Psychiatrists have made significant contributions to the field of sleep medicine. Their achievements include valuable original research and subject reviews about the important connections between sleep and psychiatric disorders. The work published has represented differing perspectives, with some studies focused on the character of sleep symptoms in psychiatric disorders (1—5) and others on the presence of psychiatric issues in sleep disorders (6,7). Authors have investigated the effects of psychotropic medications on sleep architecture (8). Restless legs syndrome, obstructive sleep apnea, insomnia, rapid eye movement (REM) behavior disorder, and narcolepsy are examples of sleep disorders for which progress in diagnostic approaches and treatment has been realized because of papers published by psychiatric groups (9—13). Accordingly, major psychiatric textbooks contain more pages devoted to sleep content than those of other disciplines, including neurology or internal medicine (14). Knowledge about sleep is an essential content area in the psychiatric curriculum and is necessary for a thorough understanding of psychopathology, neurochemistry, and psychopharmacology.
In this study, we endeavored to assess future trends concerning the involvement of psychiatrists in the field of sleep by investigating resident educational opportunities and the presence of faculty psychiatrists. We also examined program directors' attitudes and the recruitment of recently trained psychiatry residents into sleep medicine.
A one-page survey with 6 questions was sent to all U.S. general psychiatry program directors listed in the Fellowship and Residency Electronic Interactive Database (FREIDA). Nonresponders were sent a second mailing and an electronic version to increase participation. The questionnaire assessed curriculum content, including didactic lectures as well as required or elective sleep rotations. Additional items assessed the number of psychiatric faculty involved in "clinical sleep medicine," the number of psychiatric faculty involved in sleep-related research, and the number of recently graduated psychiatry residents entering the field. The survey defined "clinical sleep medicine" as involving interpretation of polysomnographic studies for at least some patients. Because sleep issues are at least of peripheral interest in most of clinical psychiatry, this focus on polysomnography was chosen to elicit use of a detailed sleep assessment. This distinction accordingly differentiated "clinical sleep medicine" from, for example, the standard psychiatric interview that inquires about sleep symptoms, or depression treatment that also targets sleep symptoms. Program directors were asked their opinion about the future sleep career prospects of psychiatry residents interested in sleep medicine.
Faculty and resident involvement was measured by counting the number of individuals with ties to either the American Board of Sleep Medicine (ABSM, a self-designated board not affiliated with the American Board of Medical Specialties) or the American Board of Psychiatry and Neurology (ABPN) with added qualifications in clinical neurophysiology.
Responses were received from 117 (66%) of the 177 general psychiatry residency programs, with 5 others declining to provide the requested data. Of the responding training programs, 107 were associated with a sleep disorders center, operated by one of the following departments: pulmonary, 39 programs (36%); neurology, 33 (28%); psychiatry, 23 (20%); interdepartmental, 10 (9%); psychology, 1 (<1%); and internal medicine, 1 (<1%). The characteristics of the nonresponders are unknown.
The majority of programs (82%) had didactic lectures pertaining to sleep, with a mean of 5 hours and a range of 1 to 18 hours. The topics taught were sleep disorders (82%), relationship of sleep complaints and psychiatric disorders (74%), sleep physiology (74%), hypnotic pharmacology (73%), stimulant pharmacology (68%), and phototherapy (38%).
Sixty-four psychiatric programs (55%) did not have a single faculty member (psychiatrist or psychologist) who met any of the following criteria: board certified by the ABSM; board certified by the ABPN with added qualifications in clinical neurophysiology; "practiced clinical sleep medicine including polysomnographic interpretation"; or "conducted sleep-related research." The sleep faculty (psychiatrists and psychologists) are described in t1.
A sleep rotation was available as an elective at 51 programs (44%) and was required by only 1. The sleep elective had been discontinued within the past 5 years for 13 programs (11%), with only 1 planning to add this elective soon. Nevertheless, 86 (73%) program directors either definitely or somewhat agreed that sleep medicine was a "viable career option for graduating psychiatric residents."
Training directors did not always know how many of their recent graduates (of the past 5 years) had entered sleep medicine. The survey data indicated that, overall, 3 recent graduates obtained ABSM certification, 1 received APBN added qualifications in clinical neurophysiology, 9 did clinical work including polysomnographic interpretation, and 9 conducted sleep research.
