After a medical student prompted medical faculty to tell their stories of depression and related mental health issues, the author wrote this article with the aim of decreasing the stigma of mental ...illness and encouraging treatment, as needed, in the medical profession. The professional culture of the house of medicine not only mimics society in attributing stigma to people with mental health issues but may also contribute to high rates of suicide in the ranks of health care professionals by leading to a delay in seeking treatment. Acculturation accelerates in the first year of medical school such that medical students experience an increase in burnout and depressive symptoms from prematriculation levels. It follows that faculty have a responsibility to improve the learning environment. Survey data from medical faculty at the author's institution showed that depression decreased respondents' willingness to seek mental health treatment because of the stigma and issues of access to help. Faculty attitudes toward mental health issues, including reluctance to admit having such issues, may be conveyed to medical students in the hidden curriculum that teaches them to keep depression hidden. Moreover, the fear of mental disorders is manifested in licensing and privileging applications under the guise of patient safety, contributing to a culture of shame and silence. As creators and guardians of this professional culture, medical faculty and other physicians must be the ones who change it. The same faculty who play a part in causing and perpetuating stigma related to mental health issues have the power to derive and enact some of the solutions. In addition to giving voice to a personal experience of mental health issues, this article offers suggestions for normalizing moderate to severe depression as a medical disorder, decreasing the stigma of mental health issues, and encouraging faculty to seek treatment.
Insomnia, alcoholism and relapse Brower, Kirk J
Sleep Medicine Reviews,
12/2003, Letnik:
7, Številka:
6
Book Review, Journal Article
Recenzirano
Insomnia and alcoholism are significantly associated in community surveys and patient samples. Insomnia occurs in 36–72% of alcoholic patients and may last for weeks to months after initiating ...abstinence from alcohol. Some correlates of insomnia in alcoholic patients are identical to those observed in non-alcoholic insomniacs, including anxiety and depression, tobacco smoking, and the use of alcohol to aid sleep. Other studies suggest that as the severity of alcoholism increases, so does the likelihood of insomnia in alcoholic patients. In the sleep laboratory, alcoholic patients who complain of insomnia have disrupted sleep continuity when compared to alcoholic patients without insomnia complaints. Recently sober alcoholics are also more likely than non-alcoholics to have sleep-disordered breathing and increased periodic leg movements, which might contribute to insomnia in some alcoholic patients. The co-occurrence of insomnia and alcoholism is clinically significant because alcoholism can exacerbate the adverse consequences of insomnia (e.g. mood changes and performance decrements) and because insomnia among patients entering treatment for alcoholism has been significantly associated with subsequent alcoholic relapse. Baseline polysomnographic correlates of subsequent relapse include prolonged sleep latency, decreased sleep efficiency and total sleep time, increased rapid eye movement sleep pressure, and decreased slow wave sleep. Whether treatment of insomnia in alcoholic patients reduces relapse rates is unknown, but preliminary treatment guidelines that accommodate the special characteristics of alcoholic patients are provided, with a goal to reduce daytime impairment and psychological distress.
In a randomized controlled trial, we evaluated the efficacy of cognitive-behavioral treatment for insomnia to improve sleep and daytime symptoms, and to reduce relapse in recovering alcohol dependent ...(AD) participants. Seventeen abstinent AD patients with insomnia (6 women, mean age 46.2
±
10.1 years) were randomized to 8 sessions of cognitive-behavioral treatment for insomnia for AD (CBTI-AD, n
=
9) or to a behavioral placebo treatment (BPT, n
=
8). Subjective measures of sleep, daytime consequences of insomnia and AD, alcohol use, and treatment fidelity were collected at baseline and post-treatment. Diary-rated sleep efficiency and wake after sleep onset, and daytime ratings of General Fatigue on the Multidimensional Fatigue Inventory improved more in the CBTI-AD compared to the BPT group. In addition, more subjects were classified as treatment responders following CBTI-AD. No group differences were found in the number of participants who relapsed to any drinking or who relapsed to heavy drinking. The findings suggest that cognitive-behavioral insomnia therapy benefits subjective sleep and daytime symptoms in recovering AD participants with insomnia more than placebo. The benefits of treating insomnia on drinking outcomes are less apparent.
Background
Insomnia is an important symptom in alcohol‐dependent patients because it may persist despite abstinence and predispose to relapse to drinking. The goal of the present study was to ...evaluate the prevalence and clinical correlates of insomnia in a sample of 302 alcohol‐dependent patients admitted to treatment programs in Poland.
Methods
Participants were mostly men (73.8%) with a mean (SD) age of 43.5 (9.7) years. Insomnia in the past 1 month was assessed using a total score of 6 or higher on the Athens Insomnia Scale.
