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“Kate” is a 15-year-old Caucasian female with a history of attention-deficit/hyperactivity disorder (ADHD), diagnosed at age 7. At age 9, she reported nightmares 2 to 3 times weekly. Although her primary symptom was inattention, Kate also reported racing thoughts and a nocturnal burst of energy associated with initial insomnia more than half of nights. These symptoms improved between ages 7 and 9 with stimulant medication, but were still present. Now in high school, Kate reports a mild worsening of inattention. As her psychiatrist, how would you educate the patient and her parents about the relationship between sleep problems and symptoms in ADHD?

Sleep disturbances are a common comorbidity in ADHD, affecting approximately one quarter to one half of patients, including those who are treatment-naïve.

 There is a potential bidirectional association between exacerbations of sleep disturbance and ADHD symptoms.

 Therefore, sleep disturbances appear relevant to the clinical management of ADHD. Previous studies of sleep and ADHD have focused on childhood/early adolescence,

 and have not included repeated measurement of symptoms. Given that these symptoms can persist into adulthood, there is a need to understand their longitudinal relationships.

 investigated associations between sleep problems and ADHD symptoms in a longitudinal population-based cohort study. Among 18 million phone numbers, 7912 were randomly selected for survey. These numbers yielded 4186 eligible families, of whom 1055 (25%) were successfully recruited. Families were assessed in 3 waves (each 4 to 5 years apart), over a 9-year follow-up period. Among the enrolled families with complete data at all waves, 256 were included in the main analysis. 

Parents were surveyed about ADHD symptoms using a structured interview based on the K-SADS at each wave. A structured interview based on the 2 main questionnaires for sleep disturbances in children were also used at wave 1 (28, 29). In waves 2 and 3, half of subjects had a repeat interview for sleep disturbances.

Study authors first investigated bivariate correlations between sleep disturbance and ADHD symptom scores. They then used a random-intercept cross-lagged panel model to explore longitudinal associations between sleep disturbance and ADHD symptoms, reported as regression coefficients (β) and 95% confidence intervals.

The mean subject age was 9.4 at wave 1, 13.4 at wave 2, and 18.2 at wave 3, and 52% of the sample was male. More than 80% of parents were married, and more than 50% had attended college or university. Both sleep disturbances (ρ>0.24 for each) and ADHD symptoms (ρ>0.29 for each) were significantly correlated across the 3 waves. At each wave, sleep disturbances and ADHD symptoms were significantly correlated with each other (ρ>0.14 for each). Furthermore, sleep disturbances at waves 1 and 2 were significantly correlated with ADHD symptoms at wave 3 (ρ>0.14 for each). 

In cross-lagged models, sleep disturbance at wave 2 was a significant indicator of ADHD symptoms at wave 3 (β=0.15), explaining 12% of the within-person variance in ADHD symptoms. By contrast, ADHD symptoms at wave 2 did not predict sleep disturbance at wave 3. In secondary analyses, findings were stronger for inattentive (versus hyperactive-impulsive) symptoms.

The authors concluded that there is a directional association between sleep disturbance in early adolescence and ADHD symptom severity in early adulthood after considering between- and within-person effects. Findings were stronger for inattentive than hyperactive-impulsive symptoms. The primary study strength was the use of a longitudinal design with repeated assessments with consideration of directionality. Study limitations included missing data, reliance on parental reports of ADHD symptoms, and the use of telephone survey (versus in-person assessment).

This study demonstrates that sleep disturbance in early adolescence is an indicator of ADHD symptom severity in early adulthood. Findings suggest that routine assessment of sleep disturbance is warranted in patients with ADHD, and ADHD symptoms in children with sleep disturbances.

is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the Editorial Board and serves as the schizophrenia section chief for 

The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.

1. Sung V, Hiscock H, Sciberras E, Efron D. 

Sleep problems in children with attention-deficit/hyperactivity disorder: prevalence and the effect on the child and family

2. Cortese S, Faraone SV, Konofal E, Lecendreux M. 

Sleep in children with attention-deficit/hyperactivity disorder: meta-analysis of subjective and objective studies

3. Quach JL, Nguyen CD, Williams KE, Sciberras E. 

Bidirectional associations between child sleep problems and internalizing and externalizing difficulties from preschool to early adolescence

4. Chervin RD, Ruzicka DL, Archbold KH, Dillon JE. 

Snoring predicts hyperactivity four years late

Severe sleep problems in infancy associated with subsequent development of attention-deficit/hyperactivity disorder at 5.5 years of age

6. Gosling CJ, Cortese S, Konofal E, et al. 

Association of parent-rated sleep disturbances with attention-deficit/hyperactivity disorder symptoms: 9-year follow-up of a population-based cohort study

Good night, sleep tight! Researchers performed a 9-year follow-up of sleep disturbance and ADHD symptoms in a population-based cohort study.

