Awoman hospitalized for treatment of her mood disorder snored so loudly
that other patients complained. A sleep study showed she had severe
obstructive sleep apnea.
After using a continuous positive airway pressure (CPAP) device that
delivers air via a mask worn in sleep, she felt more focused and alert."
Her mood improved, and we were able to make greater inroads into her
psychiatric problems," related William Clemons, M.D., then a resident in
psychiatry at West Virginia University in Morgantown.
The contribution of a previously unrecognized sleep disorder to the woman's
psychiatric illness proved a signal event for Clemons. He pursued a
sleep-medicine fellowship at the University of Michigan, completing the
one-year program in 2004. He now practices sleep medicine at the Baptist Sleep
Institute in Knoxville, Tenn.
While in medical school, Paul Teman, M.D., took a two-week elective in
sleep medicine that included undergoing an overnight sleep study. Found to
have mild obstructive sleep apnea, he was started on CPAP treatment. Then
overweight, he shed excess pounds and no longer needs the CPAP device.
"I already had planned a career in psychiatry," he recalled."
My experience helped me understand apnea patients' resistance to
wearing a CPAP mask, a big issue in compliance."
The elective also heightened his interest in behavioral consequences of
sleep disorders. Teman now is taking a sleep medicine fellowship at the Mayo
Clinic, where he also completed his psychiatry residency.
"We are seeing an explosion of interest in sleep medicine as a career
option for psychiatrists," said Michael Sateia, M.D., a professor of
psychiatry and chief of sleep medicine at Dartmouth Medical School. This
interest is reflected in the American Board of Medical Specialties' (ABMS)
approval last year of sleep medicine as a subspecialty for physicians
practicing psychiatry, neurology, internal medicine, and pediatrics, he noted.
ABMS recently added otolaryngology to the list.
Starting in 2007, the American Board of Internal Medicine will administer
the sleep-medicine board exam, with certification conferred by boards
overseeing the specialties listed above. The exam formerly was given by the
American Board of Sleep Medicine.
"The new exam acknowledges that sleep medicine involves a sufficient
body of knowledge and skill sets to qualify as an independent medical
subspecialty," said Lawrence Epstein, M.D., president of the American
Academy of Sleep Medicine (AASM) and regional medical director for Sleep
HealthCenters in Boston.
The Accreditation Council for Graduate Medical Education (ACGME) has
approved 24 sleep-medicine fellowships nationwide. ACGME recognition means
that funding for fellowships is available from the Centers for Medicare and
Medicaid Services. Fellowships typically provide an annual stipend of about
Stephen Grant, M.D., now in PGY-4 of an internal medicine/psychiatry
residency at Dartmouth, plans to apply for a sleep-medicine fellowship."
I like to bill myself as doing mind/body medicine," he said."
Sleep is the perfect example of that.
"About two-thirds of the patients I see in the psychiatry clinic and
one-third of my internal medicine patients report sleep problems. I always ask
about sleep patterns and habits."
Grant sees veterans with posttraumatic stress disorder who served in Iraq
or Afghanistan at an internal medicine/psychiatry clinic at the Veterans
Affairs Medical Center in White River Junction, Vt. "One of our
immediate challenges is to restore their sleep," he noted.
Hunter Hearn, M.D., now a PGY-3 resident in psychiatry at Dartmouth, is
exploring sleep medicine via an elective. "It's a nice hybrid of
medicine, psychiatry, and neurology," he said.
In contrast to much of psychiatry, he observed, sleep medicine utilizes
objective tests such as polysomnographic studies. Some of his fellow residents
wonder whether sleep medicine involves long hours looking at a computer
"I find that's a small part of it," he said. "Most of
what I'm doing involves direct patient contact. Even if I don't go into sleep
medicine per se, I feel comfortable evaluating patients with a sleep
complaint, knowing what I can treat and when to refer."
Allen Richert, M.D., the psychiatry residency training director at the
University of Mississippi Medical Center, thinks sleep medicine education
belongs in the psychiatry residency.
"Sleep disorders and sleep deprivation contribute to depressed mood,
irritability, attention deficits, and sleepiness," he said."
Psychiatrists need experience with hypnotic medications and cognitive
behavioral therapy for insomnia."
Patients with sleep disorders benefit from a psychiatric perspective, he
added. "Psychiatrists understand how patients' emotions drive
After completing a sleep-medicine fellowship at Beth Israel Deaconess
Medical Center in Boston in 2004, Martha Praught, M.D., entered private
practice in Brookline, Mass.
She has diagnosed sleep disorders in patients with psychiatric problems
including mood disorders, attention-deficit/hyperactivity disorder,
schizophrenia, and menopausal issues.
"It's a challenge to stay active in sleep medicine in a
private-practice situation," she said. "Not all insurers reimburse
psychiatrists for diagnosing and treating sleep disorders. That has to
Psychiatrists interested in sleep medicine should contact their local sleep
disorders centers, suggested Daniel Buysse, M.D., a professor of psychiatry at
the University of Pittsburgh School of Medicine. "Many centers are
looking for more input from psychiatrists to help them manage patients with
sleep disorders and psychiatric comorbidity."
AASM offers continuing medical education courses on sleep and sleep
disorders for psychiatrists and other physicians throughout the year. Details
are posted at<www.aasmnet.org>.
Information and application forms for ACGME-approved sleep medicine
fellowships are posted at<www.aasmnet.org/FellowshipTraining.aspx>.▪