Results
Insomnia affected 62.9% of patients, and delayed sleep induction was the most common subtype. Insomnia was associated in bivariate analyses with less education, inadequate finances, problem drinking at an earlier age of onset, drinking frequency and quantity, drinking‐related consequences, severity of alcohol and nicotine dependence, psychiatric and physical severity, and a childhood history of sexual or physical abuse (p < 0.05). Logistic regression analysis showed that mental and physical health status, severity of alcohol dependence, number of drinking days in the past 3 months, and childhood abuse were independent predictors of insomnia, explaining approximately 30 to 40% of the variance.
Conclusions
More than 60% of alcohol‐dependent patients in a Polish sample screened positive for insomnia using a validated scale, a rate similar to those assessed with other scales in other countries. The study also showed that insomnia in alcohol‐dependent patients is associated with poor physical health and childhood abuse, similar to the general population. The multifactorial nature of insomnia in alcohol‐dependent patients has treatment implications.
Highlights • Relationship between pain and relapse in alcohol-dependent patients was explored. • Decrease in pain level after treatment was associated with lower risk of relapse. • Managing pain may ...be useful in improving treatment outcomes of alcohol dependence.
Abstract Insomnia in patients with alcohol dependence has increasingly become a target of treatment due to its prevalence, persistence, and associations with relapse and suicidal thoughts, as well as ...randomized controlled studies demonstrating efficacy with behavior therapies and non-addictive medications. This article focuses on assessing and treating insomnia that persists despite 4 or more weeks of sobriety in alcohol-dependent adults. Selecting among the various options for treatment follows a comprehensive assessment of insomnia and its multifactorial causes. In addition to chronic, heavy alcohol consumption and its effects on sleep regulatory systems, contributing factors include premorbid insomnia; co-occurring medical, psychiatric, and other sleep disorders; use of other substances and medications; stress; environmental factors; and inadequate sleep hygiene. The assessment makes use of history, rating scales, and sleep diaries as well as physical, mental status, and laboratory examinations to rule out these factors. Polysomnography is indicated when another sleep disorder is suspected, such as sleep apnea or periodic limb movement disorder, or when insomnia is resistant to treatment. Sobriety remains a necessary, first-line treatment for insomnia, and most patients will have some improvement. If insomnia-specific treatment is needed, then brief behavioral therapies are the treatment of choice, because they have shown long-lasting benefit without worsening of drinking outcomes. Medications work faster, but they generally work only as long as they are taken. Melatonin agonists; sedating antidepressants, anticonvulsants, and antipsychotics; and benzodiazepine receptor agonists each have their benefits and risks, which must be weighed and monitored to optimize outcomes. Some relapse prevention medications may also have sleep-promoting activity. Although it is assumed that treatment for insomnia will help prevent relapse, this has not been firmly established. Therefore, insomnia and alcohol dependence might be best thought of as co-occurring disorders, each of which requires its own treatment.
Sedative-hypnotics have been associated with suicide attempts and completed suicides in a number of toxicologic, epidemiologic, and clinical studies. Most studies, however, inadequately address ...confounding by insomnia, which not only is a component of many mental health disorders that increase suicidal risk, but also is independently associated with suicidality. Moreover, the association of nonbenzodiazepine benzodiazepine receptor agonists (NBRAs) with suicidality has not been specifically studied in the US general population.
The purpose of this study was to assess the independent contribution of prescription sedative-hypnotic use, particularly the NBRAs, to suicidal ideas, plans, and suicide attempts in the general US population, after adjusting for insomnia and other confounding variables.
Secondary analyses of National Comorbidity Survey Replication data for 5,692 household respondents interviewed between 2001 and 2003 assessed the cross-sectional relationships between prescription sedative-hypnotic use and suicidality in the previous 12 months. Multivariate, hierarchical logistic regression analyses controlled for symptoms of insomnia, past-year mental disorders, lifetime chronic physical illnesses, and demographic variables.
Prescription sedative-hypnotic use in the past year was significantly associated with suicidal thoughts (adjusted odds ratio AOR = 2.2; P < .001), suicide plans (AOR = 1.9; P < .01), and suicide attempts (AOR = 3.4; P < .01). It was a stronger predictor than insomnia for both suicidal thoughts and suicide attempts and significantly improved the fit of these regression models (suicidal thoughts, P < .01; suicide attempts, P < .05).
Prescription sleeping pills, as exemplified by zolpidem and zaleplon, are associated with suicidal thoughts and suicide attempts during the past 12 months, but no evidence of causality was provided by this study. Clinical practitioners should recognize that patients taking similar types of sedative-hypnotics have a marker of increased risk for suicidality.