Longitudinal Study of Sleep and ADHD Symptoms

Key Takeaways and the Future of Narcolepsy Treatment

Goals of Therapy and Factors That Shape Treatment

Clinical Impressions From Patient Case #2

Patient Case #2: 27-Year Old Woman With Cataplexy

Let's talk about some of the newer medications in the last couple of years; solriamfetol and pitolisant have been approved by the FDA as well as a lower sodium version of oxybates. Any thoughts on how these slot in amongst these other medicines?

 what is interesting about pitolisant is that some of their studies have also been done as a medication that's been used with others such armodafinil and even, I believe, sodium oxybate. I personally have added pitolisant on to some of these other medications such as modafinil rather than an amphetamine, for example. Maybe I would try that first, depending on cost and availability. I think same for solriamfetol. I usually don't use it together with another stimulant, but that may be my next one up for modafinil, maybe solriamfetol rather than amphetamine.

Is there advantages of solriamfetol in that regard?

 Well, I think that being more of a reuptake inhibitor, it is supposedly less, although there are cardiovascular side effects versus, there is this issue with blood pressure, but at least in my head, I think it may be less. Just based on that there may be advantages, but I don't know about the long-term data with solriamfetol. Maybe somebody else can comment on that, the abuse liability, etcetera. I'm not as clear, I would imagine it will be similar.

My impression is the abuse liability with solriamfetol is pretty low.

And I agree with you. At higher doses, especially, it can increase blood pressure a few points. But as a reuptake blocker of dopamine and norepinephrine, I think it is a bit less prone towards the somewhat large increases in blood pressure that you can sometimes see with amphetamines.

 That's probably why I would just use that as the second line after Modafinil. It's cost that is another issue, it is being able to prescribe that to your patients. Sometimes they make you try all these other things first.

Dr. Moawad, you have some thoughts? Yes, go ahead, Dr. Benca?

 Well, as I mentioned earlier too in patients where you're concerned about substance abuse potential, and you want to stay away from amphetamines, these are also things to consider.

Have any of you encountered actual drug abuse with pitolisant, solriamfetol, or oxybate?

 I have not with the pitolisant or sodium oxybate. Not sure about solriamfetol, I just don't have enough of an experience with that, but not really. I've had patients say, “well, maybe it doesn't work even at higher doses,” and then go to the next thing. I have not seen them abuse it or go to higher doses. I have not seen that.

Thought leaders consider the role of newer medications in the therapeutic landscape. 

New Directions in Treatment

Dr. Moawad, what do you see are some of the challenges with these traditional medicines regarding abuse or side effects and so forth? What are the biggest pitfalls and concerns in your mind?

 I have, unfortunately, heard patients talking about sharing medications with friends or family members who are not given those prescriptions. Sometimes, also diagnosing friends or family members and saying. I have heard from people who have said, “I tried it, because my roommate took it or a family member took it, and it worked. So maybe this condition is what I have,” and working backwards. That is one problem. Also, potentially inconsistent use is another thing; someone might be feeling better one week so they stop taking it or do not take as much. Self-regulating can end up being problematic. Some people will report that they self-regulated or shared but some people do not necessarily share that information as willingly.

I think that once somebody gets on a good regimen, they appreciate the benefits of those promoting medicines enough that they are motivated to take it consistently every day. But certainly stopping some medicines or taking them intermittently—such as if somebody is taking an antidepressant for their cataplexy –can be a catastrophe with rebound cataplexy. Dr. Benca, Dr. Zee, what do you think? More comments on abuse or side effect issues that come up?

 Well, I think one thing to keep in mind, since we are talking to a psychiatric audience, is that many psychiatrists are very comfortable prescribing large doses of amphetamines for things like attention deficit disorders and hyperactivity disorders. We are cautioning to be a little bit more careful with these medications. Keep that in mind as well.

