European Archives of Psychiatry and Clinical Neuroscience, 2023
Schizophrenia (SCZ) is a severe psychotic disorder associated with premature mortality and aging.... more Schizophrenia (SCZ) is a severe psychotic disorder associated with premature mortality and aging. Moreover, the symptoms and progression of psychiatric disorders in general are associated with decreased lifespan, biological aging, and poorer medical outcomes. In this study, we investigated the relationship between several epigenetic clocks and scanned the entire genome for association in a cohort of SCZ individuals (n = 107). Biological age was computed from blood DNA methylation (DNAm) and tested for association against common variants across the genome using general linear models. Genes affecting epigenetic age acceleration in our cohort were found mainly when using the telomeric length clock rather than the other biological clocks. These findings pair with existing evidence that there are some genes associated with longevity and suggest further investigations of putative biological mechanisms for morbidity and premature mortality, not only in patients with SCZ but also in the general population.
Journal of the Academy of Consultation-Liaison Psychiatry, 2024
We present the case of a 67-year-old male with a history of
major depressive disorder, panic diso... more We present the case of a 67-year-old male with a history of major depressive disorder, panic disorder, treatment re- fractory hypertension, dyslipidemia, benign prostatic hy- pertrophy, and environmental allergies who was initially brought to medical attention following an unwitnessed fall. He subsequently developed symptoms of insomnia disor- der. Experts in consultation-liaison psychiatry and sleep medicine provide guidance for this clinical scenario based on their experience and a review of current literature, exploring the epidemiology of insomnia disorder and comorbidities in relation to this case. Furthermore, we offer a review of current treatment for insomnia disorder, including non-pharmacologic methods such as cognitive behavioral therapy for insomnia and pharmacotherapy. (Journal of the Academy of Consultation-Liaison Psychiatry 2024; 65:293–301)
Rapid eye movement (REM) sleep behaviour disorder (RBD) causes dream enactment behaviours such as... more Rapid eye movement (REM) sleep behaviour disorder (RBD) causes dream enactment behaviours such as vocalizations and motor actions, which can be violent
Patients who report a history of injuries to themselves (e.g., falling from bed) or to their bed partner should be assessed for RBD.1 With clinical suspicion through patient or bed partner history, or use of validated scales (e.g., RBD screening questionnaire),1 diagnosis is confirmed with polysomnography showing REM sleep without atonia (sensitivity 83%–100%; specificity 88%–100%).2 Personal and environmental factors are associated with RBD
The prevalence of the disorder among adults aged 40–80 years is about 1%, with a spectrum of severity. Risk factors include older age, male sex, smoking, traumatic brain injury and environmental exposures (e.g., pesticides). 3 Antidepressants may cause symptoms to emerge.4 The disorder should be differentiated from other mimics
Specific features differentiate RBD from non-REM parasomnias (e.g., sleepwalking, night terrors) and obstructive sleep apnea (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221820/tab-related-content); RBD occurs more frequently in the second half of the night, and patients reorient quickly upon awakening. Treatment of RBD differs from non-REM parasomnias and obstructive sleep apnea. Management includes both pharmacological and environmental interventions
Given fewer adverse effects, immediate-release melatonin (3–15 mg) is preferred over clonazepam (0.125–2 mg), despite lower efficacy in reducing symptoms (32.9% v. 66.7%).4 Melatonin causes mild sedation, nausea and disturbing dreams, while clonazepam increases risk for falls, driving or cognitive impairment and drug dependency.5 Patients should create a safe sleeping environment by removing hazardous objects from their surroundings and placing a soft mat on the ground beside their bed; they should consider avoiding cosleeping. Sleep hygiene and treatment of concomitant sleep disorders are also important. Patients should be monitored for Parkinson disease and dementia with Lewy bodies
More than 70% of patients with RBD develop α-synucleinopathies within 12 years.3 Clinicians should monitor patients for gait hesitancy, hyposmia and neuropsychiatric symptoms suggestive of early Parkinson disease. Clinicians should refer patients with such symptoms to a neurologist.