Sleep‐related complaints are widely prevalent in those with alcohol dependence (AD). AD is associated not only with insomnia, but also with multiple sleep‐related disorders as a growing body of ...literature has demonstrated. This article will review the various aspects of insomnia associated with AD. In addition, the association of AD with other sleep‐related disorders will be briefly reviewed. The association of AD with insomnia is bidirectional in nature. The etiopathogenesis of insomnia has demonstrated multiple associations and is an active focus of research. Treatment with cognitive behavioral therapy for insomnia is showing promise as an optimal intervention. In addition, AD may be associated with circadian abnormalities, short sleep duration, obstructive sleep apnea, and sleep‐related movement disorder. The burgeoning knowledge on insomnia associated with moderate‐to‐severe alcohol use disorder has expanded our understanding of its underlying neurobiology, clinical features, and treatment options.
A growing body of literature has demonstrated an association between alcohol dependence (AD), and, insomnia and other sleep disorders. Insomnia is increasingly evaluated as a disorder of inappropriate arousal during sleep with involvement of multiple underlying mechanisms and downstream daytime manifestations. This understanding may have implications on newer modalities of treatment for insomnia. In addition, AD is also implicated with insufficient sleep duration, obstructive sleep apnea, and periodic limb movement disorder.
Commercial trawling in seagrass beds Stallings, C. D.; Brower, J. P.; Loch, J. M. Heinlein ...
Marine ecology. Progress series,
10/2014, Letnik:
513
Journal Article
Recenzirano
Odprti dostop
Fisheries for penaeid shrimp have historically represented one of the largest in the Gulf of Mexico (GOM). Fishing grounds include both deeper, offshore areas, which have received considerable ...attention from scientists and managers, as well as shallow, nearshore areas. In the eastern GOM, the nearshore fishing grounds are in highly productive seagrass beds, which serve as nursery, temporary and permanent habitats to a multitude of fishes and invertebrates, including many of economic importance. Despite concerns regarding high levels of bycatch often observed in penaeid shrimp fisheries that use trawling gears, studies of potential gear impacts to seagrass ecosystems are surprisingly limited. We combined fishery-independent and -dependent methods to examine the temporal trends in bycatch rates and catch composition for the trawling gears used by the inshore fishery as well as the intra- and inter-annual patterns in fishing effort. The proportion of bycatch was consistently high (0.74 to 0.93) across the late spring through fall months, corresponding to the period of highest primary and secondary productivity in eastern GOM seagrass beds. Fifty species were captured by the rollerframe trawls, including several species of economic concern as well as abundant fishes that serve as linkages between primary and secondary production in seagrass ecosystems. Using 24 yr of fishery data, we found long-term evidence of an intra-annual shift from offshore grounds to seagrass beds during the spring through fall period of high productivity. Moreover, the proportion of total effort in seagrass beds during this period has increased in recent years, largely due to unprecedented declines in offshore effort. Extraction of both bycatch and targeted fauna from this highly productive ecosystem represents an impact that has largely been ignored. Understanding the effects of this extraction on seagrass-associated populations and communities should be considered in future ecosystem-based management and conservation efforts.
Insomnia is common, persistent, and increases the risk for relapse in alcohol‐dependent (AD) patients. Abstinence has long been considered the best strategy for allowing sleep to normalize, although ...how many and which patients respond to abstinence is unknown. The aims of this study were to investigate the prevalence and correlates of both baseline and persistent insomnia in AD patients. The course of sleep problems in response to abstinence, moderate drinking, or relapse following treatment was also examined. A naturalistic longitudinal outcomes study interviewed 267 patients (69% male; mean age of 44 years) with DSM‐IV alcohol dependence at baseline and 6 months later (84% follow‐up rate)
. The Sleep Problems Questionnaire, Time‐Line Follow‐Back Interview, and Brief Symptom Inventory measured insomnia, drinking, and psychiatric symptoms, respectively. Simple correlations, logistic regression, and repeated measures analysis of variance were used to analyze the data. At baseline, 47% of patients were classified with insomnia, which was independently predicted by female gender and psychiatric severity. Both abstinence and moderate drinking outcomes significantly predicted a reduction of insomnia symptoms after controlling for gender and psychiatric severity. Among patients with baseline insomnia, however, insomnia persisted in over 60% of cases, which was predicted by baseline insomnia severity. Moreover, insomnia persisted in one‐quarter of patients despite abstinence. Treatment aimed at preventing relapse to heavy drinking provides good first‐line therapy for insomnia in AD patients, but some may require insomnia‐specific evaluation and treatment in addition to substance‐focused treatment and psychiatric care. (Am J Addict 2011;00:1‐6)
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