 I think that cardiovascular side effects potentially from the amphetamines are foremost in my mind, especially if it is a chronic disease, a chronic disorder. We are going to be taking care of these patients for a long time as they get older, middle aged and so forth. That is something that weighs on me when I start somebody on one of these types of medications. Not so much with sodium oxybate. We're talking about the amphetamines.

You are probably familiar with the papers by Yves Dauvilliers showing that just having narcolepsy itself predisposes people to hypertension. When you add on some of these sympathomimetic medicines, I think you can get into some pretty good concerns there.

Thomas E. Scammell, MD; Heidi Moawad, MD; Phyllis C. Zee, MD, PhD; and Ruth Benca, MD, PhD, discuss abuse, side effects, and other obstacles associated with traditional medications.

Challenges in the Management of Narcolepsy

Dr. Moawad, we talked a lot about the behavioral and vocational aspects of this. Let's talk a little bit about the actual medications Let's start off with some of the traditional meds. Do you want to comment on how you see modafinil, armodafinil, amphetamines, sodium oxybate fitting in?

 Well, they are effective. The main thing is that they have been around for a long time. People use them and when patients use these as directed, they will notice improvement and that in and of itself helps with compliance and it helps with symptoms, helps with overall quality of life. These kinds of things are not to be used for treating depression, even though a lot of patients who have depression obviously will feel a little bit better because they're having fewer symptoms of their narcolepsy. But I just think they've been around for a long time, and people report success, those who are compliant.

If you have somebody who, let's just for the sake argument, has relatively mild sleepiness regarding these sorts of traditional medications. What would you turn to initially?

 I think for a typical patient, who is not on a lot of other things, I would probably try modafinil and they would, for the most part, do better and have fewer symptoms. I think that would really be the first choice.

 Do you make much of a distinction between modafinil and armodafinil?

 Not necessarily. I wonder if one of the others could comment on that.

 Most of my patients are more likely to be on armodafinil than modafinil, although initially, they were all on modafinil, I'm not sure. I think that may be part of the cost issue. Also, there are different doses for modafinil. The lowest dose is different from modafinil and armodafinil. So, I think most of my patients are on armodafinil. I don't think I have a preference, although supposedly armodafinil may have a longer period of action. I have not found that. I have patients take armodafinil twice a day as well.

I think my experience has been, it's mainly a question of whichever is less expensive on that insurer's formulary. But I tend to use them interchangeably. Dr. Zee, let's say you have a patient with more substantial sleepiness, say an Epworth score of say 17 or something like that. Do you think it's worth starting with modafinil or would you jump in with something else?

 I still will start them on one of the modafinil or armodafinil. I don't think we have data to show that if you're more sleepy on the Epworth Sleepiness Scale, that you're less likely to respond. I don't know of it. I'm not sure that there is that data. I would start with that because of the safety and, also, I think just practicality and cost of the medication. Of course, that may be different in a woman who may not want to be on birth control methods and so forth; that could change my thoughts. Of course, we have patients on amphetamine or amphetamine-like derivatives. So that is something that would probably be a second line if they fail modafinil or armodafinil or even if I go higher on the dose of modafinil.

The European treatment guidelines really push amphetamines to the background. Do you use them much in your patients?

 My patients, I would say about 30 to 40 percent, are on some type of amphetamine-like substance, but more intermittently, that would be more of what they do. For example, when they need to be driving, when they need to do something, they may then add 10 milligrams of methylphenidate for example or something of that sort. I do have a number of patients that are on both modafinil and a smaller dose of amphetamine. I try not to have high levels of that, and that's how I actually use modafinil to kind of decrease the amount of amphetamines that the individual may need.

 I like that idea. Essentially you use modafinil to lay a foundation.

 I would say create a baseline; smooth things out during the day. That's what I tell them.

And then because some of the amphetamines are short-acting, they are nice as a PRN where they can take them later in the day without necessarily messing up their sleep if it's not after dinner time or something like that.

: I think it's also the case that patients sometimes have a fluctuation in their symptoms. Particularly the ones that are not the super severe excessively sleepy patient, some days they have more trouble than others. And having the ability to add in some medication as needed is helpful to them.

Dr. Benca, do you want to talk a little bit more about oxybates?