Le trouble comportemental en sommeil paradoxal (SP) cause la manifestation de comportements oniri... more Le trouble comportemental en sommeil paradoxal (SP) cause la manifestation de comportements oniriques, comme la vocalisation et des mouvements moteurs, pouvant être violents On devrait évaluer la patientèle pour un trouble comportemental en sommeil paradoxal lorsqu'elle rapporte des antécédents de lésions qu'elle s'est infligée à elle-même (p. ex., en tombant du lit) ou à la personne qui dort avec elle 1. En présence d'un soupçon clinique en lien avec ces antécédents, ou par l'emploi d'échelles validées (p. ex., questionnaire de dépistage du trouble comportemental en sommeil paradoxal) 1 , on confirme le diagnostic à l'aide d'une polysomnographie révélant un sommeil paradoxal dépourvu d'atonie (sensibilité de 83 %-100 %; spécificité de 88 %-100 %) 2. 2 Des facteurs individuels et environnementaux sont associés au trouble comportemental en sommeil paradoxal La prévalence de ce trouble chez les adultes de 40-80 ans est d'environ 1 % et présente un éventail de gravité. Parmi les facteurs de risque, on compte le fait d'être d'un âge avancé, d'être un homme, de pratiquer le tabagisme, d'avoir subi un traumatisme crânien et d'avoir été soumis à certaines expositions environnementales (p. ex., exposition à des pesticides) 3. La consommation d'antidépresseurs peut causer l'émergence des symptômes 4 .
Introduction: Cognitive behavioral therapy for insomnia (CBT-
I) remains the first line treatment... more Introduction: Cognitive behavioral therapy for insomnia (CBT- I) remains the first line treatment for insomnia. CBT-I in com- parison with sedative-hypnotics has similar efficacy, but with treatment durability and almost no adverse effects. Despite CBT-I being recognized as the best insomnia treatment, access remains limited. Digital CBT-I hopes to address the problem of scale, so as to deliver therapy to the masses. There are now multi- ple mobile applications available both on smartphone app stores, which claim to deliver evidence based CBT-i. These applications largely come at a cost and patients have to pay to access their services. The goal of this study is to review CBT-i smartphone applications to see if they are indeed validated. Methods: We performed a search on the two most popular smartphone application platforms: Google Play and Apple Store. We used search terms: sleep, insomnia and CBT-I. We then searched for validation studies for those smartphone appli- cations on Google Scholar. We included studies conducted in the past 10 years. Our second search consisted of reviewing PubMed and Google Scholar for validation studies for CBT-I applica- tions. Our search terms consisted of CBT-I and smartphone, CBT-I and application and CBT-I and digital. Results: Of the 9 validation studies that we initially found, 6 met our inclusion criteria. 3 were excluded as they did not solely use CBT-I in their applications. All 6 applications reported signif- icant improvement in important sleep quality metrics such as sleep onset latency and total sleep time. 4 studies also reported on a subjective improvement in quality of sleep. 2 studies looked at populations with comorbidities including cannabis use disor- der and epilepsy. Both studied again found improvement in sleep quality in those specific populations. There were concerning pat- terns of bias found amongst the reviewed studies. 3/6 investiga- tors had direct relationships with companies which designed and marketed the applications. Conclusion: dCBT-I offers an opportunity to increase acces- sibility to therapy. There are only a limited number of studies which have examined the effectiveness of the applications on the market. There remains serious concerns about the risk of bias and the quality of validation studies which claim to confirm the effectiveness of these applications.
