Sleep in Adolescents with Psychiatric Disorders

A. Five or more of the following symptoms during the same 2-weeks period and represent a change from previous functioning where at least one of the symptoms is depressed mood or loss of interest and interest or pleasure

1. Depressed mood most of the day, almost every day, indicated by your own subjective report or by the report of others. This mood might be characterized by sadness, emptiness, or hopelessness

2. Markedly diminished interest or pleasure in all or almost all activities most of the day nearly every day

3. Significant weight loss when not dieting or weight gain

4. Inability to sleep or oversleeping nearly every day

5. Psychomotor agitation or retardation nearly every day

6. Fatigue or loss of energy nearly every day

7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day

8. Diminished ability to think or concentrate, or indecisiveness, nearly every day

9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning

C. The episode is not due to the effects of a substance or to a medical condition

D. The occurrence is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders

E. There has never been a manic episode or a hypomanic episode

While the majority of adolescents with major depression often report sleep complaints when compared with other age groups, insomnia (74 %) as well as hypersomnia (36 %) are prevalent in adolescents [3]. However, presence of both hypersomnia and insomnia is indicative of increased severity of depression [4, 5]. The subset of depressive specifiers and symptoms are also noted to be related to specific sleep complaints. In depression with melancholic features, there is early morning awakening and worsening of depression in the morning. In contrast, depression with atypical features is characterized by hypersomnia. Insomnia 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].

Several longitudinal studies have established a close relationship between sleep disturbances and depressive illness over time indicating possible shared neurophysiological pathways in depression and sleep disorders [6, 7]. While the onset of sleep complaints as early as age 4 has been considered a predictor of depression in adolescence [8, 9], a recent longitudinal study has also demonstrated that symptoms of depression established in early adolescence are a moderate predictor of difficulty initiating sleep (DIS) in early adulthood indicating possible bidirectional relationship in the psychopathology and physiology [10]. On the similar lines, there have been studies establishing reciprocal relationship between sleep complaints and depression. For example, a community-based, prospective cohort study of adolescents showed 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 [11]. In addition to the presence of sleep disturbance, the severity also predicts the risk of depression as demonstrated in a study of Norwegian adolescents aged 16–18 years, where presence of insomnia increased the risk of depression by 4–5 fold but those who slept for <6 h had more than eightfold increase in risk of depression [12].

In addition to functional impairment, severe depression can result in suicidal ideations, sometimes culminating in suicide attempt or completed suicide. It is estimated that over 20 % of depressed teenagers seriously contemplate suicide, whereas completed suicide is the third leading cause of death for 15–24-year-olds [13]. Significant sleep disturbances, both insomnia and hypersomnia, have been noted in youth with suicidal ideations, suicide attempts, or completing suicide as compared to those without suicidal thoughts [14, 15]. Moreover, the nature, duration, and severity of sleep disturbance also appear to be an important risk factor for suicidal thoughts. For example, the change in the sleep disturbance in the preceding week has been associated with completed suicide, and having less than 5 h or more than 10 h of sleep has been significantly correlated with higher risk of suicidality [16]. A meta-analysis of studies examining relationship between sleep disturbance and suicidal thoughts concluded that sleep disturbances in general, as well as insomnia and nightmares individually, appear to represent a risk factor for suicidal thoughts and behavior [17].

There have been several studies to identify the objective markers of depression using sleep measures such as polysomnography and actigraphy in adolescents. However, the results have been variable in the parameters used and inconsistent in the findings. In a meta-analysis of PSG studies, the only robust correlation was found for increased sleep latency and decreased intra and interhemispheric coherence on EEG in depressed youth [18]. In a study aimed to quantify circadian rhythms in rest-activity cycles using actigraphy, depressed adolescents showed lower activity levels and damped circadian rhythm when compared to healthy controls. These findings were not seen in younger age group and were unique to adolescents [19]. In general, sleep studies are not used for the diagnostic or treatment purposes in depression.

Diagnosis of depression often requires comprehensive clinical assessment by trained professionals to assess comorbid mental health conditions, rule out general medical disorders as well as medications that may present as depression (Table 7.2). However, primary care and specialty medical providers caring for adolescents play an important role in identifying the warning signs and screening for depressive disorders.

