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So that was totally a senior trap but good job in your response haha.
Some thoughts:
-Sleep isn't just for Shrinks. In the U.S. it's bread and butter for Psychiatry and Sleep Medicine (duh) but also Family Medicine. And......everyone needs to know it. What impact do you think insomnia has on surgical wound healing times? Behavioral regulation and thus overall care while admitted under care of a hospitalist? Knowing this well is important and it's a great thing you can use to help out other specialties.
-Remember OSA cause psychiatric disturbance. The DSM emphasizes that psychiatric problems are not otherwise caused by a substance or medical problem. Consider this with respect to correlation and causation. A strict doctor will not diagnose someone with depression with untreated OSA for the same reason you won't diagnosis someone with mania if they are high on meth.
-There are more CPAP and other OSA treatment options than you can imagine. Obviously the UK probably has some limitations on this front but you'd surprised where you can go with this. Don't give up (for yourself OR the patients)!
-Meds do work sometimes. Knowing when they are likely to work is why we get paid. Controlled situational depression in a high functioning patient (during for instance...residency) is a good example.
-Bitch I will use whichever is easier to spell or say. And yes don't use Seroquel for sleep (usually- general and psycho-geriatrics will use it in certain populations and that's actually the right move, also can be used in certain acute settings with care and deliberation), but you'd be shocked at how often it's used when it shouldn't be. Especially cough cough NPs.
-Do not give granny Ativan. It worsens delirium. If consulted tell medicine to fuck off and prescribe it on their own recognize and copy paste whatever your delirium protocol is into the consult note. ...and then rec Ativan anyway because your attending long ago gave up.
-You are correct! I always overstate Benzo risk with patient facing communication and writing because what we are certain on is quite bad enough and it's probably better to emphasize what we may later find to be true. AND...in the best case the Benzo is impairing establishment of more definitive care anyway. I find most patients and clinical staff underestimate just how addictive Benzos are.
-Check out the AAFP and other more updated guidelines, you'll benefit from them and they lay out the thinking and some include the evidence base for the new agents. The sleep medicine ones also.
-Put rule out other processes including OSA much higher up in algo.
-Work on your lifestyle mod, you can get some common sense sleep hygiene done usually.
-CBT-I is magic if you can get them to do it. IF but it is magic.
While this is good care, I rarely see this implemented in practice. GPs bear the brunt of insomnia, though of course it's a perennial concern in psych. I've never seen my bosses actually order formal assessments for sleep apnea, not that we have the equipment to do PSG in a psychiatric hospital.
I sleep just fine these days, thankfully. When it comes to patients, I'll keep an eye on whether GPs have attempted to exclude behavioral or medical causes like OSA, but if they do, it never seems to come up in the notes or referral letters. No mention of CBT-I that I can recall, even if NICE recommends it as the first line intervention, and there's even a dedicated app.
Even if the dementia risk wasn't an issue, just the addiction potential and cognitive effects should put most reasonable people off them. The former is nasty, but I guess they beat barbiturates.
Thanks for the pointers!
In a medical setting you should always be thinking this way - just because a patient has a psychiatric complaint doesn't mean your brain should turn off. You'll miss autoimmune encephalitis this way. Also I'm looking at you 95% of emergency medicine physicians.
In psych you should be considering sleep study in a residential or outpatient setting but for crisis or inpatient I get it, other things need to be dealt with first.
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