AN UNBIASED MONTHLY COVERING ALL THINGS PSYCHIATRIC
VOLUME 5, NUMBER 12
Sleeping Pills, New and Old
“S leep Drugs Found Only Mildly
Effective, but Wildly Popular”
proclaimed the headline of a
recent New York Times article (S. Saul,
October 23, 2007). The Times analyzed
the results of a newly published meta-
analysis of chronic insomnia treatments
and concluded that, on average, sleeping
pills reduce the time to go to sleep
(sleep latency) by only 12.8 minutes
beyond placebo, and increase total sleep
time by only 11.4 minutes.
These apparently unimpressive num-
bers were derived from an NIH-funded
study available for free on the web
(Buscemi N et al., AHRQ Report, accessed
at http://www.ahrq.gov/downloads/pub/
evidence/pdf/insomnia/insomnia.pdf), and
it’s well worth scanning, although at 135
pages (not including the 154-page
appendix), it’s not suitable for between-
appointment reading. The bottom line
of the report is that when you hook
patients up to dozens of wires and put
them in a sleep lab bed, you can still
demonstrate that sleeping pills beat
placebo, but the numbers won’t blow
your socks off. In the real world, not
only do patients snooze wirelessly in
their own Serta Perfect Sleeper, but they
benefit from both the drug effect and
the placebo effect. Combining placebo
and drug effects leads to roughly a half
hour of improved sleep latency over taking
no pill any kind.
Clearly, sleeping pills work; the more
relevant issue is whether there are any
significant differences among them, and
whether we should pony up 3 dollars
Learning objectives for this issue: 1. Evaluate the advantages and disadvantages of commonly used hypnotics. 2. Describe potential side effects of
hypnotics. 3. Develop a practical approach to discussing sleep hygiene with your patients.
This CME/CE activity is intended for psychiatrists, psychiatric nurses, psychologists and other health care professionals with an interest in the diagnosis
and treatment of psychiatric disorders.
December 2007
WWW.THECARLATREPORT.COM
per pill for the Maserati medications or just
3 cents per pill for perfectly adequate Civics.
Benadryl (Diphenhydramine)
To begin our review with the Civics,
Benadryl is an antihistamine with anti-
cholinergic properties, and is probably
being taken by more patients than you
IN THIS ISSUE
Focus of the Month:
The Treatment of
Insomnia
• Sleeping Pills, New and Old
• 2007 Index
• Practice Tips: Four Questions
to Evaluate Insomnia
• Expert Q & A:
Michael Breus, Ph.D.
Practical Sleep Hygiene Tips
realize. Why? Because it’s a popular
ingredient in over-the-counter cold and
pain remedies, including Tylenol PM
(500 mg acetominophen and 25 mg
diphenhydramine) and the newer Advil
PM (200 mg ibuprofen and 38 mg
diphenhydramine). Benadryl definitely
makes people drowsy and is an effective
sleep aid, but anecdotally, patients are
said to quickly develop tolerance and to
have nasty cognitive side effects. Is there
DECEMBER 2007
any actual data to guide us? The only
large study to look at side effects was of
426 hospitalized elderly patients (mean
age, 80), 114 of whom had been given
Benadryl vs. 312 who had not. Patients
given Benadryl had about double the
rate of subtle symptoms of delirium,
including inattention, disorganized
speech, and altered consciousness
(Agostini JV et al., Arch Int Med
2001;161(17):2091-2097). But this study
is unlikely to be generalizable to most
physically healthy outpatients in psychiatric
practices. Studies of young healthy patients
given Benadryl 50 mg BID (a dosing reg-
imen for allergic rhinitis) have shown that
any daytime sedation or cognitive impair-
ment wears off quickly, within a couple
of days (Richardson GS et al., J Clin
Psychopharm 2002;22:511-515). But
there are no published studies support-
ing the anecdotal impression that
patients quickly develop tolerance to
Benadryl when it is used at bedtime as a
sleeping pill. The bottom line on
Benadryl is that you should avoid it in
the elderly, especially those who are
medically ill, but that it is likely safe and
effective for most other patients, at least
for short term use.
Desyrel (Trazodone)
First, I’ll lay out my own bias: I think
trazodone is a great sleeping pill, I’ve
used it with hundreds of patients and
have never seen any dangerous side
effects, priapism included. Nonetheless,
trazodone has been the target of numerous
Continued on Page 2
PA G E 1
Sleeping Pills, New and Old
“critical reviews” over the last few years,
all funded by the makers of branded
hypnotics that lose market share to
trazodone (see for example, Mendelson
WB, J Clin Psychiatry 2005;66:469-476,
and James SP et al., J Clin Psychiatry
2004;65:752-755). The gist of these
reviews is that trazodone has not under-
gone the same kinds of rigorous clinical
trials for non-depressed primary insom-
nia as the newer agents, so we simply
don’t know how well it really
works. This is true, because
trazodone is generic and there
are no big-money sponsors willing
to pay for fancy studies to show
it works. Nonetheless, several
studies over the years have shown
low dose trazodone (50-100 mg
HS) to be effective for insomnia
in depressed patients (e.g.,
Saletu-Zyhlarz GM et al., Prog
Neuropsychopharmacol Biol
Psychiatry 2002;26:249-260).
One study, however, funded by
Ambien’s original manufacturer,
did compare Ambien and tra-
zodone head-to-head, and found
that both drugs were better than
placebo for primary insomnia
(Walsh JK et al., Human
Psychopharm 1998;13:191-198).
The sponsor has spun the results
of the study to argue that
Ambien was superior to tra-
zodone, but a close read of the
study does not support this con-
