Current Psychiatry

I wish to comment on “When Depression Treatment Goes Nowhere” by Drs. Ahsan Khan and Katherine Grimsley (Current Psychiatry, August 2005).

I’m surprised the authors did not mention Mr. D’s untreated (presumably obstructive) sleep apnea after reporting that he could not use nasal positive airway pressure because of his work schedule.

Untreated apnea symptoms overlap many of the symptoms and concepts addressed in the article. Mr. D’s eventual weight loss could have helped resolve those symptoms, at least partially.

Did the treating physicians get Mr. D involved with effective apnea treatment but just not mention it in the article? Could his brother’s motor vehicle accident have been caused by apnea-related sleepiness as well?

Kenneth N. Wiesert, MD
Indianapolis, IN

The authors respond

We appreciate Dr. Wiesert’s thoughtful comments on the role sleep apnea may have played in Mr. D’s symptoms.

Mr. D’s excessive fatigue, decreased energy and concentration, and mood symptoms could have been attributed to sleep apnea alone. Because his medical workup uncovered strikingly elevated blood glucose and poorly treated hypertension, we chose to highlight these findings.

Although we did not mention it in our article, Mr. D was urged early in treatment to maintain his continuous positive airway pressure (CPAP) regimen, and was educated on the importance of proper adherence to decrease his daytime sleepiness and other problems.

We addressed Mr. D’s noncompliance with CPAP during his care, but he recovered significantly after he began managing his diabetes and hypertension and abstaining from drug use. Further, even if Mr. D had been using his CPAP as recommended, his symptoms would have improved minimally or not at all because of his uncontrolled diabetes and hypertension.

Ahsan Y. Khan, MD
Katherine Grimsley, MD
Department of psychiatry and behavioral health
University of Kansas School of Medicine, Wichita

I wish to comment on “When Depression Treatment Goes Nowhere” by Drs. Ahsan Khan and Katherine Grimsley (Current Psychiatry, August 2005).

I’m surprised the authors did not mention Mr. D’s untreated (presumably obstructive) sleep apnea after reporting that he could not use nasal positive airway pressure because of his work schedule.

Untreated apnea symptoms overlap many of the symptoms and concepts addressed in the article. Mr. D’s eventual weight loss could have helped resolve those symptoms, at least partially.

Did the treating physicians get Mr. D involved with effective apnea treatment but just not mention it in the article? Could his brother’s motor vehicle accident have been caused by apnea-related sleepiness as well?

Kenneth N. Wiesert, MD
Indianapolis, IN

The authors respond

We appreciate Dr. Wiesert’s thoughtful comments on the role sleep apnea may have played in Mr. D’s symptoms.

Mr. D’s excessive fatigue, decreased energy and concentration, and mood symptoms could have been attributed to sleep apnea alone. Because his medical workup uncovered strikingly elevated blood glucose and poorly treated hypertension, we chose to highlight these findings.

Although we did not mention it in our article, Mr. D was urged early in treatment to maintain his continuous positive airway pressure (CPAP) regimen, and was educated on the importance of proper adherence to decrease his daytime sleepiness and other problems.

We addressed Mr. D’s noncompliance with CPAP during his care, but he recovered significantly after he began managing his diabetes and hypertension and abstaining from drug use. Further, even if Mr. D had been using his CPAP as recommended, his symptoms would have improved minimally or not at all because of his uncontrolled diabetes and hypertension.

Ahsan Y. Khan, MD
Katherine Grimsley, MD
Department of psychiatry and behavioral health
University of Kansas School of Medicine, Wichita

I wish to comment on “When Depression Treatment Goes Nowhere” by Drs. Ahsan Khan and Katherine Grimsley (Current Psychiatry, August 2005).

I’m surprised the authors did not mention Mr. D’s untreated (presumably obstructive) sleep apnea after reporting that he could not use nasal positive airway pressure because of his work schedule.

Untreated apnea symptoms overlap many of the symptoms and concepts addressed in the article. Mr. D’s eventual weight loss could have helped resolve those symptoms, at least partially.