Introduction: Twitter is a novel and accessible platform for the dissemination of medical educati... more Introduction: Twitter is a novel and accessible platform for the dissemination of medical education, and it is used by many medical practitioners (1). Many physicians have used Twitter as a means of meeting continuing medical education needs. This can manifest as Twitter-based Journal Clubs, curated conference data and webinars (2). Methods: I have created a Sleep Medicine Medical Education Twitter account @SleepyNeuroDoc to share complex cases in all areas of sleep medicine, including sleep-disordered breathing, movement disorders in sleep, circadian rhythm disorders and nocturnal epilepsy. I share notable images of polysomnogram outputs, home sleep apnea tests, compliance data, neuro-imaging, electroencephalogram, cardiopulmonary coupling and more. This digital education platform allows rapid circulation of unique cases and promotes in-depth scholarly discussion, with no geographical limit. Polls are conducted for complex topics to facilitate knowledge exchange and consumer engagement. This educational twitter is followed by the entire spectrum of professions within the sleep medicine care team, including physicians, allied health, and researchers. To date, there are 40 cases posted. Results: We conducted online questionnaires with consumers of this Twitter account, and the results so far indicate greater practitioner comfort with management of various sleep medicine conditions. Some consumers report having changed their approach to practice. Conclusion: Our work suggests that this unique use of a social medical platform is beneficial for continuing medical education and knowledge exchange in the field of Sleep Medicine.
This position paper has been substantially revised by the Canadian Psychiatric Association (CPA) ... more This position paper has been substantially revised by the Canadian Psychiatric Association (CPA) Education Committee and approved for republication by the CPA's Board of Directors on May 11, 2023. The original position paper1 was developed by the CPA Education Committee and approved by the Board of Directors on June 22, 2015.
Background Primary care physicians often lack resources and training to correctly diagnose and ma... more Background Primary care physicians often lack resources and training to correctly diagnose and manage chronic insomnia disorder. Tools supporting chronic insomnia diagnosis and management could fill this critical gap. A survey was conducted to understand insomnia disorder diagnosis and treatment practices among primary care physicians, and to evaluate a diagnosis and treatment algorithm on its use, to identify ways to optimize it specifically for these providers. Methods A panel of experts developed an algorithm for diagnosing and treating chronic insomnia disorder, based on current guidelines and experience in clinical practice. An online survey was conducted with primary care physicians from France, Germany, Italy, Spain, and the United Kingdom, who treat chronic insomnia patients, between January and February 2023. A sub-sample of participants provided open-ended feedback on the algorithm and gave suggestions for improvements. Results Overall, 106 primary care physicians completed the survey. Half (52%, 55/106) reported they did not regularly screen for insomnia and half (51%, 54/106) felt they did not have enough time to address patients' needs in relation to insomnia or trouble sleeping. The majority (87%,92/106) agreed the algorithm would help diagnose chronic insomnia patients and 82% (87/106) agreed the algorithm would help improve their clinical practice in relation to managing chronic insomnia. Suggestions for improvements were making the algorithm easier to read and use. Conclusion The algorithm developed for, and tested by, primary care physicians to diagnose and treat chronic insomnia disorder may offer significant benefits to providers and their patients through ensuring standardization of insomnia diagnosis and management.
European Archives of Psychiatry and Clinical Neuroscience, 2023
Schizophrenia (SCZ) is a severe psychotic disorder associated with premature mortality and aging.... more Schizophrenia (SCZ) is a severe psychotic disorder associated with premature mortality and aging. Moreover, the symptoms and progression of psychiatric disorders in general are associated with decreased lifespan, biological aging, and poorer medical outcomes. In this study, we investigated the relationship between several epigenetic clocks and scanned the entire genome for association in a cohort of SCZ individuals (n = 107). Biological age was computed from blood DNA methylation (DNAm) and tested for association against common variants across the genome using general linear models. Genes affecting epigenetic age acceleration in our cohort were found mainly when using the telomeric length clock rather than the other biological clocks. These findings pair with existing evidence that there are some genes associated with longevity and suggest further investigations of putative biological mechanisms for morbidity and premature mortality, not only in patients with SCZ but also in the general population.