clusion. bottom line: For a very
cheap, long-half-life sleeping pill,
it’s hard to beat trazodone, but be sure to
assess your patients for next-day sedation,
orthostatic hypotension, and priapism, all
of which are possible side effects.
Ambien (Zolpidem) and Ambien CR
We’ll start with the potential dark
side of Ambien, simply because this has
been on patients’ minds ever since an
Ambien-addled Patrick Kennedy crashed
his car enroute to a 2 AM “vote” on
December 2007
Continued from Page 1
Capitol Hill (the last vote had occurred Lunesta) abuse from 1992 to 1997. They
at 9 PM). Since then, the FDA has issued found an average of 4.5 cases of nonben-
alerts regarding possible “sleep-driving” zo abuse per 10,000 doses, vs. a rate of
and “sleep-eating” on all sleeping pills. benzo abuse of 106.7 per 10,000 doses
Is Ambien (and by extension, the (Hajak G et al., Addiction 2003;98:1371-
other nonbenzodiazepines) “abusable?” 1378). This implies that benzos are
Undoubtedly. But is it less abusable then about 20 times more likely to be abused
benzodiazepines? Almost certainly. There than the non-benzos.
have been numerous case reports of Sleep-driving, -eating, and -walking
zolpidem abuse (for example, see are not really abuse issues, but possible
Cubala WJ et al., Br J Clin Pharm side effects. While not common, they occur
frequently enough that most psy-
Practice Tips: Four Questions to Evaluate chiatrists have seen cases in their
practices. They can usually (but
Insomnia
not always) be prevented by
Stephen C. Ellen, a psychiatrist and sleep medicine reminding patients to get into bed
expert who is the medical director of The Counseling right after taking their sleeping
Center of Nashua, New Hampshire, recommends the pill.
following four questions for a quick initial evaluation of On the positive side, Ambien
insomnia. is an effective, FDA-approved
1) How long does it usually take you to fall asleep? sleeping pill. Now that it is avail-
(Normal sleep latency is about 10 minutes; while we focus able generically, its manufactur-
on long latencies for diagnosing initial onset insomnia, er, Sanofi, has been pushing us
patients who report very short latencies, such as 2 minutes, to switch patients from Ambien
may be suffering sleep deprivation and should be counseled to Ambien CR. Well, should we?
to increase sleep time.) Theoretically, Ambien CR has
2) How many times a night do you wake up? (Ask the ideal pharmacokinetic pro-
this of the patient’s sleep partner as well.) file. After ingestion, 60% of the
3) After each awakening, how long does it take to fall dose is released immediately,
back asleep? (This, combined with the answer to question and the remainder is released
#2, gives you an accurate measure of exactly how much gradually throughout the night.
sleep is being lost.) This means that it should pro-
4) Do you feel refreshed upon awakening in the vide enough GABA agonism to
morning? (This is really the most important question for get patients to sleep and keep
assessing the need for clinical intervention.) them asleep. Indeed, while
Note: These practice tips are not a part of this month’s Ambien is approved for sleep
formal ACCME-accredited continuing medical education initiation only, Ambien CR pro-
material. vided sufficient evidence to win
an additional FDA approval for
2007;online early article). Typically, “sleep maintenance.”
Ambien abusers take an awful lot of the Nonetheless, it is troubling to many
stuff to get high (these authors reported that Sanofi has never funded a head-to-
a range from 160 mg/day to 2000 mg/day – head trial comparing Ambien with
yes, 2000 mg), and in rare cases zolpi- Ambien CR. Are they afraid that IR will end
dem withdrawal seizures have occurred. up outshining CR? Instead of an appro-
But one study provided strong evidence priate comparative trial, we see research
that Ambien abuse is much rarer than designed to guarantee a favorable impres-
benzodiazepine abuse. Researchers in sion of Ambien CR, such as one recent
Germany looked at the reported rates of study of elderly patients comparing
ambien and zopiclone (mother of Ambien CR with Dalmane 30 mg, which
Continued on Page 3
PA G E 2
 EDITORIAL INFORMATION
Publisher and Editor-in-Chief: Daniel J. Carlat, M.D., is assistant clinical professor of psychiatry at Tufts University School of Medicine and
maintains a private practice in Newburyport, Massachusetts. He graduated from the psychiatric residency at Massachusetts General Hospital in
1995 and is founding editor of The Practical Guide Series in Psychiatry, published by Lippincott Williams & Wilkins.
Associate Editor: Marcia L. Zuckerman, M.D., practices psychiatry at HRI/Arbour in Brookline, Massachusetts.
Editorial Board:
Dan Egli, Ph.D., private practice, Williamsport, Pennsylvania
Ivan Goldberg, M.D., creator, Depression Central Web Site, psychopharmacologist in private practice, New York City
Alan D. Lyman, M.D., child and adolescent psychiatrist in private practice, New York City
Robert L. Mick, M.D., medical director, DePaul Addiction Services, Rochester, New York
Michael Posternak, M.D., staff psychiatrist, Massachusetts General Hospital, Boston
Dr. Carlat, with editorial assistance by Dr. Zuckerman, is the author (unless other authorship is specified) of all articles and interviews for
The Carlat Psychiatry Report. All editorial content is peer reviewed by the editorial board. Dr. Carlat, Dr. Egli, Dr. Goldberg, Dr. Lyman, Dr. Mick,
Dr. Posternak, and Dr. Zuckerman have disclosed that they have no significant relationships with or financial interests in any commercial
companies pertaining to this educational activity.

