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VOLUME 5, NUMBER 12
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 metaanalysis 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 numbers 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 betweenappointment 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
Sleeping Pills, New and Old
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 anticholinergic 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
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 regimen for allergic rhinitis) have shown that any daytime sedation or cognitive impairment 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 supporting 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
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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.
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Sleeping Pills, New and Old
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“critical reviews” over the last few years, Capitol Hill (the last vote had occurred Lunesta) abuse from 1992 to 1997. They all funded by the makers of branded at 9 PM). Since then, the FDA has issued found an average of 4.5 cases of nonbenhypnotics that lose market share to alerts regarding possible “sleep-driving” zo abuse per 10,000 doses, vs. a rate of trazodone (see for example, Mendelson and “sleep-eating” on all sleeping pills. benzo abuse of 106.7 per 10,000 doses WB, J Clin Psychiatry 2005;66:469-476, Is Ambien (and by extension, the (Hajak G et al., Addiction 2003;98:1371and James SP et al., J Clin Psychiatry other nonbenzodiazepines) “abusable?” 1378). This implies that benzos are 2004;65:752-755). The gist of these Undoubtedly. But is it less abusable then about 20 times more likely to be abused reviews is that trazodone has not underbenzodiazepines? Almost certainly. There than the non-benzos. gone the same kinds of rigorous clinical have been numerous case reports of Sleep-driving, -eating, and -walking trials for non-depressed primary insomzolpidem abuse (for example, see are not really abuse issues, but possible nia as the newer agents, so we simply Cubala WJ et al., Br J Clin Pharm side effects. While not common, they occur don’t know how well it really frequently enough that most psyworks. This is true, because chiatrists have seen cases in their Practice Tips: Four Questions to Evaluate trazodone is generic and there practices. They can usually (but Insomnia are no big-money sponsors willing not always) be prevented by to pay for fancy studies to show reminding patients to get into bed Stephen C. Ellen, a psychiatrist and sleep medicine it works. Nonetheless, several right after taking their sleeping expert who is the medical director of The Counseling studies over the years have shown pill. Center of Nashua, New Hampshire, recommends the low dose trazodone (50-100 mg On the positive side, Ambien following four questions for a quick initial evaluation of HS) to be effective for insomnia is an effective, FDA-approved insomnia. in depressed patients (e.g., sleeping pill. Now that it is avail1) How long does it usually take you to fall asleep? Saletu-Zyhlarz GM et al., Prog (Normal sleep latency is about 10 minutes; while we focus able generically, its manufacturNeuropsychopharmacol Biol er, Sanofi, has been pushing us on long latencies for diagnosing initial onset insomnia, Psychiatry 2002;26:249-260). to switch patients from Ambien patients who report very short latencies, such as 2 minutes, One study, however, funded by may be suffering sleep deprivation and should be counseled to Ambien CR. Well, should we? Ambien’s original manufacturer, Theoretically, Ambien CR has to increase sleep time.) did compare Ambien and trathe ideal pharmacokinetic pro2) How many times a night do you wake up? (Ask zodone head-to-head, and found file. After ingestion, 60% of the this of the patient’s sleep partner as well.) that both drugs were better than 3) After each awakening, how long does it take to fall dose is released immediately, placebo for primary insomnia and the remainder is released back asleep? (This, combined with the answer to question (Walsh JK et al., Human gradually throughout the night. #2, gives you an accurate measure of exactly how much Psychopharm 1998;13:191-198). This means that it should prosleep is being lost.) The sponsor has spun the results vide enough GABA agonism to 4) Do you feel refreshed upon awakening in the of the study to argue that get patients to sleep and keep morning? (This is really the most important question for Ambien was superior to trathem asleep. Indeed, while assessing the need for clinical intervention.) zodone, but a close read of the Note: These practice tips are not a part of this month’s Ambien is approved for sleep study does not support this coninitiation only, Ambien CR proformal ACCME-accredited continuing medical education clusion. bottom line: For a very vided sufficient evidence to win material. cheap, long-half-life sleeping pill, an additional FDA approval for 2007;online early article). Typically, it’s hard to beat trazodone, but be sure to “sleep maintenance.” Ambien abusers take an awful lot of the assess your patients for next-day sedation, Nonetheless, it is troubling to many stuff to get high (these authors reported orthostatic hypotension, and priapism, all that Sanofi has never funded a head-toa range from 160 mg/day to 2000 mg/day – of which are possible side effects. head trial comparing Ambien with yes, 2000 mg), and in rare cases zolpiAmbien CR. Are they afraid that IR will end Ambien (Zolpidem) and Ambien CR dem withdrawal seizures have occurred. up outshining CR? Instead of an approWe’ll start with the potential dark But one study provided strong evidence priate comparative trial, we see research side of Ambien, simply because this has that Ambien abuse is much rarer than designed to guarantee a favorable impresbeen on patients’ minds ever since an benzodiazepine abuse. Researchers in sion of Ambien CR, such as one recent Ambien-addled Patrick Kennedy crashed Germany looked at the reported rates of study of elderly patients comparing his car enroute to a 2 AM “vote” on ambien and zopiclone (mother of Ambien CR with Dalmane 30 mg, which
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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
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. 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 impairment 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 recommend 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 funding opinion leaders to write something about it, no matter how irrelevant – eventually, 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 contribution 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
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a scourge of Luna moths fluttering around people’s ears while they are trying to sleep.
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 disadvantages. Its half-life is long, at 6 hours, meaning that it likely causes more next-day impairment than its competitors. 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
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;28:15401555). 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
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This Month’s Expert: Michael Breus, Ph.D. Practical Sleep Hygiene Tips With the Expert
Author, Good Night: The Sleep Doctor’s 4-Week Program to Better Sleep and Better Health, New York: Dutton, 2006.