Journal of the Academy of Consultation-Liaison Psychiatry, 2024
We present the case of a 67-year-old male with a history of
major depressive disorder, panic diso... more We present the case of a 67-year-old male with a history of major depressive disorder, panic disorder, treatment re- fractory hypertension, dyslipidemia, benign prostatic hy- pertrophy, and environmental allergies who was initially brought to medical attention following an unwitnessed fall. He subsequently developed symptoms of insomnia disor- der. Experts in consultation-liaison psychiatry and sleep medicine provide guidance for this clinical scenario based on their experience and a review of current literature, exploring the epidemiology of insomnia disorder and comorbidities in relation to this case. Furthermore, we offer a review of current treatment for insomnia disorder, including non-pharmacologic methods such as cognitive behavioral therapy for insomnia and pharmacotherapy. (Journal of the Academy of Consultation-Liaison Psychiatry 2024; 65:293–301)
Rapid eye movement (REM) sleep behaviour disorder (RBD) causes dream enactment behaviours such as... more Rapid eye movement (REM) sleep behaviour disorder (RBD) causes dream enactment behaviours such as vocalizations and motor actions, which can be violent
Patients who report a history of injuries to themselves (e.g., falling from bed) or to their bed partner should be assessed for RBD.1 With clinical suspicion through patient or bed partner history, or use of validated scales (e.g., RBD screening questionnaire),1 diagnosis is confirmed with polysomnography showing REM sleep without atonia (sensitivity 83%–100%; specificity 88%–100%).2 Personal and environmental factors are associated with RBD
The prevalence of the disorder among adults aged 40–80 years is about 1%, with a spectrum of severity. Risk factors include older age, male sex, smoking, traumatic brain injury and environmental exposures (e.g., pesticides). 3 Antidepressants may cause symptoms to emerge.4 The disorder should be differentiated from other mimics
Specific features differentiate RBD from non-REM parasomnias (e.g., sleepwalking, night terrors) and obstructive sleep apnea (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221820/tab-related-content); RBD occurs more frequently in the second half of the night, and patients reorient quickly upon awakening. Treatment of RBD differs from non-REM parasomnias and obstructive sleep apnea. Management includes both pharmacological and environmental interventions
Given fewer adverse effects, immediate-release melatonin (3–15 mg) is preferred over clonazepam (0.125–2 mg), despite lower efficacy in reducing symptoms (32.9% v. 66.7%).4 Melatonin causes mild sedation, nausea and disturbing dreams, while clonazepam increases risk for falls, driving or cognitive impairment and drug dependency.5 Patients should create a safe sleeping environment by removing hazardous objects from their surroundings and placing a soft mat on the ground beside their bed; they should consider avoiding cosleeping. Sleep hygiene and treatment of concomitant sleep disorders are also important. Patients should be monitored for Parkinson disease and dementia with Lewy bodies
More than 70% of patients with RBD develop α-synucleinopathies within 12 years.3 Clinicians should monitor patients for gait hesitancy, hyposmia and neuropsychiatric symptoms suggestive of early Parkinson disease. Clinicians should refer patients with such symptoms to a neurologist.
