Improving Sleep-Wake Assessment in Major Depressive Disorder

As a key characteristic of major depressive disorder (MDD), it is imperative that clinicians are equipped to evaluate sleep disturbances in clinical practice. In this video, Psych Congress faculty member Hara Oyedeji, DNP, PMHNP-BC, MSEd, provides an overview of the relationship between sleep-wake disruptions and MDD. She highlights the impact that sleep may have on mood dysregulation and physical health, outlines practical strategies for better assessing sleep disturbances in routine interactions with patients, and explains how emerging research may be leading to more precise sleep interventions for this patient population.

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• Excessive daytime sleepiness affects an estimated 30% to 40% of patients with MDD, while insomnia affects approximately 60% to 80%, according to research estimates. 
• Sleep disturbances can affect executive functioning, memory, work, relationships, mood, and physical health and may persist even when MDD is otherwise treated effectively. 
• Clinicians should use sleep-specific screeners and targeted questions about sleep duration, restfulness, daytime functioning, routines, and sleep environment to distinguish symptoms such as insomnia and hypersomnia and individualize treatment.

Psych Congress NP Institute: What is the prevalence of sleep-wake disturbances in patients with major depressive disorder?

Hara Oyedeji, DNP, PMHNP-BC, MSEd: That's a great question. When you think about the prevalence of sleep-wake disorders, you can think of it in 2 categories. If you're thinking about those who suffer with excessive daytime sleepiness, in that case, you're estimating anywhere from 30% to 40% prevalence of the population that may have that as an issue. 

When you think about insomnia, it's even more, about 60% to 80% based on trials and research that's been out there as an estimate with regards to how prevalent it affects that patient population. It’s definitely huge.

Overall, if you are treating a patient with major depressive disorder, there is a strong chance and correlation of [the patient] having sleep-wake symptoms.

PCNPI: How do sleep-wake disturbances impact patient quality of life and treatment approaches?

Oyedeji: Having sleep-wake symptoms can definitely impact a patient's quality of life. If you think about it in terms of just major areas—cognitively, your executive functioning—those things are hugely impacted, and that affects how you do everything from your work and how you're able to carry out tasks to your memory. 

That is something that a lot of times patients will complain about and say, “I'm really having trouble with sleep, but I also can't remember things or I forget things.” Those should be flags for us as clinicians.

You also have to think about the high correlation to overall medical comorbidities. Those who have sleep-wake symptoms are going to be at risk for cardiovascular issues.

In general, there is the overall burden on one's body for lack of sleep. If you think about it, sleep essentially is the time for your body to prepare itself and do the work that needs to be done so it can basically get back to a place so that you can do it all over again the next day. When you are affecting those areas when you're having impacted sleep or sleep-wake symptoms, that definitely is an issue. So, there’s a high correlation to issues with your physical health and your mental health. 

As mental health practitioners and clinicians, this is what we do. We think about it when people say, “Oh, I just woke up on the wrong side of the bed.” 

Sleep is so foundational. It affects our mood. And oftentimes, it's the one thing that gets sacrificed. So that's something that we need to pay more attention to.

If it's something that should be elevated to a point where we're focusing on it, why aren't we doing it? Why aren't we doing it with more precision? It's just something that has really eluded us as well as our patients. 

We do the best that we can but it definitely impacts all of those different areas in one's life, and then not to mention your social interactions. Your relationships and the people around you who you love, care for, or have to work with, they are also going to be recipients of that mood dysregulation or just the effects of having sleep-wake symptoms and dysregulated sleep.

PCNPI: What practical approaches should be considered to improve the assessment of sleep-wake symptoms and align treatment strategies with individual patient needs? 

Oyedeji: Some practical approaches to help better align the treatment needs of sleep-wake symptoms and disorders within the context of MDD for our patients is using screeners. Making sure that when you're having that time with your patient, you're getting a good baseline for where they might be, and also intermittently screening to see, are they exhibiting certain symptoms that might actually help you identify a more specific phenotype with regards to their MDD?

I think that is a really big piece that we need to hone in on, [because it’s] easy enough to work into your workflow. We're already doing screeners, and there are a lot of them, but we haven't been as educated in everything that we do. A lot of newer clinicians, and myself included, are fairly new to seeing some of the screeners that exist looking at insomnia specifically and looking at sleep so I think that that's going to be really important. 

Another thing that we can do is once again get an adequate profile for what your patient's day-to-day functioning and what their schedule is like. I'll often ask my patients what is it that you're doing when you're sleeping: are you in an environment that makes sense? Are you in a quiet space? What are you doing to also contribute holistically to a better sleep environment? 

And then you also want to ask them to quantify it and then get a subjective report.  Quantify meaning: Ask, “How many hours are you sleeping? Is it restful sleep? How do you feel when you wake up?”

Honing in on the questions are going to be really specific as opposed to a blanket, “Tell me about your sleep,” or, “Are you sleeping well?” I think we have to get a lot more specific. 

Those are some practical things that we can do in our everyday interactions with patients.

PCNPI: What are some key takeaways from the latest clinical evidence on emerging pharmacotherapies targeting sleep-wake dysfunction in MDD? 

Oyedeji: Some key clinical takeaways with a lot of the emerging information and data that we are seeing now with regards to sleep-wake symptoms in MDD is that we have an opportunity to be more focused and honed in on understanding what our patients' needs are when it comes to sleep. 

For a long time, sleep has just been something that we understand and know to be an issue. Our patients complain about it, but it's really escaped us on how to treat it. 

We have sleep agents and current pharmacotherapies that we're able to utilize to help. But for many of our patients, they’ve only been partial in its efficacy or don’t get the job done. 

A lot of times we are treating the MDD, and we may be doing it fairly effectively, but there's still that complaint that, “I'm not able to get enough sleep.” 

I think we have to go back to our roots and understand, have a conversation, and get a clear idea about what our patient's day-to-day activities are like. What is it like in their evenings or at their bedtime? From there, are we also using screeners? Are we using best practice to really understand what we’re seeing? Is there a possibility that they have MDD with a specific specifier? Is it hypersomnia or is it insomnia? And then from there, we can better tailor what we need to do.

Right now, the clinical evidence is showing us that we can be more precision-based. We have an opportunity to utilize other mechanisms of action, not just use of traditional antidepressants and other medications for sleep but is there another pathway? Do we have another way of treating sleep, but doing it more effectively with a better side effect profile, and are we also able to treat sleep within the context of MDD?

So not just separating it aside as its own thing, which it can be, but understanding it in the context of MDD. 

I think it's just exciting. It's opened the gates to a runway that for a long time we've been yearning for because we really have been operating in a space doing the best that we can, not knowing how to treat sleep, and just trying to see what we can do to help patients. But we can do better. We can use biomarkers. We can utilize holistic approaches like chromotherapy to understand the big picture.

Hara Oyedeji, DNP, PMHNP-BC, MSEd, is a board-certified Psychiatric Nurse Practitioner currently working in outpatient care with experience in inpatient and psychiatric hospital settings. She serves as owner, clinician and clinical preceptor in her private group practice, Fortitude Wellness Group, and is the Chief Operating Officer and Medical Director of a CARFaccredited Outpatient Mental Health Clinic, Greater Chesapeake Health and Wellness in Baltimore City. Hara completed her undergraduate degree at Rutgers University and her Master’s degree in education from Monmouth University in New Jersey. She completed her Master’s degree in nursing from the University of Maryland with her Post-Master's training as a psychiatric mental health nurse practitioner from Drexel University.

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