So many of the letters I receive as an advice columnist here at PsychCentral start with a list of mental health symptoms and end with an almost “by the way” report of sleep disturbance. You’d think that the multiple articles online and in popular magazines about the importance of sleep – and the negative effects of not getting enough – would be getting through to people. Apparently not.

As clinicians, it’s crucial that we not make the same mistake. Chronic sleep problems affect 50% to 80% of patients in a typical psychiatric practice. Over 1/3 of Americans report symptoms of insomnia, i.e., trouble getting to sleep, staying asleep or waking too early.

Before assigning a mental health diagnosis to a client, it’s crucial to determine if a sleep disorder is either causing or contributing to their distress. Disturbances in mood, difficulty in anger management, relationship stress, inadequate performance in school or at work and/or anxiety and depression may be an outcome of irregular or insufficient sleep.

A sleep disorder may cause problems in concentration, attention and judgment. It can interfere with learning and slows down an individual’s ability to think and problem-solve. Chronic fatigue from lack of sleep or frequently interrupted sleep can negatively affect mood, energy and the ability to cope with life’s inevitable frustrations. Further, it is just plain dangerous. It’s a significant cause of injuries and accidents.

Complicating our assessments, however, is that more than half of those who suffer with insomnia do have concurrent anxiety, depression or another mental illness like schizophrenia, Attention Deficit Hyperactivity Disorder (ADHD) or Obsessive Compulsive Disorder (OCD).

In addition, sleep disturbance may be the result of nightmares associated with trauma or an outcome of substance abuse.

Assessment of a new patient, then, must always include detailed questions about sleep. Be alert for the following causes of a sleep disorder that may be contributing to your client’s distress:

Causes of Sleep Disorders

Medical issues: Sometimes a medical condition is in the background. Obstructive sleep apnea is the most common. An obstruction of the airway while sleeping can happen as often as every 15 minutes, resulting in interruption of REM (Rapid Eye Movement) sleep. Interrupted REM means insufficient deep sleep, the stage of sleep that is essential to mental and physical health.

Obstructive sleep apnea is often unrecognized by the sufferer. If your client reports that he or she is chronically fatigued despite getting a reasonable number of hours of shuteye, a sleep study may be in order.

Other medical illnesses that contribute to sleep deprivation are gastrointestinal reflux (GERD), nocturnal angina, COPD (chronic obstructive pulmonary disease), Parkinson’s disease or arthritis or osteoporosis pain. Frequent need to use the bathroom during the night also disrupts sleep. Older women sometimes are waked up by hot flashes.

Medication issues: The side effects of some medications (alpha blockers, beta blockers, SSRIs, Statins, etc.) include nightmares, strange dreams or agitation that makes it difficult for a person to get to sleep or to stay asleep. See this site for a good list.

Screens in the bedroom: A 2011 poll by the National Sleep Foundation found that almost 90% of Americans use some form of technology in the hour before bed. The researchers found that the more types of devices a person used, the more the individuals reported having difficulty falling asleep or staying asleep. Those who kept their phones on during the night reported being waked a few nights a week – which not only interfered with deep sleep but also caused difficulty staying asleep.

Any clinician who treats teens needs to be aware that more than half of  eight to 18 year olds say that they have a video game player in their room and more than 2/3 have their own TV. 73% of teens have access to cell phones. A 2015 report by Common Sense Media found that teens in the U.S. spend about 9 hours per day using media for entertainment.

Meanwhile, their idea of “day” stretches into night. Teens need an average of eight to nine hours of sleep a night. But it’s not at all unusual for teens to be on their devices well past a reasonable bedtime. One 2012 study in Norway found that kids who spend more than four hours per day on screens were three and a half times likelier to sleep fewer than five hours per night.

A longitudinal study of teens in New York found that viewing three or more hours of TV per day doubled the risk of difficulty falling asleep as opposed to those who watched an hour per day. Further, the light from screens in their rooms (TVs, computer monitors, phones) at night may interfere with melatonin release which then interferes with sleep.

Assessment and Treatment Planning

There is no consensus about cause and effect. Does insomnia cause the patient’s mental distress? Or does the distress cause the insomnia? Regardless, we do need to factor in both when determining a diagnosis. A good initial assessment includes the usual Mental Status Exam and questions regarding the symptoms that brought the person to therapy and includes questions about sleep routines.

Don’t be surprised if your client is dismissive about the importance of getting six to nine hours of sleep every night. One of the hallmarks of sleep disturbance is poor judgment about the importance of sleep and/or denial about just how much sleep he or she isn’t getting. When in doubt, insist on a week-long sleep log that documents when the client went to bed, when he or she got up and whether sleep was interrupted. Ask the client to also document what they were doing in the hour before bedtime.

Treatment planning proceeds accordingly. Yes, of course, address the presenting psychological symptoms. But if the client isn’t getting good sleep, addressing that problem directly is an important support to recovery from mental illness and for maintenance of good mental health.

Although it is not at all unusual for clients to think of mind and body as being separate entities, it’s important that we clinicians emphasize the fact that the two are in a constant recursive loop with each influencing the other. Paying attention to our clients’ physical well-being is a crucial part of responsive and responsible treatment.