Sleeping Pills, New and Old Continued from Page 2

is double the recommended dose for
older patients. Dalmane, with a half-life
of between 50-100 hours, is not exactly a
first-line sleeping pill for the elderly,
and, not surprisingly, it caused more
next-day cognitive impairment than
Ambien CR.
Bottom line: In the absence of the
relevant comparative data, we’re left to our
own anecdotal sense of whether Ambien
CR actually poses clinical advantages.
Sonata (Zaleplon)
Sonata seems to have completely
dropped off everybody’s radar screen,
which is too bad, because it helps
patients get to sleep and it causes no
next day grogginess, even when taken in
the middle of the night (Hindmarch I, et
al., Hum Psychopharmacol. 2001;16(2):
159-167). It is not approved for sleep
maintenance.
Lunesta (Eszopiclone)
Let’s face it: aside from a memorable
commercial, Lunesta has no advantages
over its competitors and has marked dis-
advantages. Its half-life is long, at 6
hours, meaning that it likely causes
more next-day impairment than its com-
petitors. In its promotional material,
Sepracor claims no next-day residual effects
in most patients. But if you dig into the
actual data behind this claim, you’ll find
that they chose a very convenient time
point for their assessment-9.5 hours and
12 hours (Lunesta package insert) –
whereas the other nonbenzos assessed
for cognitive effects at 8 hours (see, for
example, Ambien CR package insert).
Like the foolish man looking for his car
keys far from where he dropped them
“because the light’s better here,” Sepracor
opted to shed their research light far
enough away from the time of ingestion to
guarantee a good marketing line.
In fact, the precursor of Lunesta,
zopiclone, does cause next-day impair-
ment and is associated with a risk of car
accidents (Staner L et al., Psychopharm
(Berlin) 2005;181(4):790-798). The nail
in Lunesta’s coffin is that it causes an
unpleasant taste in 20-40% of people
who take it (Lunesta package insert),
prompting some Sepracor reps to recom-
mend that patients bite into a lemon when
they wake up in the morning. Thanks, but
I’ll order the waffles instead.
If you don’t have anything compelling
to say about your product, just keep fund-
ing opinion leaders to write something
about it, no matter how irrelevant – even-
tually, you’ll build up market share, if
only through literature saturation alone.
Thus, we have company-funded studies
such as a recent one in which 410
menopausal women with insomnia were
randomized to receive either Lunesta or
placebo. And indeed, Lunesta, a sleeping
pill, helped these women sleep better
(Soares CN et al., Obset Gynecol
2006;108:1402-1410). This is a contribu-
tion to the medical literature…how?
bottom line: Lunesta has the same
half life as Restoril (temazepam), is 100
times more expensive, and has resulted in
a scourge of Luna moths fluttering around
people’s ears while they are trying to sleep.
Rozerem (Ramelteon)
There are two good things to say
about Rozerem: it has no abuse potential
(really, none, nada) and it has a different
mechanism of action from its competitors.
Rather than acting by revving up GABA, it
stimulates two subtypes of the melatonin
receptors in the brain’s suprachiasmatic
nucleus (SCN): MT1 and MT2. Of the two,
MT1 is most specific for sedation, and
Rozerem has a 15-fold greater affinity for
MT1 than straight melatonin, a fact that
probably accounts for why melatonin is
only mildly effective as a sleep aid (see
this meta-analysis of melatonin studies:
Brzezinski A et al., Sleep Med Rev
2005;9:41-50).
For some reason, Rozerem has the
anecdotal reputation of having a one to
two week “lag time” before working, but
this is not true. In fact, a recent review
of the Rozerem studies, written by two
pharmacists who received no payments
from Takeda, concluded that it improves
sleep latency on nights one and two as
well as any of the competing agents
(Borja NL et al., Clin Ther 2006;28:1540-
1555). It has not been shown to
decrease a standard measure of sleep,
WASO (wake time after sleep onset), so
it did not win the sleep maintenance
indication.
According to experts I consulted,
Rozerem doesn’t deliver the obvious
