Excessive Daytime Sleepiness: What to Look Out For in Assessment

Excessive daytime sleepiness was underrecognized and undertreated in psychiatric practice, according to Manish Zinzuvadia, MD, because fatigue, sleepiness, and insomnia often went unaddressed in patients who slept fewer than 7 hours per night. Treatment did not always require a medication. A comprehensive assessment, including deprescribing, could identify the root cause before the problem spilled over into other areas of a patient's life.

Medication-induced sedation was a common contributor. Antidepressants could cause sedation, and more than half of antipsychotics (18 of 32) did so. Rather than adding a second agent to counter an iatrogenic effect, Zinzuvadia recommended reevaluating the regimen: "Rather than keeping something that's iatrogenically causing a problem and then reaching for yet another medication, we're better off by actually consolidating their regimen and or going to a different option for the same condition." A more activating antidepressant or a less sedating antipsychotic could resolve the problem.

The Epworth Sleepiness Scale quantified the complaint and helped separate sleepiness from fatigue and insomnia.¹ Correcting sleep debt and sedating medications could resolve the problem before referral for a sleep study, specialist evaluation, or further testing. Sleepiness meant a patient would fall asleep given the chance, whereas a fatigued patient would not sleep even under optimal conditions.

This distinction mattered in depression. Untreated sleep apnea could underlie daytime sleepiness in a patient who appeared depressed, and treatment with continuous positive airway pressure sometimes improved mood considerably more than an antidepressant or other medication. Clinically depressed patients also spent long periods in bed without sleeping, and Zinzuvadia noted that "somebody who tells you they're in bed 10, 12, 14 hours, they may not be sleeping that much. They may be sleeping a fraction of that."

Wake-promoting agents improved Epworth Sleepiness Scale scores by 3 to 5 points at most and did not replace a full night of sleep.² These agents could exacerbate underlying psychosis or mania, and as scheduled substances they carried abuse potential.

Dr Zinzuvadia is the medical director and chief executive officer of Park Avenue Wellness Center in New York.

References

1. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545.

2. Pitre T, Mah J, Roberts S, et al. Comparative efficacy and safety of wakefulness-promoting agents for excessive daytime sleepiness in patients with obstructive sleep apnea: a systematic review and network meta-analysis. Ann Intern Med. 2023;176(5):676-684.