Table 7.2

Differential diagnosis of depression in adolescents

Medical disorders

• Hypothyroidism

• Anemia

• Mononucleosis

• Chronic fatigue syndrome

• Autoimmune diseases

• Seizure disorders

• SLE or collagen vascular disorder

• Infectious mononucleosis

Medication induced

• Corticosteroids

• Contraceptives

• Stimulants

• Isotretinoin

• Beta blockers

Psychiatric disorders

• Adjustment disorder with depressive features

• Bipolar disorder

• Substance abuse disorder

• Eating disorders

• ADHD—inattentive presentation

There are several rating scales available for screening and monitoring of depression which can be easily administered during routine clinic visits. One of the widely used depression rating scales adapted for teenagers is PHQ-9 (Parent Health Questionnaire) (Table 7.3), which is validated for use in the medical settings for depression screening and severity monitoring against the gold standard. Another adaptation, PHQ-2, has also been promising as a brief screening tool but not for monitoring treatment, and it does not appear to be as well-validated as the PHQ-9 in teenagers [20, 21]. Other specific rating scales for teenage depression include Center for Epidemiologic Studies Depression Scale (CES-D) and Columbia Suicide-Severity rating scale (CSS) that are shown to be specific, sensitive, and valid in screening and monitoring severity of depression [22, 23].

Table 7.3

PHQ-9 modified for teenagers

PHQ-9: Modified for teens

Name: ____________Clinician: ___________ Date: ___________

Instructions: How often have you been bothered by each of the following symptoms during the past two weeks? For each symptom put an “X” in the box beneath the answer that best describes how you have been feeling

	(0)	(1)	(2)	(3)
	Not At All	Several Days	More Than Half the Days	Nearly Every Day
1. Feeling down, depressed, irritable, or hopeless?
2. Little interest or pleasure in doing things?
3. Trouble falling asleep, staying asleep, or sleeping too much?
4. Poor appetite, weight loss, or overeating?
5. Feeling tired, or having little energy?
6. Feeling bad about yourself—or feeling that you are a failure, or that you have let yourself or your family down?
7. Trouble concentrating on things like school work, reading, or watching TV?
8. Moving or speaking so slowly that other people could have noticed?
Or the opposite—being so fidgety or restless that you were moving around a lot more than usual?
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
In the past year have you felt depressed or sad most days, even if you felt okay sometimes?
[ ] Yes [ ] No
If you are experiencing any of the problems on this form, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people?
[ ] Not difficult at all [ ] Somewhat difficult [ ] Very difficult [ ] Extremely difficult
Has there been a time in the past month when you have had serious thoughts about ending your life?
[ ] Yes [ ] No
Have you EVER, in your WHOLE LIFE, tried to kill yourself or made a suicide attempt?
[ ] Yes [ ] No

Treatment of adolescent depression consists of psychotherapy, medication management or both depending on the severity of symptoms. Cognitive behavioral therapy (CBT) has been found to be more effective in treatment of milder forms of depression as compared to other therapies. The first-line medications approved for treating adolescents are Citalopram (Celexa), Fluoxetine (Prozac), Sertraline (Zoloft), and Escitalopram (Lexapro). However, the results from two large, multi-center, randomized controlled trials—The Treatment for Adolescents with Depression Study (TADS) and the Treatment of Resistant Depression in Adolescents (TORDIA) , indicate that the most therapeutic response was found with the combination of cognitive behavioral therapy and SSRI [24, 25]. Interestingly, the presence of sleep complaints has been associated with responsiveness of depression-focused treatment as well as future relapse of depression. The TADS study results indicated that sleep issues were the most common residual symptoms in adolescents under treatment. Similarly, a longitudinal study of depressed adolescents treated with different modalities indicated that persistent sleep disturbances were associated with poor treatment response independent of treatment modality, age, and gender [26]. In addition to the effect of sleep on treatment response of depression, there is also evidence of the impact of SSRIs on sleep architecture, although the findings have been inconsistent in various studies depending on the medication, age, and psychiatric conditions [27]. Although trazodone has been used in adults and children, co-treatment with trazodone and SSRI in adolescent has not been more effective in relieving insomnia [28]. Since there is scarcity of data about use, effectiveness and safety of sleep adjunctive medications in adolescents, it is important to consider medication properties, sleep symptoms, and concurrent SSRIs when using sleep medications in adolescents treated for depression.

In addition to traditional treatment of depression, specific psychotherapy and behavioral interventions to address insomnia can be used in the treatment of depressed adolescents. CBT for Insomnia (CBT-i) is a specific modality for insomnia that includes multiple interventions including sleep diary, sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. In adults with insomnia and depression, CBT-i has been shown to improve mood as well as sleep [29]. The application of CBT-i interventions in depressed adolescents can be effective and may result in better response to concurrent pharmacological treatment.

Clinical Pearls and Pitfalls: Depression

Subjective sleep complaints including sleep onset and maintenance insomnia and excessive daytime sleepiness are extremely common in adolescents with major depressive disorder.
Early recognition and treatment of sleep disturbance in youth with major depression significantly improves their health outcomes and reduces risk for relapse.