“knock out punch” that the benzos and

Continued on Page 8

December 2007 PA G E 3
 This Month’s Expert:
Michael Breus, Ph.D.
Practical Sleep Hygiene Tips
Author, Good Night: The Sleep Doctor’s 4-Week Program to Better Sleep and
With Better Health, New York: Dutton, 2006.
the Expert
Disclosures: Dr. Breus has disclosed that he derives income from books and a website relating to sleep issues. Dr. Carlat has
ensured that the interview is a fair and balanced presentation of the use of sleep hygiene practices.

TCPR: You wrote an excellent book on non-pharmacological approaches to insomnia, and I’d like to go over some of the
techniques you suggested. What are some practical techniques that psychiatrists can use in the context of short visits
with patients?
Dr. Breus: The first thing is to give patients some sort of a sleep hygiene worksheet. This is pretty standard advice, and most clinicians
have these around and give them out, but, in all honesty, many of them are not particularly effective, because they tend not to be
realistic. If I told every one of my patients that they could never drink caffeine again and that they had to go to bed at 9 o’clock in
a perfectly darkened room and that they could never drink a glass of wine in the evening, I wouldn’t have very many patients left.
TCPR: So describe your more realistic approach to sleep hygiene.
Dr. Breus: I begin talking about nicotine. I tell my patients who smoke that they should not try to stop smoking and fix their sleep
at the same time, because it doesn’t work. People who are undergoing smoking cessation are miserable – they have headaches, they
are nauseous and they don’t sleep. If you smoke and you have problems sleeping, pick one or the other to work on.
TCPR: In addition to limiting nicotine intake, most standard sleep hygiene sheets discourage caffeine use.
Dr. Breus: I tell patients to taper their caffeine throughout the day. If you can get yourself under about 200 or 250 mg of
caffeine, that is pretty good. The National Sleep Foundation uses that as a recommendation. Don’t ever tell somebody to go cold
turkey off caffeine because it is a nightmare.
TCPR: Give us some benchmarks for what 200 or 250 mg of caffeine translates to.
Dr. Breus: If you have a regular brewed cup of coffee at your home, depending upon the bean that you choose, you could have
anywhere from 110 to 180 mg of caffeine in one cup. A bottle of cola contains 60-65 mg of caffeine. The National Sleep Foundation
web site has a handy caffeine calculator (http://www.sleepfoundation.org/atf/cf/%7BF6BF2668-A1B4-4FE8-8D1AA5D39340D9CB%7D/caf-
feine.pdf). I tell people to start with their highest caffeine content beverage in the morning and to taper down throughout the day.
By 2 in the afternoon, patients should switch to fruit juice or water. Chocolate doesn’t have enough caffeine in it to worry about.
TCPR: What about the effects of alcohol on sleep?
Dr. Breus: When you fall asleep after drinking alcohol, you may fall asleep quickly and go right into stage I and stage II sleep, but
you get less deep sleep and it affects your ability to get into REM sleep. So I advise people to do the “one-to-one.” This means
drinking one 8-ounce glass of water for every one alcoholic beverage. The reason for this is three-fold. Number one, it helps flush
out your system. Number two, it slows down the amount of alcohol you drink. And finally, it helps prevent dehydration, which is
one of the causes of hangover. The other thing I tell patients is that usually when you are drinking, you are staying out past your
bedtime, and so you are giving yourself a double whammy – ingesting something that affects your sleep, and also depriving yourself
of sleep.
TCPR: Aside from all these things to avoid, what can patients do in order to improve sleep?
Dr. Breus: Exercise is the single best way to increase the overall quality of your sleep. So encouraging patients to get onto a regular
exercise program is crucial.
TCPR: Should they avoid exercising at night?
Dr. Breus: We used to believe that night exercise causes too much autonomic arousal, but the data are very inconsistent. Many
patients feel relaxed after exercise and sleep fine.
Continued on Page 5