: Well, I'll talk about it from my psychiatric hat. Certainly, sodium oxybate is something that is quite helpful to patients who have cataplexy and I pretty much only use it in patients with cataplexy. But the other thing I think for psychiatrists to be aware of is that there are psychiatric side effects of sodium oxybate. In particular, there have been reports of psychosis developing as well as cases of bipolar disorder triggered by oxybate. We want to be careful with that medication and be aware of that. I tell psychiatrists you're more likely to see side effects of sodium oxybate than ever use it yourself.

When I'm prescribing an oxybate this is part of that initial conversation of whether that person is psychiatrically solid enough to be able to take it safely.

: Because it can unmask things or worsen tendencies that patients have, particularly for mood disorders or suicide.

 One of the potential benefits of sodium oxybate, other than cataplexy, is in a patient who may have prominent sleep fragmentation or disruption. So occasionally that helps me weigh that versus the amphetamines or just awake-promoting agents.

Could I just ask for clarification, Dr. Benca? You had talked about using oxybates in your patients with cataplexy. Are you using it because you think it's a great drug for cataplexy, or are you using it because patients with cataplexy tend to have more substantial sleepiness as well?

: A bit of both. And if other treatments that I try for cataplexy, like some of the antidepressants, aren't working, I may add that in. And again, I agree with Dr. Zee about the patients who have fragmented sleep. I think back and there been a couple of cases that I've seen where patients didn't come in complaining at all about excessive sleepiness but complained that they just kept waking up at night and couldn't get a solid night of sleep. When we tested them, they turned out to have narcolepsy. So that can be a significant symptom in some patients, and sodium oxybate would be something that I would consider in that case, particularly if there's cataplexy as well.

If you saw a patient who only recorded spontaneous awakenings during the night, but not a lot of sleepiness, would you be thinking of narcolepsy?

We see plenty of insomnia patients like that.

: Insomnia patients complain that they are tired and fatigued, but they are not falling and cannot ever fall asleep. So no, that's a whole different ballgame. But patients who fall asleep during the day think it is because they didn’t sleep at night. I think one of the things in sleep that we see is patients tend to interpret their symptoms. If they don't feel good during the day, they assume it's because they didn't sleep well at night, or they attribute it to feeling depressed. They create these stories about why they are feeling the way they are and what they are attributing it to, which may or may not be accurate.

Thomas E. Scammell, MD; Heidi Moawad, MD; Phyllis C. Zee, MD, PhD; and Ruth Benca, MD, PhD, discuss the advantages and disadvantages of specific drug mechanisms for the treatment of narcolepsy.

Pharmacological Treatment Approaches

Let's change gears a little bit and talk about treatment approaches for narcolepsy. In your own experience, is this the case that we just saw typical, Dr. Zee, before patients get diagnosed? Do you see them coming up with self-medication, like caffeine or something like that?

 Almost always it's caffeine, and it stops working or they stop, they have side effects or rebound OTC medications. A lot of these ephedrine or pseudoephedrine types of things also tend to use a lot of that. I think that is very typical and very common before that. Nicotine is something else. People are smoking, and they are not even realizing that perhaps that is what is helping them; also, the weight issue, because sometimes they stop smoking, they also have more appetite. It's common.

I've seen some data, I think in Europe, that smoking is actually very common amongst narcolepsy patients. Do you have that impression amongst your population as well?

 Not as much. It's interesting; I saw that data but, I do not see in my practice that smoking is that common. But I do know of individuals who smoke, and if they do, it's not one cigarette, but like our patient here, it is many cigarettes, perhaps two or three in a row. And I think when they're doing that, it probably is for self-medication for alertness or sleepiness.

Let's talk about the non-pharmacologic approaches. We have already touched on this, but Dr. Zee, since you have the floor at the moment, how do you counsel patients, on what they're eating, when they eat, drinking alcohol, getting exercise, etc.

 I think everyone should do this as a basic approach. I want to start looking at the regularity of their sleep and wake schedule. I want to regulate that. I give them some leeway (about an hour or so of difference on school days or weekdays), and then a little bit more on weekends. I do a food diary, as part of our sleep diary, because it gives me some idea of when they are eating and how that relates to their symptoms of sleepiness. Sometimes a large meal, for example, in the middle of the day may be relevant, or knowing if they have smaller meals can be helpful. With this, I am just trying to figure out ways that I can maximize from a behavior standpoint. I don't know many narcoleptic patients that drink much alcohol, which is interesting. In fact, it's almost hardly ever, except for social reasons. I track exercise, and I also add something like exposure to bright light in the morning and during the day because it can have a mild direct effect on improving a function and perhaps alertness. I want to mention that there are now studies and trials with CBT, cognitive behavior therapy, for narcolepsy and hypersomnia that are under development. I think that would be interesting to be able to have that as another tool for our patients.