Learning Points

Insomnia and hypersomnia are a major part of the current DSM-5 diagnostic criteria for major depression.
Sleep evaluation is an essential part of the assessment of adolescents that present with symptoms of depressive disorders.
Increased sleep onset latency emerged as a most consistent feature of insomnia associated with depression in youth.
Several studies indicated a relationship between sleep disturbances and increased risk for suicide among adolescents with depression.
Successful treatment of sleep disturbances improves mental health outcome and reduce risk for relapse in adolescents with depression.

Clinical Case : PTSD

Jane is a 17-year-old girl senior class student who presents due to concerns of feeling tired “all the time,” excessive daytime sleepiness, and poor attention. Parents also report that she has been irritable, at times “lost in her own world,” and has been avoiding the tennis practice despite getting selected to play at the state level. Parents report that Jane has been insisting on quitting sports due to “tiredness,” despite high chances of being awarded a sports scholarship at the college of her choice. She is able to attend school, but her academic grades have declined in the past quarter. She has not had any history of ADHD, although she was evaluated due to concerns of inattention, impulsivity, and agitation at age 14. At that time, the symptoms were attributed to exhaustion from the busy schedule of tennis practice and traveling for tennis camps in different cities. Jane and her parents denied any medical issues except for a minor ankle sprain. She does not take any medications or OTC products. There is a family history of anxiety and obstructive sleep apnea. On exploring sleep symptoms, she reports having difficulty falling asleep, nonrestorative sleep despite >9 h in bed, and feeling exhausted throughout the day. She denied any OSA-like symptoms. On further questioning, she does report nightmares on a daily basis with multiple awakenings. When asked about the content, she reveals that she was sexually assaulted by two boys at age 14 during the out of town tennis camp that she disclosed only to close friends in the camp. However, during the most recent tournament, she saw one of the boys and suddenly started having anxiety, nightmares about the assault, and irritability during the day due to intrusive thoughts. She reports feeling emotionally drained and very guilty when thinking about the incident and always worries about the reaction of her parents and friends if they were to find out. Jane reports that her decision to quit sports is based on avoiding any chances to confront the boy again. She also endorses significant anxiety interfering with her ability to focus on school and family.

Management and Clinical Course

Jane’s parents were involved after she was encouraged to inform them about the traumatic incident. Jane was referred to the clinic psychologist who conducted a detailed clinical evaluation including an interview of Jane and her parents. Jane was diagnosed with PTSD and a specific from of psychotherapy—trauma-focused cognitive behavioral therapy was suggested. Despite some improvement in her symptoms of PTSD, she continued to report insomnia and nightmares. She was initiated on low-dose Zoloft and also suggested to implement relaxation exercises prior to bedtime. Jane responded well to the combination of therapy and treatment with improvement in anxiety and sleep. Parents also took action by contacting the appropriate authorities and the tennis camp organizers.

Discussion

Posttraumatic stress disorder (PTSD) is characterized by the direct or indirect exposure to the traumatic event , persistent re-experiencing of the event, avoidance of distressing trauma-related stimuli, negative mood, hyper-arousal and increased reactivity to stimuli, and at times dissociative symptoms lasting more than a month (Table 7.4) [2]. According to the recent National Comorbidity Survey Replication (NCSR) , over 5 % adolescents meet criteria for Posttraumatic stress disorder (PTSD) with higher prevalence in girls (8 %) than boys (2.3 %) [30]. The increase in prevalence can be attributed to the variety of traumatic life-threatening events in the past few decades such as mass shootings, violent crimes, suicide bombings, terrorist attacks, motor vehicle accidents, wars, in addition to the natural disasters such as hurricanes, earthquakes, floods, and fire. However, the major causes of traumatic experience in adolescents remain physical abuse, sexual abuse, and witnessing community violence [31]. Adolescents are more likely than younger children or adults to exhibit impulsive and aggressive behaviors. They are also likely to exhibit traumatic re-enactment, in which they incorporate aspects of the trauma into their daily lives.

Table 7.4

DSM—5 criteria for PTSD

A. Exposure to actual or threatened death, serious injury, or sexual violence, in one or more of the following ways:

1. Directly experiencing the traumatic event

2. Witnessing, in person, the event(s) as it occurred to others

3. Learning that the traumatic event(s) occurred to a close family member or close friend. If the event involved actual or threatened death, it must have been violent or accidental

4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s), (e.g., first responders, collecting body parts; police officers repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures

B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred

1. Recurrent, involuntary, and intrusive distressing memories of the traumatic events(s)

2. Recurrent distressing dreams in which the content and/or the affect of the dream is related to the traumatic event

3. Dissociative reactions (e.g., flashbacks) in which individual dream or act as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum from brief episodes to complete loss of awareness of present surroundings)

4. Intense or prolonged distress at exposure to internal or external cues that symbolize or resemble an aspect of traumatic event

5. Marked physiologic reactions to internal or external cues that symbolize or resemble an aspect of traumatic event

C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)

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