Author's Accepted Manuscript
Sleep in Children with Psychiatric Disorders Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD.
www.elsevier.com/locate/enganabound
PII: DOI: Reference:
S1071-9091(15)00027-3 http://dx.doi.org/10.1016/j.spen.2015.04.004 YSPEN542
To appear in: Semin Pediatr Neurol
Cite this article as: Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD., Sleep in Children with Psychiatric Disorders, Semin Pediatr Neurol , http://dx.doi.org/10.1016/j.spen.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Sleep in Children with Psychiatric Disorders Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD. Abstract Sleep disturbances are common in pediatric psychiatric disorders and constitute key elements in diagnostic symptomatology of various primary psychiatric disorders including bipolar disorder, depression and anxiety disorder. Although sleep is not included in key defining criteria of some impairing illnesses such as obsessive compulsive disorder and schizophrenia, these disorders present with a very high prevalence of sleep disturbances. The interaction between sleep and psychopathology is very complex with significant inter relationship in development, severity and prognosis of psychiatric disorders and comorbid sleep disturbances. The research ranging from small intervention case series to large epidemiological studies have demonstrated the role of specific sleep complaints in specific psychiatric diagnoses. However, the research using objective instruments such as polysomnography and actigraphy remains limited in youth with psychiatric disorders. The intervention studies using pharmaceutical treatment specifically focusing on sleep disturbances in psychiatric disorders are also sparse in the pediatric literature. Early identification of sleep disturbances and behavioral management using cognitive behavior therapy based tools appears to be the most effective approach for treatment. The use of psychotropic medications such as SSRIs for the treatment of primary psychiatric disorder often alleviate the psychological barriers for sleep but may lead to emergence of other sleep issues such as restless leg syndrome. The safety and efficacy data of hypnotics for primary sleep disorders are limited in pediatrics and should be avoided or used with extreme caution in children with comorbid sleep and psychiatric problems.
Introduction Sleep complaints are frequently reported in children and adolescents with psychiatric disorders. Numerous studies have demonstrated a high prevalence of sleep initiation and maintenance insomnia, restless sleep, nocturnal fears, nightmares and daytime sleepiness among pediatric patients with mood and anxiety disorders. Bidirectional relationship between sleep disorders and psychiatric symptoms has been supported by the growing evidence of research data. Evaluation and treatment of sleep disturbances are shown to improve health outcomes in children and adolescents with and without mental health comorbidities. This article aims to provide comprehensive review of literature on sleep characteristics in children with mood and anxiety disorders and to outline treatment approaches for sleep interventions in the context of mental illness. Pediatric depression and sleep Major depressive disorder (MDD) presents primarily with pervasive sadness, loss of interest or pleasure and many other symptoms leading to significant impairment in social, academic and other important areas of functioning. The presentation of MDD in youth is very similar to adults but children often present with irritability, behavioral dysregulation and failure to gain weight.1 The prevalence of MDD increases with age ranging from 1% in early childhood, 2% in middle childhood to about 8% in adolescence with often recurring and remitting course.2 According to the latest DSM‐5 criteria, two of nine diagnostic features of MDD are sleep related and include presence of insomnia or hypersomnia nearly every day and fatigue or loss of energy nearly every day. In pediatric depression, some of the commonly reported sleep disturbances include delayed sleep onset, intermittent nocturnal awakenings, difficult morning awakenings and excessive daytime sleepiness. 3 Among these, the presence of insomnia is far more common than hypersomnia in depressed children4 but the presence of both hypersomnia and insomnia is indicative of increased severity of depression.45
Sleep complaints and depressive symptoms are often intertwined indicating possible bidirectional relationship in the psychopathology and physiology. The specific sleep complaints noted to correspond with the subset of depressive phenomenology include for example, insomnia which is often associated with psychomotor agitation, excessive worrying and somatic complaints, whereas hypersomnia is associated with psychomotor retardation, low mood, fatigue, reduced appetite, hopelessness and helplessness.5 In a recent prospective cohort study using community based sample of youth aged 11‐17 years, researchers observed that insomnia at baseline increased the risk of developing MDD by 2‐3 fold and the presence of MDD increased the risk of subsequent insomnia by 2‐3 fold thus demonstrating potential reciprocal relationship between sleep and depression.6 On similar lines, a recent population based study of Norwegian adolescents aged 16‐18 years indicated that presence of insomnia increased the risk of depression by 4‐5 fold but those who slept for
Sleep in Children with Psychiatric Disorders Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD.
