Insomnia during pregnancy: Diagnosis and Rational Interventions.

UNLABELLED: Sleep disturbances are common in pregnancy. Insomnia is a frequent sleep disturbance experienced by pregnant women which can be primary or due to co-morbid conditions. The differential diagnosis of insomnia in pregnancy includes anxiety disorders, mood disorders, breathing related sleep disorders and restless legs syndrome. Early interventions to treat the sleep disturbance are recommended to avoid adverse pregnancy outcomes. Management strategies include improving sleep hygiene, behavioral therapies, and pharmacotherapy. The risks of pharmacotherapy must be weighed against their benefits due to the possible risk of teratogenicity associated with some medications. METHODS: We searched PubMed and Google Scholar employing a combination of key words: pregnancy, sleep disturbances, Obstructive Sleep Apnea, Sleep disorders and insomnia. We included original studies, review articles, meta-analysis and systematic reviews in our search prioritizing articles from the last 10-15 years. Articles older than 15 years were only included if their findings had not been superseded by more recent data. Further selection of articles was done from bibliographies and references of selected articles. CONCLUSION: Sleep disturbances in pregnancy are common and cause considerable morbidity. Management includes a combination of non-pharmacological and pharmacological treatments carefully weighing the risks and benefits of each for the expectant mother and fetus.

The Bhagavad Gita and contemporary psychotherapies.

The Bhagavad Gita is based on a discourse between Lord Krishna and Arjuna at the inception of the Kurukshetra war and elucidates many psychotherapeutic principles. In this article, we discuss some of the parallels between the Gita and contemporary psychotherapies. We initially discuss similarities between psychodynamic theories of drives and psychic structures, and the concept of three gunas. Arjuna under duress exhibits elements of distorted thinking. Lord Krishna helps remedy this through a process akin to Cognitive Behavioral Therapy (CBT). We ascertain the analogies between the principles of Gita and CBT, grief emancipation, role transition, self-esteem, and motivation enhancement, as well as interpersonal and supportive psychotherapies. We advocate the pragmatic application of age old wisdom of the Gita to enhance the efficacy of psychotherapeutic interventions for patients from Indian subcontinent and to add value to the art of western psychotherapies.

Childhood and adolescent depression.

Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies.

Preparing for a successful psychiatry residency review committee site visit: a guide for new training directors.

OBJECTIVE: New residency training directors are often faced with multiple competing tasks such as meeting Accreditation Council for Graduate Medical Education (ACGME) Psychiatry Program Requirements and achieving successful completion of residency review committee (RRC) site visits. For many years, the authors have presented workshops on this subject at the American Association of Directors of Psychiatry Residency Training (AADPRT) annual meetings, and many attendees have suggested publishing this information in detail. The authors provide new residency training directors with a model of comprehensive resident, faculty, and training program records and accurate documentation of compliance with psychiatry program requirements for a successful RRC site visit. METHODS: The authors carefully reviewed the ACGME Psychiatry Program Requirements, the Program Director's Reference Guide, and literature and incorporated many comments of AADPRT workshop attendees. This is in addition to 25 years combined experience of the authors as training directors. CONCLUSIONS: The proposed working guide designed to meet program requirements for full program accreditation may be of particular use to new residency training directors.

Diagnosis and treatment of premenstrual dysphoric disorder.

From 2 to 10 percent of women of reproductive age have severe distress and dysfunction caused by premenstrual dysphoric disorder, a severe form of premenstrual syndrome. Current research implicates mechanisms of serotonin as relevant to etiology and treatment. Patients with mild to moderate symptoms of premenstrual syndrome may benefit from nonpharmacologic interventions such as education about the disorder, lifestyle changes, and nutritional adjustments. However, patients with premenstrual dysphoric disorder and those who fail to respond to more conservative measures may also require pharmacologic management, typically beginning with a selective serotonin reuptake inhibitor. This drug class seems to reduce emotional, cognitive-behavioral, and physical symptoms, and improve psychosocial functioning. Serotoninergic antidepressants such as fluoxetine, citalopram, sertraline, and clomipramine are effective when used intermittently during the luteal phase of the menstrual cycle. Treatment strategies specific to the luteal phase may reduce cost, long-term side effects, and risk of discontinuation syndrome. Patients who do not respond to a serotoninergic antidepressant may be treated with another selective serotonin reuptake inhibitor. Low-dose alprazolam, administered intermittently during the luteal phase, may be considered as a second-line treatment. A therapeutic trial with a gonadotropin-releasing hormone agonist or danazol may be considered when other treatments are ineffective. However, the risk of serious side effects and the cost of these medications limit their use to short periods.