Did the treating physicians get Mr. D involved with effective apnea treatment but just not mention it in the article? Could his brother’s motor vehicle accident have been caused by apnea-related sleepiness as well?

Kenneth N. Wiesert, MD
Indianapolis, IN

The authors respond

We appreciate Dr. Wiesert’s thoughtful comments on the role sleep apnea may have played in Mr. D’s symptoms.

Mr. D’s excessive fatigue, decreased energy and concentration, and mood symptoms could have been attributed to sleep apnea alone. Because his medical workup uncovered strikingly elevated blood glucose and poorly treated hypertension, we chose to highlight these findings.

Although we did not mention it in our article, Mr. D was urged early in treatment to maintain his continuous positive airway pressure (CPAP) regimen, and was educated on the importance of proper adherence to decrease his daytime sleepiness and other problems.

We addressed Mr. D’s noncompliance with CPAP during his care, but he recovered significantly after he began managing his diabetes and hypertension and abstaining from drug use. Further, even if Mr. D had been using his CPAP as recommended, his symptoms would have improved minimally or not at all because of his uncontrolled diabetes and hypertension.

Ahsan Y. Khan, MD
Katherine Grimsley, MD
Department of psychiatry and behavioral health
University of Kansas School of Medicine, Wichita

Granting prescribing privileges to psychologists, particularly in “underserved” areas, is a popular topic. Psychologists and social workers are integral treatment team players and in many cases know more about the patient than the psychiatrist does.

I recall, however, when I was a second-year resident in a crisis clinic. Police brought in a man who was floridly psychotic, out of control, talking nonsense, and behaving lewdly. He was a police officer who had just finished an extra shift. His fellow officers were concerned; they said he had never behaved like this, and they were reluctant to believe he had “gone crazy.” He was about age 30, an Army veteran, a decorated police officer, well-liked and dependable. After much effort, we got him into an interview room.

I was not afraid of him, but was a little irritated that he could not give me a coherent story. Then I asked him if he had any medical problems. Between the slurred words, nonsensical phrases and sexual suggestions, I heard “insulin-dependent diabetic.”

I requested a blood glucose check and got a reading of 39 mg/dL. I gave the patient some orange juice and told the officers to drive him across the parking lot to the ER. They were surprised; they had expected him to be admitted to the locked psychiatric unit, though they acknowledged that he had skipped his last meal and had given himself insulin.

The patient was admitted to the medicine floor, where he recovered quickly and was discharged. If not for the glucose check, we might have given him an antipsychotic and transferred him to inpatient psychiatry—and he could have died in the process.

A psychologist could very easily have missed this diagnosis. Psychologists who want prescribing privileges need to go to medical school first, regardless of how well trained and experienced they are.

Susan Redge, MD
Rochester Hills, MI

Granting prescribing privileges to psychologists, particularly in “underserved” areas, is a popular topic. Psychologists and social workers are integral treatment team players and in many cases know more about the patient than the psychiatrist does.

I recall, however, when I was a second-year resident in a crisis clinic. Police brought in a man who was floridly psychotic, out of control, talking nonsense, and behaving lewdly. He was a police officer who had just finished an extra shift. His fellow officers were concerned; they said he had never behaved like this, and they were reluctant to believe he had “gone crazy.” He was about age 30, an Army veteran, a decorated police officer, well-liked and dependable. After much effort, we got him into an interview room.

I was not afraid of him, but was a little irritated that he could not give me a coherent story. Then I asked him if he had any medical problems. Between the slurred words, nonsensical phrases and sexual suggestions, I heard “insulin-dependent diabetic.”

I requested a blood glucose check and got a reading of 39 mg/dL. I gave the patient some orange juice and told the officers to drive him across the parking lot to the ER. They were surprised; they had expected him to be admitted to the locked psychiatric unit, though they acknowledged that he had skipped his last meal and had given himself insulin.

The patient was admitted to the medicine floor, where he recovered quickly and was discharged. If not for the glucose check, we might have given him an antipsychotic and transferred him to inpatient psychiatry—and he could have died in the process.