www.elsevier.com/locate/enganabound
PII: DOI: Reference:
S1071-9091(15)00027-3 http://dx.doi.org/10.1016/j.spen.2015.04.004 YSPEN542
To appear in: Semin Pediatr Neurol
Cite this article as: Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD., Sleep in Children with Psychiatric Disorders, Semin Pediatr Neurol , http://dx.doi.org/10.1016/j.spen.2015.04.004 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Sleep in Children with Psychiatric Disorders Ujjwal Ramtekkar MD, MPE, Anna Ivanenko MD, PhD. Abstract Sleep disturbances are common in pediatric psychiatric disorders and constitute key elements in diagnostic symptomatology of various primary psychiatric disorders including bipolar disorder, depression and anxiety disorder. Although sleep is not included in key defining criteria of some impairing illnesses such as obsessive compulsive disorder and schizophrenia, these disorders present with a very high prevalence of sleep disturbances. The interaction between sleep and psychopathology is very complex with significant inter relationship in development, severity and prognosis of psychiatric disorders and comorbid sleep disturbances. The research ranging from small intervention case series to large epidemiological studies have demonstrated the role of specific sleep complaints in specific psychiatric diagnoses. However, the research using objective instruments such as polysomnography and actigraphy remains limited in youth with psychiatric disorders. The intervention studies using pharmaceutical treatment specifically focusing on sleep disturbances in psychiatric disorders are also sparse in the pediatric literature. Early identification of sleep disturbances and behavioral management using cognitive behavior therapy based tools appears to be the most effective approach for treatment. The use of psychotropic medications such as SSRIs for the treatment of primary psychiatric disorder often alleviate the psychological barriers for sleep but may lead to emergence of other sleep issues such as restless leg syndrome. The safety and efficacy data of hypnotics for primary sleep disorders are limited in pediatrics and should be avoided or used with extreme caution in children with comorbid sleep and psychiatric problems.
Introduction Sleep complaints are frequently reported in children and adolescents with psychiatric disorders. Numerous studies have demonstrated a high prevalence of sleep initiation and maintenance insomnia, restless sleep, nocturnal fears, nightmares and daytime sleepiness among pediatric patients with mood and anxiety disorders. Bidirectional relationship between sleep disorders and psychiatric symptoms has been supported by the growing evidence of research data. Evaluation and treatment of sleep disturbances are shown to improve health outcomes in children and adolescents with and without mental health comorbidities. This article aims to provide comprehensive review of literature on sleep characteristics in children with mood and anxiety disorders and to outline treatment approaches for sleep interventions in the context of mental illness. Pediatric depression and sleep Major depressive disorder (MDD) presents primarily with pervasive sadness, loss of interest or pleasure and many other symptoms leading to significant impairment in social, academic and other important areas of functioning. The presentation of MDD in youth is very similar to adults but children often present with irritability, behavioral dysregulation and failure to gain weight.1 The prevalence of MDD increases with age ranging from 1% in early childhood, 2% in middle childhood to about 8% in adolescence with often recurring and remitting course.2 According to the latest DSM‐5 criteria, two of nine diagnostic features of MDD are sleep related and include presence of insomnia or hypersomnia nearly every day and fatigue or loss of energy nearly every day. In pediatric depression, some of the commonly reported sleep disturbances include delayed sleep onset, intermittent nocturnal awakenings, difficult morning awakenings and excessive daytime sleepiness. 3 Among these, the presence of insomnia is far more common than hypersomnia in depressed children4 but the presence of both hypersomnia and insomnia is indicative of increased severity of depression.45
Sleep complaints and depressive symptoms are often intertwined indicating possible bidirectional relationship in the psychopathology and physiology. The specific sleep complaints noted to correspond with the subset of depressive phenomenology include for example, insomnia which is often associated with psychomotor agitation, excessive worrying and somatic complaints, whereas hypersomnia is associated with psychomotor retardation, low mood, fatigue, reduced appetite, hopelessness and helplessness.5 In a recent prospective cohort study using community based sample of youth aged 11‐17 years, researchers observed that insomnia at baseline increased the risk of developing MDD by 2‐3 fold and the presence of MDD increased the risk of subsequent insomnia by 2‐3 fold thus demonstrating potential reciprocal relationship between sleep and depression.6 On similar lines, a recent population based study of Norwegian adolescents aged 16‐18 years indicated that presence of insomnia increased the risk of depression by 4‐5 fold but those who slept for