December 2007 PA G E 4
Q & A With the Expert Continued from Page 4

TCPR: What about the importance of the bedroom environment?

Dr. Breus: I work with my patients in helping them to do an “extreme bedroom makeover.” For example, one of the first things I
do is advise patients to decrease the wattage of their bedside lamp bulbs to around 45 watts. I also recommend the use of book
lights (especially for the bed partner) and night lights for hallways and bathrooms. Turning on a bathroom light in the middle of
the night can initiate the waking process prematurely by decreasing melatonin levels, and obviously we want to avoid that. There
are many other bedroom tips for patients, many of which sound obvious, but I’m often surprised by how helpful they can be for
sleep. This includes very specific advice about sheets and thread-count issues, pillows, mattresses, the effect of odors, the effect of
clutter, etc. [Ed. note: I found Chapter 4 of Dr. Breus book chock-full of practical tips and highly recommend it.]
TCPR: What do you tell patients about sleep restriction techniques?
Dr. Breus: Sleep restriction means reducing time in bed to sleep time only. I tell patients, “I want you to stay in bed only during
times that you are asleep. So if you get in bed at 10 o’clock, but you don’t really fall asleep until 12, don’t go to bed until 12:30. If
you wake up at 6 and you don’t usually get out of bed until 7, then start getting out of bed at 6. Try to restrict the time in bed to
almost less time than you are actually sleeping. So if generally you sleep about five hours because you have insomnia, I only want
you in bed for five hours. Also, don’t take any naps throughout the day.” I have patients continue this regimen for seven days in a
row. If they are successful, by the end of that period, they are exhausted, and
they fall asleep easily. Is Cognitive Behavior Therapy more
TCPR: Do you recommend any other behavioral techniques? Effective than Medication?
Dr. Breus: I also use “stimulus control,” which is an old tried and true
Skinner idea – don’t do anything except sleep or have sex when you are in According to a review in the New England
the bed. And the reason for that, of course, is that we don’t want people to Journal of Medicine, cognitive behavioral
associate a poor night’s rest with the bedroom. That said, I certainly don’t therapy (CBT) is at least as effective as
insist that patients do nothing other than sleep or sex in the bedroom, since hypnotics for chronic insomnia, and prob-
that’s unrealistic. So I might say, “If you want to read in bed, fine. But use a ably provides more sustained benefit
book light as opposed to a bedside table lamp so you don’t have direct light (Silber MH, NEJM 2005;353:803-810). For
towards your eyes, which would be telling your brain that it is daytime.” As example, in one study, young and middle-
far as the television is concerned, I would say about a third of my patients aged patients with chronic sleep-onset
cannot fall asleep unless the T.V. is on. The reason is that they haven’t had any insomnia were randomized to CBT,
time throughout the entire day to just sit down quietly with no stimulation, and Ambien 10 mg QHS, combined CBT and
so when it is finally quiet, they can’t turn their brain off. They watch 20 or 30 Ambien, or placebo. Patients receiving CBT
minutes of boring T.V. and they can drop off. There is nothing wrong with improved sleep latency and sleep efficien-
that. I just advise them to get a T.V. timer so that it shuts off in the middle of cy more than patients in the medication
the night. group, and there was no difference
TCPR: How is cognitive behavior therapy (CBT) related to these behavioral between CBT and combination treatment
approaches? (Jacobs GD, Arch Intern Med
Dr. Breus: CBT is different because it focuses on changing the way patients 2004;164:1888-1896). These results were
think about sleep. Patients might have catastrophic thoughts such as, “Oh my replicated in a more recent study compar-
God, I am never going to get a good night’s sleep. I am going to die ten years ing CBT with zopiclone (precursor of
earlier because of it.” This is very rigid thinking, and a therapist will say, “Let us Lunesta) in 46 older patients (mean age
look at the data that proves to you that that is not true. Now how can we think 61) with chronic insomnia (Sivertsen B,
about this a little bit differently so hopefully we can change some of those
JAMA 2006;295:2851-2858).
thoughts or patterns?”
TCPR: What about relaxation exercises and meditation?
Dr. Breus: Generally speaking, I like to start off with classical Jacobsonian muscle relaxation. I created a meditation/relaxation CD
and it is extremely self-explanatory. It basically says, get in bed, get into a dark quiet place, and I start with deep breathing exercises
and I move from the deep breathing exercises on to progressive tension and relaxation of the muscles going from the head all the
way down to the feet. [Ed. note: Dr. Breus maintains a website, www.soundsleepsolutions.com, which sells various products but
also has some useful free resources for patients and clinicians. In addition, he has made a Sleep Hygiene Sheet available to TCPR
readers as a free download from our website at www.TheCarlatReport.com.

