Sleepless in C-L! An Integrative Approach to Treating Insomnia in the Consultation-Liaison Setting

Abstract: Background

Insomnia is a common concern experienced by over half of inpatients, particularly those in the Consultation-Liaison (C-L) setting (1). Notably, poor sleep disproportionately affects women as well as Black, Asian American, and Native American patients (2). The causes of insomnia in the hospital include primary insomnia, medical conditions, psychiatric disorders, and behavioral and environmental contributions. It is no surprise that normal, healthy sleep is easily disrupted given the intricate neurocircuitry that underlies it (3). Insomnia treatment in C-L typically involves sedating medication, but this doesn’t take into account this complexity. Furthermore, sleep disturbances are challenging to address in C-L due to environmental factors, acuity of other symptoms, and limitations of cognitive behavioral methods in the inpatient context.

Treating sleep disorders in the C-L setting therefore necessitates a novel, multimodal approach. This session, led by a multidisciplinary international panel, will educate about the underlying complex neurocircuitry of sleep. This will provide a foundation to discuss assessment (sleep measurement and use of validated scales), treatment (including novel psychopharmacologic agents and evidence-based behavioral and environmental techniques), and systems design to address insomnia in a more integrative way.

Content, Learning Approaches, and Organization

Dr. Yaakov Green will provide a primer on sleep-wake neurobiology, using an interactive neurobiological model (3). Common pharmacologic treatments will be elicited from participants using polling and incorporated into the model (20 minutes).

Dr. Yoel Green will present an integrative approach for assessing and treating insomnia in C-L, incorporating the neurobiological model, biopsychosocial and cultural formulations, and guidelines from the American Academy of Sleep Medicine (15 minutes).

Dr. Bernice Yau, along with the other speakers, will guide participants through a typical C-L case in which insomnia is a presenting concern, using a case recently published by Dr. Mak in the Journal of the ACLP (4). Learners will split into groups facilitated by the session’s presenters to discuss utilization of the approach in the case and will reconvene for a presenter-mediated discussion (25 minutes).

Dr. Michael Mak will then discuss sleep-wake disorders that might require further specialized care – such as parasomnias and breathing-related sleep disorders – including recognition and referral (10 min).

The session will conclude with a Q&A with the speakers (5 min).



References

1. Rocha, F. L., Hara, C., Rodrigues, C. V., Costa, M. A., e Costa, É. C., Fuzikawa, C., & Santos, V. G. (2005). Is insomnia a marker for psychiatric disorders in general hospitals?. Sleep Medicine, 6(6), 549-553.

2. Cheng, P., Cuellar, R., Johnson, D. A., Kalmbach, D. A., Joseph, C. L., Castelan, A. C., ... & Drake, C. L. (2020). Racial discrimination as a mediator of racial disparities in insomnia disorder. Sleep health, 6(5), 543-549.

3. Green, Y. D., Green, Y. S., Yau, B. N., & Ross, D. A. (2023). From Foot-Bread to Flip-Flop Circuits: What History Can Teach Us About Sleep and How to Treat It. Biological Psychiatry, 94(8), e29-e31.

4. Aversa, V., Hawa, R., Lee, E. K., & Mak, M. (2023). CL Case Conference: Insomnia Disorder. Journal of the Academy of Consultation-Liaison Psychiatry.

Content Contributors: The speakers would like to thank Sara S. Nash, MD for her mentorship, support in ideating this session, and edits to the abstract.
Drs. Green and Yau would like to thank David A. Ross, MD, PhD for his mentorship and contribution to their written work on sleep neurobiology and treatment of insomnia .
Reference: Green, Y. D., Green, Y. S., Yau, B. N., & Ross, D. A. (2023). From Foot-Bread to Flip-Flop Circuits: What History Can Teach Us About Sleep and How to Treat It. Biological Psychiatry, 94(8), e29-e31.

Diversity, Equity, and Inclusion: The session will discuss ways in which sleep disorders disproportionately impact women and minority patients (e.g., women 40% more likely than men to have insomnia; black patients more likely to experience disrupted sleep). Better recognition and treatment of sleep disorders can therefore address these disparities. The session will also encourage participants to integrate cultural formulations into their treatment approaches.
Reference: Zhou, E. S., Ritterband, L. M., Bethea, T. N., Robles, Y. P., Heeren, T. C., & Rosenberg, L. (2022). Effect of culturally tailored, internet-delivered cognitive behavioral therapy for insomnia in black women: a randomized clinical trial. JAMA psychiatry, 79(6), 538-549.

Learning Objectives:

• Participants will be able to identify fundamental sleep-wake neurocircuitry – including the reticular activating system, ventrolateral preoptic nucleus, circadian rhythm, sleep-wake homeostasis, and orexin pathway – and their associated neurotransmitters.
• Participants will be able to apply an integrative approach to treating insomnia in typical C-L cases, using current guidelines.
• Participants will be able to name other sleep-wake disorders, recognize their core symptoms, and identify when to pursue specialized consultation.