In psychiatry training programs, didactic lectures addressing sleep issues are common but not universal, despite sleep symptoms being listed as DSM-IV criteria for most psychiatric disorders. The ABPN Part One examination considers sleep physiology and pathophysiology content areas necessary for certification. Required topics include knowledge of sleep architecture, including the significance of REM latency measurements for depression, which calls for an understanding of polysomnography. An elementary background in sleep issues is important for all psychiatrists, although a detailed understanding of sleep tests and sleep disorders may be desirable but not absolutely necessary. Not all psychiatry departments with training programs have access to the necessary resources to provide training in sleep for all residents. Making sleep medicine a required component of residency programs is not feasible, especially in the context of the increasing number of mandatory competencies.
This study demonstrates that the availability of elective rotations for psychiatry residents in sleep medicine is decreasing. These rotations offer trainees an opportunity to experience clinical sleep medicine or sleep-related research. Electives do enhance contact with a specialized practice, and they may increase recruitment into the field. The reasons for this downward trend concerning elective rotations are unknown. Competing educational priorities, poor access to sleep disorder centers operated by other departments, lack of supervisors, and the perception that sleep experience is no longer relevant to psychiatrists may contribute to this situation. Other possibilities include the paucity of psychiatrist mentors and the emphasis on sleep-related breathing disorders rather than neuropsychiatric conditions within the sleep community.
The number of psychiatrists engaged in sleep research is unknown. Collecting data about this group is not straightforward because of imprecise definitions of what constitutes sleep research. Involvement in sleep research is clear-cut when a department has a faculty member conducting research sleep studies on animals or humans. But would a psychiatrist doing mechanistic research exploring dopaminergic function that potentially could have relevance to sleep count as a sleep researcher? The most practical approach is to have researchers designate themselves as sleep researchers on the basis of their interests and the applications of their work. Conducting a survey of psychiatrists engaged in sleep research would be a direct way to characterize this important group. Obtaining an appropriate mailing list, however, is a challenge because these individuals are active in a variety of professional societies. A survey of department chairs might be a different method to obtain these data.
Another approach to assessing the vitality of the research efforts is to determine the number of sleep-related manuscripts in psychiatric journals. A search by the term "sleep disorders" of the journals published by American Psychiatric Publishing, Inc., yielded only 20 articles from January 1996 through January 2001, as compared with 369 for depression. This result does suggest that sleep disorders research is not a high-priority topic for the editors and readership. The number of high-quality papers addressing sleep issues submitted to journals but not accepted because of concerns about their fit with the journals' focus would be another useful measure, but one that was not available.
The future of psychiatrists in clinical or research sleep medicine is unclear. Few reliable indicators exist that indicate trends about the role of psychiatrists in this domain. The number of psychiatric candidates obtaining ABSM certification has declined from 10 in 1991 to 3 in 1998 (ABSM, personal communication). The ABPN has offered added qualifications in clinical neurophysiology for 10 years, with sleep medicine being a minor component. Although potentially eligible, few psychiatrists have taken this examination, and most of this small group concentrated on electroencephalography or electromyography. Several residencies in clinical neurophysiology have recently adapted their programs to emphasize polysomnography, but primarily neurologists have pursued this subspecialty training.
Despite the program directors' enthusiasm, graduating residents are unlikely to pursue sleep fellowships, conduct research, or practice clinical sleep medicine without significant exposure during training. Didactic series covering sleep topics are essential for all psychiatry residents and ideally would be provided by faculty members with extensive knowledge of the science of sleep. The consequences of discontinuing sleep electives need careful consideration. These electives should be preserved if possible. Experiences that help trainees to gain specialized knowledge, or that offer research potential, should be protected. Psychiatry may gradually lose its critical mass in the sleep medicine community unless more residents have the opportunity to have sleep electives, faculty mentoring, or the option of sleep research.
Many gaps exist in our understanding of psychiatric disorders accompanied by sleep complaints and of sleep disorders with a psychiatric dimension. To provide optimal patient care and to advance neuroscience in the years ahead, more research into the connections between psychiatry and sleep is needed. For example, the effects of psychotropic medications on sleep-related breathing and movement disorders remain poorly understood. Psychiatrists are arguably the best trained and most motivated to answer the important unanswered questions at the psychiatric— sleep interface. If few psychiatrists have the requisite sleep training, these topics are less likely to be investigated, and that will be to the detriment of patient care.
This work was presented in part at the 30th annual meeting of the American Association of Directors of Psychiatric Residency Training, Seattle, WA, March 1—4, 2001, and at the 12th annual scientific meeting of the Association of Professional Sleep Societies, Chicago, IL, June 5—10, 2001.