Novel portable, at-home sleep study program helps uncover undiagnosed sleep apnea

By Robin Jay, BHC Editorial Director

It may be a question similar to the chicken and the egg: Which came first - depression or the sleep disorder? But what is clear is that there is a link between the two. Studies at Stanford University found that 800 out of 100,000 people have both major depressive disorder and obstructive sleep apnea (a condition causing highly interrupted sleep patterns). And what may be even more important for clinicians to be aware of is that 20 percent of these patients will present with only one of them. It's vital that patients being screened for depression are also screened for a sleep disorder, and vice versa. In fact, according to Benjamin Gerson, M.D., Chief Executive Officer and Medical Director at UniversityServices headquartered in the Philadelphia area, it's important to first treat the sleep disorder, because that could be a cause for the depression.

Dr. Gerson addressed the issue at the World Congress Leadership Summit on Behavioral Health in July. He explained that overlooking the possibility of sleep apnea in patients dealing with depression could have significant consequences. One of the common barriers to diagnosing sleep apnea in the past, however, has been the patient reluctance, inconvenience and/or the out-of-pocket costs of spending the night in an outpatient sleep center. Dr. Gerson provided a solution to this barrier. University Services has developed a novel program - available in most regions nationally - that includes an at-home, patient-administered sleep assessment. The patient simply wears a light apparatus on the hand and wrist. With a simple push of a button before sleeping and after waking in the morning, the mechanism automatically records the number of times the patients is awakened during the night. (Patients with sleep apnea can wake up dozens and dozens of time nightly without being aware of it.) The patient returns the apparatus via mail for evaluation by a sleep specialist. Results are then communicated to the referring clinician.

Dr. Gerson spoke on camera with Behavioral Health Central after his presentation at the World Congress Summit. You can find out more about this innovative program by watching the video on this page, or by reading the interview transcript that follows.

BHC: This is Robin Jay with Behavioral Health Central. We're talking today with Dr. Benjamin Gerson, the Medical Director of University Services in the Philadelphia area. Dr. Gerson thank you for joining us.

Benjamin Gerson: Thank you. It's good to be here.

BHC: Dr. Gerson, tell us about the unique areas of service related to behavioral health and sleep disorders at University Services.

BG: At University Services, we're primarily involved in identifying sleep disorders. There are 81 recognized sleep disorders. The overlap with behavioral health and depression, in particular, is that sleep disorders can have symptoms similar to depression. Depression clearly can present with sleep problems, and it's very important to differentiate depression from sleep disorders - they can be comorbid.

BHC: Let's discuss the importance during a diagnosis of somebody dealing with depression. Why is it important also to determine whether there is a comorbid sleep issue?

BG: An untreated sleep problem in a patient with depression can make the depressive symptoms even worse. A lot of the treatments are similar and a lot of the risk factors are similar, so it's very important to make sure that you've identified the sleep problem, treated the sleep problem, so that you can differentiate the symptoms that are coming from the depression and those that are coming from the sleep problem.

Frequently when you get the treatment and the sleep problem taken care of, the depressive symptoms are going to ameliorate. At the very least, you now have a clear set of symptoms to deal with. Frequently what we're talking about is insomnia or sleep apnea; those are the two most common ones. Anything that interferes with the quality or quantity of sleep is going to give you symptoms that look very much like depression.

BHC: Dr. Gerson, lack of sleep in the U.S. has, of course, been an issue long before this economy turned south. But have you seen an increase in problems with sleep and depression, or is it something that is still highly under-diagnosed?

BG: I think it is always there and it is definitely under-diagnosed. We know for instance with sleep apnea, maybe 10 to 15 percent of the people who have it, have been identified. Depression, I don't need to tell you, is not something that is addressed nearly to the extent that it should be, so that's something else they share.

BHC: At University Services, when it comes to diagnosing sleep issues, you have a very novel approach that is available as an alternative to an inpatient setting. Tell us about that.

BG: Just by way of background, we have several fixed-site, traditional sleep centers in Pennsylvania and New Jersey. In the last few years, we've gotten involved in portable sleep testing, which some people call "home" sleep testing. We've done a study proving that the system works (that we're now providing nationwide) where we use a device, a diagnostic, not a screening, but a diagnostic device we ship to the patient. The patient puts it on himself or herself, sleeps with it for one night, ships it back to us for interpretation by our sleep physicians. It's much higher acceptance by the patients because it's private. It's very convenient because the device gets delivered to the home or wherever the patient wants to wear it. And as far as third-party payers are concerned, it's much less expensive.

Now, as I said earlier in our conversation, there are 81 sleep disorders. This portable device is good for sleep apnea (that and insomnia are the more common sleep disorders). So in the question of sleep apnea, this portable device is certainly a very good convenient and cost effective diagnostic alternative.

BHC: I know that there's an apprehension often at times for outside sleep centers because a person might be afraid about spending the night or be apprehensive about being able to sleep in a facility. But when the testing is at home, what is the patient experience like?

BG: Well, in a home sleep test, the device gets delivered in a box. We've included written instructions, as well as a DVD. We also offer our toll free telephone number that a patient can access any time of day or night, and if after looking at the instructions and watching the DVD the person is still not sure, he or she can call us for help.

The device that we've selected (we're not the manufacturer, we just selected a device that we thought would work,) actually goes on the arm and the fingers, nothing on the head, nothing on the face. So it's very, very comfortable. You push the button when you go to sleep and you push the button when you get up. Other than that, it's very straightforward and it's a night in your own bed.

BHC: So it is a single night duration like it would be if you went to a traditional sleep center?

BG: Yes.

BHC: Then it's mailed back to you for analysis?

BG: Yes, we ask that the device be shipped back to us and we download the information from the device. It still requires a board-certified sleep physician to interpret the output of the device, but that's how it works.

BHC: And Dr. Gerson, if a facility or a provider is reading or watching this and they're interested in how they might use this service for one of their patients, even in another state, what is the proper procedure for them to go about doing that?

BG: We provide the service in just about every state - pretty soon I'll be able to say every state. So we have sleep physicians who are licensed in the states. It still requires a prescription. That is, it has to be ordered by a doctor, and we've already worked out the systems for that. So once a physician orders the test, we fulfill that request by shipping out the device, getting it shipped back, as we discussed, and then getting one of our board-certified sleep physicians to issue a medical report to the doctor who ordered the test.

BHC: Dr. Gerson, is there anything important about the technology that you'd like to discuss that I haven't asked yet ?

BG: The technology is actually very sophisticated. It's based on research that came out of Technion, which is in Israel. The novel approach is that this particular device works by measuring peripheral arterial tone and using an algorithm so that we're able to determine when the patient is asleep and how many times per hour the sleep is interrupted. That's what we're looking for in the sleep apnea. This has been FDA cleared for a few years and at this point it's really a very reliable method. The main advantages that we saw, again, was it seemed simple enough to use for someone who's never encountered it before, and it seemed to be more comfortable. There are other devices out there that work, and work very well, but we just wanted something that didn't involve a lot of wires or to be put on the head or face.

BHC: That's going to help with patient compliance and using it properly.

BG: I would agree with that.

BHC: Thank you. And Dr. Gerson, what is the contact information for your organization for anyone that might want to contact you about this technology or program?

BG: Oh sure. We'll be happy to talk to anyone about it. Our toll free number works in the U.S. and Canada; it is 800-624-3784.

BHC: Thank you very much Dr. Gerson.

BG: Thank you.

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