Le trouble comportemental en sommeil paradoxal (SP) cause la manifestation de comportements oniri... more Le trouble comportemental en sommeil paradoxal (SP) cause la manifestation de comportements oniriques, comme la vocalisation et des mouvements moteurs, pouvant être violents On devrait évaluer la patientèle pour un trouble comportemental en sommeil paradoxal lorsqu'elle rapporte des antécédents de lésions qu'elle s'est infligée à elle-même (p. ex., en tombant du lit) ou à la personne qui dort avec elle 1. En présence d'un soupçon clinique en lien avec ces antécédents, ou par l'emploi d'échelles validées (p. ex., questionnaire de dépistage du trouble comportemental en sommeil paradoxal) 1 , on confirme le diagnostic à l'aide d'une polysomnographie révélant un sommeil paradoxal dépourvu d'atonie (sensibilité de 83 %-100 %; spécificité de 88 %-100 %) 2. 2 Des facteurs individuels et environnementaux sont associés au trouble comportemental en sommeil paradoxal La prévalence de ce trouble chez les adultes de 40-80 ans est d'environ 1 % et présente un éventail de gravité. Parmi les facteurs de risque, on compte le fait d'être d'un âge avancé, d'être un homme, de pratiquer le tabagisme, d'avoir subi un traumatisme crânien et d'avoir été soumis à certaines expositions environnementales (p. ex., exposition à des pesticides) 3. La consommation d'antidépresseurs peut causer l'émergence des symptômes 4 .
Introduction: Cognitive behavioral therapy for insomnia (CBT-
I) remains the first line treatment... more Introduction: Cognitive behavioral therapy for insomnia (CBT- I) remains the first line treatment for insomnia. CBT-I in com- parison with sedative-hypnotics has similar efficacy, but with treatment durability and almost no adverse effects. Despite CBT-I being recognized as the best insomnia treatment, access remains limited. Digital CBT-I hopes to address the problem of scale, so as to deliver therapy to the masses. There are now multi- ple mobile applications available both on smartphone app stores, which claim to deliver evidence based CBT-i. These applications largely come at a cost and patients have to pay to access their services. The goal of this study is to review CBT-i smartphone applications to see if they are indeed validated. Methods: We performed a search on the two most popular smartphone application platforms: Google Play and Apple Store. We used search terms: sleep, insomnia and CBT-I. We then searched for validation studies for those smartphone appli- cations on Google Scholar. We included studies conducted in the past 10 years. Our second search consisted of reviewing PubMed and Google Scholar for validation studies for CBT-I applica- tions. Our search terms consisted of CBT-I and smartphone, CBT-I and application and CBT-I and digital. Results: Of the 9 validation studies that we initially found, 6 met our inclusion criteria. 3 were excluded as they did not solely use CBT-I in their applications. All 6 applications reported signif- icant improvement in important sleep quality metrics such as sleep onset latency and total sleep time. 4 studies also reported on a subjective improvement in quality of sleep. 2 studies looked at populations with comorbidities including cannabis use disor- der and epilepsy. Both studied again found improvement in sleep quality in those specific populations. There were concerning pat- terns of bias found amongst the reviewed studies. 3/6 investiga- tors had direct relationships with companies which designed and marketed the applications. Conclusion: dCBT-I offers an opportunity to increase acces- sibility to therapy. There are only a limited number of studies which have examined the effectiveness of the applications on the market. There remains serious concerns about the risk of bias and the quality of validation studies which claim to confirm the effectiveness of these applications.
Introduction: Twitter is a novel and accessible platform for the dissemination of medical educati... more Introduction: Twitter is a novel and accessible platform for the dissemination of medical education, and it is used by many medical practitioners (1). Many physicians have used Twitter as a means of meeting continuing medical education needs. This can manifest as Twitter-based Journal Clubs, curated conference data and webinars (2). Methods: I have created a Sleep Medicine Medical Education Twitter account @SleepyNeuroDoc to share complex cases in all areas of sleep medicine, including sleep-disordered breathing, movement disorders in sleep, circadian rhythm disorders and nocturnal epilepsy. I share notable images of polysomnogram outputs, home sleep apnea tests, compliance data, neuro-imaging, electroencephalogram, cardiopulmonary coupling and more. This digital education platform allows rapid circulation of unique cases and promotes in-depth scholarly discussion, with no geographical limit. Polls are conducted for complex topics to facilitate knowledge exchange and consumer engagement. This educational twitter is followed by the entire spectrum of professions within the sleep medicine care team, including physicians, allied health, and researchers. To date, there are 40 cases posted. Results: We conducted online questionnaires with consumers of this Twitter account, and the results so far indicate greater practitioner comfort with management of various sleep medicine conditions. Some consumers report having changed their approach to practice. Conclusion: Our work suggests that this unique use of a social medical platform is beneficial for continuing medical education and knowledge exchange in the field of Sleep Medicine.