When you are talking about light, you are not talking about it simply as phototherapy and treatment in the morning but using it for its arousing effect through the day.

 Through the day, and it is not to shift the clock and they do not have a circadian rhythm sleep week disorder, but using light to really enhance in the morning, get up, blinds up, get as much as light as you can in that morning time. Even in the afternoon, when they feel like they are sleepy, go out and take a walk. Walking around and exercise can be activating, as well. Both of those can be used; they don't last long, but at least intermittently could be helpful.

It's also doubly beneficial in the sense that people with narcolepsy have a propensity to put on weight. And so, encouraging physical activity is key. Anybody else? I hear this anecdotally, I don't know if there has been any proper research on it, but I get the impression that patients with narcolepsy are more sensitive to carbohydrate loads. If they have a big lunch, they crash afterward. Do you guys have that sense as well?

Sometimes snacking through the day, particularly when you need to be awake and alert, eating smaller meals and not so many carbohydrates is helpful. I also find that getting up and moving around, not sitting at a desk a long time. Some patients report having a standing desk because if you are engaging your anti-gravity muscles or moving around a little bit, you're less likely to fall asleep, as long as you don't have cataplexy.

I think the points that you guys brought up in the last couple minutes are important, and we're going to come to this about the various medications from narcolepsy, but speaking for myself, I don't spend enough time doing this education about the non-pharmacologic approaches. There is an awful lot to be gained with that as far as, not only just having a healthier life in general, but doing things that are practical impact to improve alertness.

 Schedule napping. that is something can be quite useful, short naps strategically placed according to their performance, what they need to be doing during the day, can be quite helpful as well.

And it's a way of minimizing medications too. Instead of giving somebody an afternoon dose of some weight-promoting agent, maybe a nap is all they need.

 One other thing I want to add is counseling patients about reasonable lifestyle goals or professional goals. Over the years I have had a number of physicians or students who will potentially go into careers that are going to exacerbate their narcolepsy. Something where you're going to have to be doing a lot of rotating shift work or have prolonged shifts where you're going to get sleep deprived. Those are probably not ideal career paths for people with narcolepsy. Helping them adjust to what is essentially a disability so that they can have the most normal function possible and be able to be successful.

Dr. Moawad, do you talk to people about vocational things if you're talking to a high school student?

 It's funny that you brought that up because I did have one who went through a lot of trial and error in her life and then became an athletic trainer. And this was something that encouraged her to be physically active, but also there was a bit of flexibility in her job. She felt that that was a healthy option for her. Not only because of the lack of shift demands but also because it did encourage her in her job to be doing exercises, which she felt made her more alert. I think that this is something that can really be beneficial for people.

That's great. I have to say, I think some of my most vocationally successful narcolepsy patients are elementary school teachers where they have an extremely stimulating environment, but sometimes they say when the kids go home at 3:00 they put their head down on their desk and take a nap. I think I would add jobs that require sustained attention like air traffic controller, which is probably not going to be a good match if you're just sitting there staring at a screen.

What do you all think about jobs such as commercial driving for narcolepsy patients?

Would you say, is it absolutely forbidden? Would you say this really applies to all patients?

 I think it depends on a combination of how severe the narcolepsy is. Because we see quite a range. There are people with milder disease, and it also depends on what kind of driving we're talking about; cross country driving 10 hours a day, probably not; doing city driving where you're never driving more than 10 or 15 minutes at a time, that might be okay.

 I agree. It needs to be individualized, but certainly, if you're in commercial driving or you're a truck driver going long distances we already know that they're at risk for obesity for many of the other comorbidities. That would just be increasing, I think, their vulnerability to developing other sleep disorders or other medical conditions already comorbid with narcolepsy.

I'm reminded of a patient of mine who got fired from his job because he was just too drowsy at work and to make money, he started doing Uber driving. I thought, oh no, it's going from bad to worse. Fortunately, he got a more appropriate job soon after.

A multidisciplinary panel of sleep experts reviews the role of light exposure, exercise, and other non-pharmacological methods in narcolepsy management.