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/caffeine.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.
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Q & A With the Expert
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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 According to a review in the New England Skinner idea – don’t do anything except sleep or have sex when you are in Journal of Medicine, cognitive behavioral the bed. And the reason for that, of course, is that we don’t want people to therapy (CBT) is at least as effective as associate a poor night’s rest with the bedroom. That said, I certainly don’t hypnotics for chronic insomnia, and probinsist that patients do nothing other than sleep or sex in the bedroom, since ably provides more sustained benefit that’s unrealistic. So I might say, “If you want to read in bed, fine. But use a (Silber MH, NEJM 2005;353:803-810). For book light as opposed to a bedside table lamp so you don’t have direct light example, in one study, young and middletowards your eyes, which would be telling your brain that it is daytime.” As aged patients with chronic sleep-onset far as the television is concerned, I would say about a third of my patients 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 efficienthat. 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 comparGod, 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.
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Acupuncture 1:6 Agitation in elderly 5:4 Alcohol abuse 6:6 Ambien 12:1 Antipsychotics, atypical 1:6, 2:1, 3:1,5:6,7:6 Antipsychotics, conventional 1:6,7:6 Aricept 5:2 Benadryl 12:1 Bereavement 4:6 Bipolar disorder 5:6, 9:6 Breastfeeding and psychotropics 4:1 Dementia 5:1, 7:6 Depression, treatment-resistant 1:1, 4:6, 9:1-4
Eating disorders 10:1-8 Exelon 5:2 Exercise (as antidepressant) 10:6 Fibromyalgia 6:6,8:6 Guanfacine 2:6 Insomnia 12:18 Invega 3:1 Laboratory monitoring 8:1 Lithium 9:2 Lunesta 12:1 Malpractice 11:1-8 Menopause 4:4 Meridia 9:6 Metformin 3:6 Mirapex 10:6
Mood stabilizers 8:3 Namenda 5:2 Omega-3 fatty acids 3:6 Pharmacogenetics 2:6, 8:4-5 Prazosin 6:5 Pregnancy and psychotropics 4:1 Provigil 9:2,6 Psychostimulants 2:6, 3:6, 4:6, 5:6, 7:6 Psychotherapy 6:6, 7:1-5, 10:2, 4-5, 12:4-5 PTSD 6:1 Razadyne 5:2 Remeron 9:2 Research methods 1:4, 2:1
Rozerem 12:1 Seroquel 3:1,6 Side effect management 9:4-5 Sonata 12:16 SSRIs 1:1,8: STAR-D 1:1 Suicidality 1:6, 6:6, 10:6 Thyroid 9:2 Topamax 1:6, 9:6 Transcranial magnietic stimulation 3:6, 5:6 Trazodone 12:1 Vitamin E 2:6 Vyvanse 4:6 Wellbutrin 8:6,9:1 Zoloft 7:6
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
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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 or fax the completed page (no cover sheet required) to Clearview CME Institute, P.O. Box 626, Newburyport, MA 01950; fax (978) 499-2278. For customer service, please call (978) 499-0583. Only the first entry will be considered for credit and must be received by Clearview CME Institute by November 30, 2008. Acknowledgment will be sent to you within six to eight weeks of participation. This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the sponsorship of the Clearview CME Institute. Clearview CME Institute is accredited by the ACCME to provide continuing medical education for physicians. Clearview CME Institute is also approved by the American Psychological Association to sponsor continuing education for psychologists. Clearview CME Institute maintains responsibility for this program and its content. Clearview CME Institute designates this educational activity for a maximum of one (1) AMA PRA Category 1 CreditTM or 1 CE for psychologists. Physicians or psychologists should claim credit commensurate only with the extent of their participation in the activity. Please identify your answer by placing a check mark or an X in the box accompanying the appropriate letter.
1. Studies of Benadryl (diphenhydramine) have demonstrated: [ ] a. It causes cognitive impairment in adolescents. [ ] b. An increased incidence of hip fractures in elderly users. [ ] c. An increased incidence of delirium in the elderly. [ ] d. Tolerance to its effects when used at bedtime. 2. According to a study in Germany: [ ] a. Ambien is abused more frequently than Sonata. [ ] b. Nonbenzos are 20 times less likely to be abused than benzos. [ ] c. Withdrawal seizures have never occured in Ambien abusers. [ ] d. Rozerem is associated with car accidents.
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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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Sleeping Pills, New and Old
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nonbenzos do, because it doesn’t act as a generalized CNS depressant at the GABA receptors. On the plus side, this means Rozerem is unlikely to cause the bizarre sleep-related behavior and the dizziness and falls implicated for the nonbenzos. Bottom line: Rozerem’s worth a try, particularly for substance abusers and for the elderly. But, like all of the newer sleeping pills, it’s expensive, around $3/dose.
Chloral Hydrate and Anna Nicole Smith
On February 8, 2007 the model and actress Anna Nicole Smith was found dead in her hotel room at the Seminole Hard Rock Hotel in Florida. An autopsy report ruled that the primary cause of death was a toxic overdose 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, but the amounts of chloral hydrate were relatively high. Chloral hydrate is approved as sedative-hypnotic, but it should be used only for patients unresponsive to multiple trials of other hypnotics.
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An Indispensable New Reference The Carlat Psychiatry Report
Medication Fact Book
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Indications Mechanism Dosing Side Effects Drug-Drug Interactions "Pearls" On 49 of the most prescribed psychiatric medications
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