Thought leaders discuss clinical considerations regarding the many intersecting and complicating conditions that individuals with narcolepsy may experience.
Thomas E. Scammell, MD: 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?
Ruth Benca, MD, PhD: Or even a sleep doctor.
Thomas E. Scammell, MD: Yeah.
Ruth Benca, MD, PhD: 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.
Thomas E. Scammell, MD: Yeah. Maybe you can go into that a little bit more about how would you treat his narcolepsy and this potential mood issue?
Ruth Benca, MD, PhD: 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.
Thomas E. Scammell, MD: Yeah. Actually, Dr. Zee or Dr. Moawad, do you have other angles that you'd consider with this?
Phyllis C. Zee, MD, PhD: 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.
Thomas E. Scammell, MD: And when you say modafinil, we can sort of lump in armodafinil.
Phyllis C. Zee, MD, PhD: Yeah, armodafinil.
Ruth Benca, MD, PhD: 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.
Heidi Moawad, MD: 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.
Thomas E. Scammell, MD: 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?
Heidi Moawad, MD: 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.
Ruth Benca, MD, PhD: 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.
Phyllis C. Zee, MD, PhD: 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.
Thomas E. Scammell, MD: 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.
Transcript edited for clarity