This position paper has been substantially revised by the Canadian Psychiatric Association (CPA) ... more This position paper has been substantially revised by the Canadian Psychiatric Association (CPA) Education Committee and approved for republication by the CPA's Board of Directors on May 11, 2023. The original position paper1 was developed by the CPA Education Committee and approved by the Board of Directors on June 22, 2015.
Background Primary care physicians often lack resources and training to correctly diagnose and ma... more Background Primary care physicians often lack resources and training to correctly diagnose and manage chronic insomnia disorder. Tools supporting chronic insomnia diagnosis and management could fill this critical gap. A survey was conducted to understand insomnia disorder diagnosis and treatment practices among primary care physicians, and to evaluate a diagnosis and treatment algorithm on its use, to identify ways to optimize it specifically for these providers. Methods A panel of experts developed an algorithm for diagnosing and treating chronic insomnia disorder, based on current guidelines and experience in clinical practice. An online survey was conducted with primary care physicians from France, Germany, Italy, Spain, and the United Kingdom, who treat chronic insomnia patients, between January and February 2023. A sub-sample of participants provided open-ended feedback on the algorithm and gave suggestions for improvements. Results Overall, 106 primary care physicians completed the survey. Half (52%, 55/106) reported they did not regularly screen for insomnia and half (51%, 54/106) felt they did not have enough time to address patients' needs in relation to insomnia or trouble sleeping. The majority (87%,92/106) agreed the algorithm would help diagnose chronic insomnia patients and 82% (87/106) agreed the algorithm would help improve their clinical practice in relation to managing chronic insomnia. Suggestions for improvements were making the algorithm easier to read and use. Conclusion The algorithm developed for, and tested by, primary care physicians to diagnose and treat chronic insomnia disorder may offer significant benefits to providers and their patients through ensuring standardization of insomnia diagnosis and management.
Uploads
Psychiatry Research by Michael Mak
major depressive disorder, panic disorder, treatment re-
fractory hypertension, dyslipidemia, benign prostatic hy-
pertrophy, and environmental allergies who was initially
brought to medical attention following an unwitnessed fall.
He subsequently developed symptoms of insomnia disor-
der. Experts in consultation-liaison psychiatry and sleep
medicine provide guidance for this clinical scenario based
on their experience and a review of current literature,
exploring the epidemiology of insomnia disorder and
comorbidities in relation to this case. Furthermore, we
offer a review of current treatment for insomnia disorder,
including non-pharmacologic methods such as cognitive
behavioral therapy for insomnia and pharmacotherapy.
(Journal of the Academy of Consultation-Liaison
Psychiatry 2024; 65:293–301)
Patients who report a history of injuries to themselves (e.g., falling from bed) or to their bed partner should be assessed for RBD.1 With clinical suspicion through patient or bed partner history, or use of validated scales (e.g., RBD screening questionnaire),1 diagnosis is confirmed with polysomnography showing REM sleep without atonia (sensitivity 83%–100%; specificity 88%–100%).2
Personal and environmental factors are associated with RBD
The prevalence of the disorder among adults aged 40–80 years is about 1%, with a spectrum of severity. Risk factors include older age, male sex, smoking, traumatic brain injury and environmental exposures (e.g., pesticides). 3 Antidepressants may cause symptoms to emerge.4
The disorder should be differentiated from other mimics
Specific features differentiate RBD from non-REM parasomnias (e.g., sleepwalking, night terrors) and obstructive sleep apnea (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221820/tab-related-content); RBD occurs more frequently in the second half of the night, and patients reorient quickly upon awakening. Treatment of RBD differs from non-REM parasomnias and obstructive sleep apnea.
