 6) Acathisie (RLS – Fer – Dopamine – PLMS - SSRIs)• 7) Apnées (parce que nous avons une approche
hollistique du patient psychiatrique)• 1, 2, 3 => clinique• 4, 5, 6 => labo du sommeil• 7 => labo du sommeil ou maison
Un grandmerci
aux Pr.
• D. Saravane• A Krystal • P Linkowski
& Mme. Mazzia