December 2007 PA G E 5
Acupuncture 1:6 Eating disorders 10:1-8 Mood stabilizers 8:3 Rozerem 12:1
Agitation in elderly 5:4 Exelon 5:2 Namenda 5:2 Seroquel 3:1,6
Alcohol abuse 6:6 Exercise (as antidepressant) Omega-3 fatty acids 3:6 Side effect management 9:4-5
Ambien 12:1 10:6 Pharmacogenetics 2:6, 8:4-5 Sonata 12:16
Antipsychotics, atypical Fibromyalgia 6:6,8:6 Prazosin 6:5 SSRIs 1:1,8:
1:6, 2:1, 3:1,5:6,7:6 Guanfacine 2:6 Pregnancy and psychotropics STAR-D 1:1
Antipsychotics, conventional Insomnia 12:18 4:1 Suicidality 1:6, 6:6, 10:6
1:6,7:6 Invega 3:1 Provigil 9:2,6 Thyroid 9:2
Aricept 5:2 Laboratory monitoring 8:1 Psychostimulants Topamax 1:6, 9:6
Benadryl 12:1 Lithium 9:2 2:6, 3:6, 4:6, 5:6, 7:6 Transcranial magnietic
Bereavement 4:6 Lunesta 12:1 Psychotherapy 6:6, 7:1-5, stimulation 3:6, 5:6
Bipolar disorder 5:6, 9:6 Malpractice 11:1-8 10:2, 4-5, 12:4-5 Trazodone 12:1
Breastfeeding and Menopause 4:4 PTSD 6:1 Vitamin E 2:6
psychotropics 4:1 Meridia 9:6 Razadyne 5:2 Vyvanse 4:6
Dementia 5:1, 7:6 Metformin 3:6 Remeron 9:2 Wellbutrin 8:6,9:1
Depression, treatment-resistant Mirapex 10:6 Research methods 1:4, 2:1 Zoloft 7:6
1:1, 4:6, 9:1-4