Management includes both pharmacological and environmental interventions
Given fewer adverse effects, immediate-release melatonin (3–15 mg) is preferred over clonazepam (0.125–2 mg), despite lower efficacy in reducing symptoms (32.9% v. 66.7%).4 Melatonin causes mild sedation, nausea and disturbing dreams, while clonazepam increases risk for falls, driving or cognitive impairment and drug dependency.5 Patients should create a safe sleeping environment by removing hazardous objects from their surroundings and placing a soft mat on the ground beside their bed; they should consider avoiding cosleeping. Sleep hygiene and treatment of concomitant sleep disorders are also important.
Patients should be monitored for Parkinson disease and dementia with Lewy bodies
More than 70% of patients with RBD develop α-synucleinopathies within 12 years.3 Clinicians should monitor patients for gait hesitancy, hyposmia and neuropsychiatric symptoms suggestive of early Parkinson disease. Clinicians should refer patients with such symptoms to a neurologist.
I) remains the first line treatment for insomnia. CBT-I in com-
parison with sedative-hypnotics has similar efficacy, but with
treatment durability and almost no adverse effects. Despite
CBT-I being recognized as the best insomnia treatment, access
remains limited. Digital CBT-I hopes to address the problem of
scale, so as to deliver therapy to the masses. There are now multi-
ple mobile applications available both on smartphone app stores,
which claim to deliver evidence based CBT-i. These applications
largely come at a cost and patients have to pay to access their
services. The goal of this study is to review CBT-i smartphone
applications to see if they are indeed validated.
Methods: We performed a search on the two most popular
smartphone application platforms: Google Play and Apple
Store. We used search terms: sleep, insomnia and CBT-I. We
then searched for validation studies for those smartphone appli-
cations on Google Scholar. We included studies conducted in the
past 10 years. Our second search consisted of reviewing PubMed
and Google Scholar for validation studies for CBT-I applica-
tions. Our search terms consisted of CBT-I and smartphone,
CBT-I and application and CBT-I and digital.
Results: Of the 9 validation studies that we initially found, 6 met
our inclusion criteria. 3 were excluded as they did not solely use
CBT-I in their applications. All 6 applications reported signif-
icant improvement in important sleep quality metrics such as
sleep onset latency and total sleep time. 4 studies also reported
on a subjective improvement in quality of sleep. 2 studies looked
at populations with comorbidities including cannabis use disor-
der and epilepsy. Both studied again found improvement in sleep
quality in those specific populations. There were concerning pat-
terns of bias found amongst the reviewed studies. 3/6 investiga-
tors had direct relationships with companies which designed and
marketed the applications.
Conclusion: dCBT-I offers an opportunity to increase acces-
sibility to therapy. There are only a limited number of studies
which have examined the effectiveness of the applications on the
market. There remains serious concerns about the risk of bias
and the quality of validation studies which claim to confirm the
effectiveness of these applications.
Papers by Michael Mak
major depressive disorder, panic disorder, treatment re-
fractory hypertension, dyslipidemia, benign prostatic hy-
pertrophy, and environmental allergies who was initially
brought to medical attention following an unwitnessed fall.
He subsequently developed symptoms of insomnia disor-
der. Experts in consultation-liaison psychiatry and sleep
medicine provide guidance for this clinical scenario based
on their experience and a review of current literature,
exploring the epidemiology of insomnia disorder and
comorbidities in relation to this case. Furthermore, we
offer a review of current treatment for insomnia disorder,
including non-pharmacologic methods such as cognitive
behavioral therapy for insomnia and pharmacotherapy.