Non-Pharmacological Approaches and Counseling

Dr. Benca, could you just maybe take this angle of the importance of psychiatrists? Let's say that, just for the sake argument, this guy has a narcolepsy. How do you see the role of the psychiatrist in this picture working with a primary care doctor, who is trying to handle the narcolepsy?

 Well, this is a patient who has some other issues going on. Clearly, he has had a history of mood disorder. And depression is common in patients with narcolepsy, as is the general struggle they have because even when we treat narcoleptics, they may be totally normal in terms of their sleep propensity. They are having to deal with a lot of issues in their lives that can be increasing stress and exacerbating stress-related illnesses like depression. This is also a patient who clearly has predilection to substance use disorders and that would also be amenable to psychiatric treatment. And then we want to make sure that we keep his depression under control. Although he says his depression is better, I would be suspicious that he still may have insufficiently treated depression. Working with a psychiatrist to help manage the comorbid psychiatric illnesses and providing emotional support to these patients may be useful.

Yeah. Maybe you can go into that a little bit more about how would you treat his narcolepsy and this potential mood issue?

: This is not someone I’d be starting on amphetamines at step one. Again, it's not clear he's got cataplexy so we wouldn't be doing sodium oxybate probably on him. We'd probably want to make sure that he is in some substance abuse treatment, so he is not abusing other stuff, because you don't want to start him on a stimulant and then have him go out and start using cocaine. And he has in a lot of nicotine, so you want to manage his caffeine use, things like that. Then you might want to think about some of the newer agents that might be a little less likely to lead to abuse issues, like solriamfetol or pitolisant. I would defer to Dr. Zee to see what her thoughts would be on that, as well.

Yeah. Actually, Dr. Zee or Dr. Moawad, do you have other angles that you'd consider with this?

: I agree with Dr. Benca and her approach, but I think in addition to that, thinking about not just the patient support groups or narcolepsy support groups, but also the behavioral components of that. Again, he is in college and having a lot of difficulty dealing with the psychosocial aspects of excessive daytime sleepiness. I think that would be also helpful in addition to the medications. But again, I agree that being in college, having this history of substance abuse, it's tough with regards to what type of medication you would add. And I would probably still favor something like modafinil, for example, as probably my first line still here again, knowing that there are other options.

And when you say modafinil, we can sort of lump in armodafinil.

: Yeah. I would agree with that. And then if that is not sufficient to think about adding on some of the other ones, but pretty much stay away from amphetamines if at all possible.

 Yeah. I think to add to that, I would say because of the challenges with the drug use that he has had in the past, that definitely patient education will play a big role in this, so that he is actually very aware of that potential for addiction and negative aspects of using the medication and that can help prevent some of the adverse effects.

Dr. Moawad, you touched on something that I don't think we are really going to get to later on, but it's the role of psychologists in sleep clinic. And I am just curious, I think different clinics have different focuses and so forth. But I think we have been talking mainly about how the psychiatrist and so forth would manage this, but do you see a role for psychologist here?

: I do. I think that it's time-consuming and it can be something that some patients might not feel they want to invest the time and they just want to get that prescription and get better. But certainly long term, the outcome can be a lot better if patients understand how behavior modification, lifestyle modification can help their overall symptoms and can also be aware of potential adverse effects of medication so they can use them more responsibly. I think it's something that I can imagine a patient like this wanting to not spend the time, but certainly, it would pay off for him in the long run.

: Another issue I think to keep in mind is that given that he may need ongoing treatment for depression, be careful about which antidepressants we select, he's on fluoxetine now, which is probably one of the better ones in terms of not increasing excessive sleepiness, but again, some antidepressants can cause increased fatigue or sleepiness.

 One more thing to add perhaps is the nicotine use, that is pretty high and it may be self-medication to improve alertness during the day, but that could also potentially have an adverse effect on his sleep quality. Referral, perhaps, to a smoking cessation clinic would probably be important, as well.

When I was mentioning the role of a psychologist in this, I was thinking there is so much counseling needed here. It almost seems a little bit beyond what many doctors would be able to have the bandwidth for. Because who knows, maybe he is smoking a whole bunch before he goes to bed or he is drinking a lot of caffeine in the evening and they are contributing to insufficient sleep. As we have discussed there's lots of approaches to this patient and I think just simply putting them on a med will help, but more than that is necessary, there's a lot of behavioral work here.

Thought leaders discuss clinical considerations regarding the many intersecting and complicating conditions that individuals with narcolepsy may experience.

Sleep Disorders