Report from the <scp>WPA</scp> Section on Psychiatry and Sleep‐Wakefulness Disorders
Authors: Adam Wichniak, Dimitris Dikeos, Thorsten Mikoteit, Martin Hatzinger, Thomas Pollmächer, Constantin Soldatos
Journal: World Psychiatry (2025)

Insomnia, which is considered a psychiatric disorder itself, is the most common sleep-related complaint in the general population. Furthermore, complaints about sleep and wakefulness are among the most common and impairing symptoms in psychiatric patients. Disturbed sleep frequently precedes the onset of several mental disorders, exacerbates as mental disorders progress, and frequently presents as a residual and treatment-resistant symptom. In recent years, remarkable progress has been made in sleep research and the treatment of sleep and wakefulness disorders in psychiatry, although many questions remain to be answered1. We still do not know exactly the causative link(s) between the various psychiatric disorders and sleep complaints, although it would be important to know, for instance, whether early treatment of sleep disturbances can prevent the development of depressive disorders. Moreover, the relationship between subjective complaints of insomnia patients and objective polysomnographic results remains elusive, and we do not know whether the health consequences of insomnia, for example on metabolic systems, are related to subjective or objective measures of sleep, or both. Besides objective methods for assessing sleep and wakefulness – such as polysomnography (PSG), actigraphy, multiple sleep latency test, and maintenance of wakefulness test – there is now considerable literature on various biomarkers for sleep disorders. For insomnia, the measures with the highest performance include PSG-derived cyclic alternating patterns, actigraphy, and brain-derived neurotrophic factor (BDNF) levels. These are followed by heart rate around sleep onset, deficient melatonin rhythm, and specific neuroimaging patterns, mainly reflecting the activity of the prefrontal cortex, hippocampus, and basal ganglia2. For central disorders of hypersomnolence, novel measures derived from quantitative electroencephalogram (qEEG), high-density EEG, cognitive testing, structural and functional neuroimaging, and pupillometry have been proposed3. Significant progress has also been made in the assessment of circadian rhythm sleep-wake disorders. In addition to established laboratory protocols, circadian rhythms can now be assessed through long-term ambulatory monitoring of activity, skin temperature, heart rate, and light exposure4. Significant progress has also been made in the treatment of insomnia, emphasizing not only the role of appropriate pharmacotherapy but, above all, non-pharmacological treatment options. Cognitive-behavioral therapy for insomnia (CBT-I) is currently recommended as the evidence-based psychotherapy for chronic insomnia, also in patients with comorbidities5. This treatment includes techniques such as sleep restriction, stimulus control, sleep education and hygiene, relaxation techniques, and cognitive restructuring. These techniques help strengthen the basic sleep-regulating mechanisms, including the homeostatic sleep drive and circadian rhythm, and reduce sleep-related anxiety and arousal6. The treatment of insomnia in psychiatry should be based on an integration of pharmacotherapy (including novel medications, such as orexin antagonists) and non-pharmacological interventions, to address psychological and behavioral factors that contribute to the development or persistence of insomnia. It is particularly important to emphasize the need to maintain a consistent sleep schedule, getting up at the same time every day, even after a night of poor sleep, and to exercise regularly. Additionally, creating a relaxing bedtime routine, and limiting naps and rest periods during the day are essential. To prevent insomnia, it is also important to limit screen time during the day and avoid screens (phones, tablets, TVs) at least one hour before bed. Several new wakefulness-promoting agents have been introduced for the treatment of central disorders of hypersomnolence7. Moreover, it is now well recognized that effective treatment of obstructive sleep apnea in patients with mental disorders is critical for improving their response to treatment, quality of life, and overall health7. As the prevalence of sleep and wakefulness disorders has further increased during the COVID-19 pandemic, resulting in deterioration of mental health and increased alcohol and hypnotic use8, it is evident that mental health professionals require effective training in diagnosing and treating disrupted sleep. People with mental disorders can greatly benefit from mental health services that incorporate routine assessment and treatment of sleep and wakefulness disorders within standard care pathways. Consequently, the main aim of the WPA Section on Psychiatry and Sleep-Wakefulness Disorders is to educate psychiatrists in recognizing and giving appropriate attention to sleep disturbances (such as insomnia and hypersomnolence) and in being able to provide guidance to their patients on the importance of basic sleep hygiene rules. The education of psychiatrists should also include awareness on obstructive sleep apnea, which can manifest with psychiatric symptoms, including increased daytime sleepiness, fatigue or loss of energy, loss of interest or pleasure, irritability, mood swings, emotional instability, and cognitive dysfunction such as impaired memory, attention and executive functions. These psychiatric manifestations highlight the importance of diagnosing and treating sleep apnea promptly, as managing the sleep disorder can improve overall well-being and quality of life. Moreover, since 30-40% of patients with chronic insomnia fulfill diagnostic criteria for obstructive sleep apnea, screening for this condition should be performed before initiating any hypnotic medication. This is crucial, because medications such as benzodiazepines are contraindicated in patients with untreated obstructive sleep apnea. Such screening can be performed with short questionnaires such as the STOP-BANG. This questionnaire consists of eight yes-or-no questions, focusing on snoring, tiredness, observed apneas, pressure (high blood pressure), body mass index, age, neck circumference, and gender (male). Each "yes" answer scores one point. A higher total score indicates a greater risk of obstructive sleep apnea9. Our WPA Section has been active for many years. Its activities have been focused on providing information about sleep and sleep-related disorders to clinical health professionals, as well as optimizing the diagnosis and therapy of sleep disturbances in patients with mental disorders. Since sleep is an interdisciplinary field, one of our main goals is to connect sleep specialists from around the world. We believe that our Section can mediate between basic researchers, clinicians, educational institutions, scientific professional societies, health care institutions, and governmental authorities, in order to improve the recognition and treatment of sleep disorders. Our Section's action plan for 2023-2026 includes several goals. A primary one is advancing research and knowledge about disturbances of sleep and wakefulness in patients with mental disorders, by fostering collaboration between basic researchers, clinical scientists, and health care providers. Additionally, we will keep focusing on education and training on diagnosis and treatment of sleep disorders, by organizing workshops, webinars and scientific conferences with WPA involvement. Furthermore, we will be active in promoting clinical practice guidelines, to improve the quality and interdisciplinary nature of care in people with mental disorders suffering from disturbed sleep. A major goal also pertains to engaging in policy and advocacy, by calling for pertinent actions in support of research and public health initiatives to improve access of patients with mental disorders to sleep medicine services. We will also be supporting the building up of networking and collaboration, by fostering relationships with scientific societies to promote interdisciplinary research and clinical care. To this end, our Section has already organized a highly successful symposium, "State of the Art in the Management of Insomnia", during the World Congress of Psychiatry in 2023. Finally, we intend to develop public sleep health campaigns to educate the public on sleep hygiene, health consequences of poor sleep, and prevention of sleep disorders. By implementing this action plan, our Section can play a pivotal role in advancing the field, improving patient care, and promoting the importance of sleep health in the broader mental health context.