(Journal of the Academy of Consultation-Liaison
Psychiatry 2024; 65:293–301)
Patients who report a history of injuries to themselves (e.g., falling from bed) or to their bed partner should be assessed for RBD.1 With clinical suspicion through patient or bed partner history, or use of validated scales (e.g., RBD screening questionnaire),1 diagnosis is confirmed with polysomnography showing REM sleep without atonia (sensitivity 83%–100%; specificity 88%–100%).2
Personal and environmental factors are associated with RBD
The prevalence of the disorder among adults aged 40–80 years is about 1%, with a spectrum of severity. Risk factors include older age, male sex, smoking, traumatic brain injury and environmental exposures (e.g., pesticides). 3 Antidepressants may cause symptoms to emerge.4
The disorder should be differentiated from other mimics
Specific features differentiate RBD from non-REM parasomnias (e.g., sleepwalking, night terrors) and obstructive sleep apnea (Appendix 1, available at www.cmaj.ca/lookup/doi/10.1503/cmaj.221820/tab-related-content); RBD occurs more frequently in the second half of the night, and patients reorient quickly upon awakening. Treatment of RBD differs from non-REM parasomnias and obstructive sleep apnea.
Management includes both pharmacological and environmental interventions
Given fewer adverse effects, immediate-release melatonin (3–15 mg) is preferred over clonazepam (0.125–2 mg), despite lower efficacy in reducing symptoms (32.9% v. 66.7%).4 Melatonin causes mild sedation, nausea and disturbing dreams, while clonazepam increases risk for falls, driving or cognitive impairment and drug dependency.5 Patients should create a safe sleeping environment by removing hazardous objects from their surroundings and placing a soft mat on the ground beside their bed; they should consider avoiding cosleeping. Sleep hygiene and treatment of concomitant sleep disorders are also important.
Patients should be monitored for Parkinson disease and dementia with Lewy bodies
More than 70% of patients with RBD develop α-synucleinopathies within 12 years.3 Clinicians should monitor patients for gait hesitancy, hyposmia and neuropsychiatric symptoms suggestive of early Parkinson disease. Clinicians should refer patients with such symptoms to a neurologist.
I) remains the first line treatment for insomnia. CBT-I in com-
parison with sedative-hypnotics has similar efficacy, but with
treatment durability and almost no adverse effects. Despite
CBT-I being recognized as the best insomnia treatment, access
remains limited. Digital CBT-I hopes to address the problem of
scale, so as to deliver therapy to the masses. There are now multi-
ple mobile applications available both on smartphone app stores,
which claim to deliver evidence based CBT-i. These applications
largely come at a cost and patients have to pay to access their
services. The goal of this study is to review CBT-i smartphone
applications to see if they are indeed validated.
Methods: We performed a search on the two most popular
smartphone application platforms: Google Play and Apple
Store. We used search terms: sleep, insomnia and CBT-I. We
then searched for validation studies for those smartphone appli-
cations on Google Scholar. We included studies conducted in the
past 10 years. Our second search consisted of reviewing PubMed
and Google Scholar for validation studies for CBT-I applica-
tions. Our search terms consisted of CBT-I and smartphone,
CBT-I and application and CBT-I and digital.
Results: Of the 9 validation studies that we initially found, 6 met
our inclusion criteria. 3 were excluded as they did not solely use
CBT-I in their applications. All 6 applications reported signif-
icant improvement in important sleep quality metrics such as
sleep onset latency and total sleep time. 4 studies also reported
on a subjective improvement in quality of sleep. 2 studies looked
at populations with comorbidities including cannabis use disor-
der and epilepsy. Both studied again found improvement in sleep
quality in those specific populations. There were concerning pat-
terns of bias found amongst the reviewed studies. 3/6 investiga-
tors had direct relationships with companies which designed and
marketed the applications.
Conclusion: dCBT-I offers an opportunity to increase acces-
sibility to therapy. There are only a limited number of studies
which have examined the effectiveness of the applications on the
market. There remains serious concerns about the risk of bias
and the quality of validation studies which claim to confirm the
effectiveness of these applications.