Articles in Volume 5, 2007

January: Antidepressant Round-up 2007
• SSRI Nonresponse: What to Do Next?
• STAR-D Results: How do the results help our Depressed
Patients?
• Research Updates
• Michael Thase, M.D., on Deciphering Antidepressant Research
February: Understanding Psychiatric Research
• How to Read a Journal Article
• Statistical Significance: What does it really mean?
• Research Updates
• Ivan Oransky, M.D., on Clarifying the Risks of Antidepressants
March: Antipsychotic Roundup 2007
• Invega: Can You Say "Patent Extender?"
• Do Second-Generation Antipsychotics Treat Depression? An
Update
• Research Updates
• William Carpenter, M.D., on Choosing the Right Antipsychotic
April: Pregnancy and Menopause in Psychiatry
• Psychotropics and Pregnancy: An Update
• Prescribing Medication during Pregnancy and Breastfeeding
• Research Updates
• Louann Brizendine, M.D., on Treating Depression in
Perimenopause
May: Topics in Geriatric Psychiatry
• Medications for Dementia: An Update
• Normal Forgetfulness vs. Pre-Dementia: How to Distinguish
Them
• Research Updates
• James Ellison, M.D., on Treating Agitation and/or Depression in
Older Patients
June: Posttraumatic Stress Disorder
• PTSD: Is it "Real"?
• The Latest, Greatest Treatments for PTSD
• Research Updates
• David Osser, M.D., on Topics in the Diagnosis and Treatment of
PTSD
July: Psychotherapy in Psychiatry
• Does Psychotherapy Work?
• Psychotherapy: A Practical, Integrative Approach
• Research Updates
• Jesse Wright, M.D., on High Yield Cognitive Behavior Therapy
Techniques
August: Laboratory Testing in Psychiatry
• Screening Labs for New Patients: Are they Useful?
• Laboratory Monitoring When Prescribing Psychotropics
• Research Update
• Roy Perlis, M.D., on Pharmacogenetic Testing in Psychiatry
September: Complex Psychopharmacology
• Combining Meds for Depression: The State of the Art
• Dosing Psychotropics: How High Can We Go?
• Research Updates
• Ronald Pies, M.D., on Managing Side Effects of Psychotropics
October: Update on Eating Disorders
• What's New in Eating Disorders?
• Research Updates
• Cynthia Bulik, Ph.D., Therapeutic Strategies for Disordered
Eating
November: Avoiding Malpractice in Psychiatry
• Good Forensic Habits for your Practice
• Research Updates
• Rebecca Brendel, M.D., J.D., Topics in Confidentiality and Duty
to Warn
December: Treating Insomnia
• Sleeping Pills, New and Old
• Practice Tips: Four Questions for Insomnia
• Michael Breus, Ph.D., on Practical Sleep Hygiene Tips
• Index to 2007

December 2007 PA G E 6
 CME Post-Test
To earn CME or CE credit, you must read the articles and complete the quiz below, answering at least four of the questions correctly. Mail a photocopy
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1. Studies of Benadryl (diphenhydramine) have demonstrated:

[ ] a. It causes cognitive impairment in adolescents. Visit Our
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[ ] c. An increased incidence of delirium in the elderly.
[ ] d. Tolerance to its effects when used at bedtime. www.TheCarlatReport.com
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[ ] a. Ambien is abused more frequently than Sonata. quizzes online and print
[ ] b. Nonbenzos are 20 times less likely to be abused than benzos.
[ ] c. Withdrawal seizures have never occured in Ambien abusers. their certificates instantly!
[ ] d. Rozerem is associated with car accidents.

3. Lunesta’s next-day impairment studies were based on 8 hour post-dose assessments.

[ ] a. True [ ] b. False

4. Rozerem’s mechanism of action entails:

[ ] a. Preferential simulation of the melatonin type 1 receptor.
[ ] b. Equal stimulation of melatonin type 1 and type 2 receptors.
[ ] c. Global stimulation of the GABA system.
[ ] d. Antagonism at histamine receptors.

5. According to Dr. Breus, sleep restriction is most effective when continued for three days.
[ ] a. True [ ] b. False

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December 2007 PA G E 7
 Yes! I would like to try The Carlat Psychiatry Report for
Sleeping Pills, New and Old Continued from Page 3 one year. I may cancel my subscription at any time for
a full refund if not completely satisfied.
nonbenzos do, because it doesn’t act as a generalized CNS Regular subscriptions — $109
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Chloral Hydrate and
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Anna Nicole Smith
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On February 8, 2007 the model and actress Anna
Nicole Smith was found dead in her hotel room at the Name
Seminole Hard Rock Hotel in Florida. An autopsy report
ruled that the primary cause of death was a toxic overdose
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of several prescription medications, but most coverage
has centered on chloral hydrate. Smith also had traces
of Klonopin, Valium, Ativan, and Benadryl in her system, City State Zip
but the amounts of chloral hydrate were relatively high.
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Next Month in The Carlat Psychiatry Report: Update on Devices in Psychiatry, including reviews
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