Treating insomnia in women

Vithyalakshmi Selvaraj, MD, PGY-4 resident, Department of psychiatry, Creighton University, Omaha, NE

Sriram Ramaswamy, MD, Assistant professor, Department of psychiatry, Creighton University, Omaha, NE

Daniel R. Wilson, MD, PhD, Professor and chair of psychiatry, Department of psychiatry, Creighton University, Omaha, NE

Compared with men, women have a 1.3- to 1.8-fold greater risk for developing insomnia. Multiple factors contribute to this increased risk of insomnia, including:

• hormonal changes across the reproductive cycle
• predilection to mood and anxiety disorders
• psychosocial factors, such as being single, separated, or widowed.

Furthermore, the higher prevalence of psychiatric disorders during the reproductive stages may confer additional risk for sleep problems.

Insomnia has tremendous impact on health and quality of life, resulting in reduced work productivity and increased absenteeism, accidents, and health care costs. This article examines the factors that contribute to women’s sleep difficulties throughout the life cycle, and suggests evaluation and treatment approaches appropriate for each phase.

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Cholesterol, mood, and vascular health

Jess G. Fiedorowicz, MD, MS, Assistant professor, Departments of psychiatry and epidemiology, Roy A. and Lucille J. Carver College of Medicine, College of Public Health, University of Iowa, Iowa City, IA

William G. Haynes, MD, Professor, Department of internal medicine, Institute for Clinical and Translational Science, Roy A. and Lucille J. Carver College of Medicine, University of Iowa, Iowa City, IA

Does low cholesterol predispose to depression and suicide, or vice versa? A growing body of literature examining the putative links among cholesterol, mood disorders, and suicide has produced inconsistent findings and unclear clinical implications that may leave psychiatrists unsure of how to interpret the data. Understanding cholesterol’s role in mood disorders may be relevant to the 2 primary causes of excess deaths in patients with mood disorders: suicide and vascular disease health.

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Psychiatric futurology

Henry A. Nasrallah, MD
Editor-in-Chief

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities liberties.

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Lowering Alzheimer's risk

Nazem Bassil, MD, Fellow, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

George T. Grossberg, MD, Samuel W. Fordyce Professor, Department of neurology and psychiatry, St. Louis University School of Medicine, St. Louis, MO

Pharmacologic treatments for Alzheimer’s disease (AD) may improve symptoms but have not been shown to prevent AD onset. Primary prevention therefore remains the goal. Although preventing AD by managing risk factors such as age or genetics is beyond our control, we can do something about other factors.

This article summarizes the findings of many studies that address AD prevention and includes an online-only bibliography for readers seeking an in-depth review. The evidence does not support a firm recommendation for any specific form of primary prevention and has revealed hazards associated with estrogen therapy and nonsteroidal anti-inflammatory drugs. Most important, it suggests that you could reduce your patients’ risk of developing AD by routinely supporting their mental, physical, and social health.

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Impaired physicians

Robert P. Bright, MD, Instructor of psychiatry, Department of psychiatry and psychology, Mayo Clinic, Scottsdale, AZ

Lois Krahn, MD, Professor of psychiatry, Department of psychiatry and psychology, Mayo Clinic, Scottsdale, AZ

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence. Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

• review substance abuse, cognitive decline, and other causes of impairment
• address legal and ethical issues involved in reporting a colleague to the state medical board
• provide resources for physician treatment and assistance.

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A psychiatrist/lawyer crossfire

Henry A. Nasrallah, MD
Editor-in-Chief

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

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Antidepressants in bipolar disorder

Joseph F. Goldberg, MD Associate clinical professor, Department of psychiatry, Mount Sinai School of Medicine, New York, NY, Affective Disorders Research Program, Silver Hill Hospital, New Canaan, CT

Few topics are as controversial as the role of antidepressants for patients with bipolar disorder. Although depression usually is the predominant, most enduring mood state in bipolar disorder, clinicians often face uncertainty about using antidepressants because of concerns about safety and efficacy. Whether and when to use antidepressants for bipolar depression hinges on complex parameters that preclude any single, simple rule.

Rather than asking if antidepressants are useful or detrimental for depressed patients with bipolar disorder, a more practical question might be: Under what circumstances are antidepressants likely to be beneficial, deleterious, or ineffective for an individual patient? Because “real world” patients often have idiosyncrasies that defy practice guidelines’ generic treatment recommendations, clinicians who practice in the proverbial trenches need strategies to tailor treatments to each patient that are informed—but not dictated—by evidence-based research.

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