A psychologist could very easily have missed this diagnosis. Psychologists who want prescribing privileges need to go to medical school first, regardless of how well trained and experienced they are.

Susan Redge, MD
Rochester Hills, MI

Granting prescribing privileges to psychologists, particularly in “underserved” areas, is a popular topic. Psychologists and social workers are integral treatment team players and in many cases know more about the patient than the psychiatrist does.

I recall, however, when I was a second-year resident in a crisis clinic. Police brought in a man who was floridly psychotic, out of control, talking nonsense, and behaving lewdly. He was a police officer who had just finished an extra shift. His fellow officers were concerned; they said he had never behaved like this, and they were reluctant to believe he had “gone crazy.” He was about age 30, an Army veteran, a decorated police officer, well-liked and dependable. After much effort, we got him into an interview room.

I was not afraid of him, but was a little irritated that he could not give me a coherent story. Then I asked him if he had any medical problems. Between the slurred words, nonsensical phrases and sexual suggestions, I heard “insulin-dependent diabetic.”

I requested a blood glucose check and got a reading of 39 mg/dL. I gave the patient some orange juice and told the officers to drive him across the parking lot to the ER. They were surprised; they had expected him to be admitted to the locked psychiatric unit, though they acknowledged that he had skipped his last meal and had given himself insulin.

The patient was admitted to the medicine floor, where he recovered quickly and was discharged. If not for the glucose check, we might have given him an antipsychotic and transferred him to inpatient psychiatry—and he could have died in the process.

A psychologist could very easily have missed this diagnosis. Psychologists who want prescribing privileges need to go to medical school first, regardless of how well trained and experienced they are.

Susan Redge, MD
Rochester Hills, MI

Dr. Jon Grant describes a 26-year-old Texas psychiatric inpatient who suffocated himself with cellophane wrap and a pillowcase (Malpractice Verdicts, Current Psychiatry, November 2005). As a forensic psychiatrist, let me offer some insights regarding this case.

A psychiatrist expects that hospitalization will prevent a patient’s suicide. Based on the facts Dr. Grant presented, however, the staff did not follow the standard of care and was obviously negligent:

• The patient was not adequately supervised, nor were the 15-minute checks properly documented.
  
• The rigor mortis is evidence that, contrary to the staff’s report, the patient could not have been checked 5 minutes before he was found dead.
  

The level of negligence appears clear enough not to require an expert witness to testify about the standard of care.

More information is needed before determining liability, however. Did the suicidality assessment contain factual errors? Did the patient reveal suicidal thoughts? Why wasn’t he assigned to onetoone observation? If the patient denied that he was suicidal and had not previously tried to kill himself, this case would be viewed differently.

Also, did lapses in the patient’s outpatient care lead to his hospitalization? In studying 481 suicides, Desai et al¹ uncovered variables that increase suicide risk, including poor continuity of care and failure to readmit within 6 months. We need to be aware that borderline personality disorder or major depressive disorder enhances a patient’s ability to plan a suicide.²

As Dr. Grant notes, we can decrease suicide risk by identifying and minimizing risk factors, such as withholding potentially injurious material objects. Patients, however, can find many other ways to harm themselves. The patient Dr. Grant describes used a seemingly harmless object—a pillowcase—for his suicide.

Finally, as psychiatrists we find it fundamentally difficult to act on our suspiciousness, probably because of our positive countertransference toward patients and our trust in therapeutic alliances. We need to remember that acutely suicidal patients view us as obstacles to suicide, and that they probably will not give us reliable information.

Theodor Rais, MD
Assistant professor of psychiatry
Director, outpatient and partial hospitalization services
Medical University of Ohio at Toledo

Dr. Jon Grant describes a 26-year-old Texas psychiatric inpatient who suffocated himself with cellophane wrap and a pillowcase (Malpractice Verdicts, Current Psychiatry, November 2005). As a forensic psychiatrist, let me offer some insights regarding this case.

A psychiatrist expects that hospitalization will prevent a patient’s suicide. Based on the facts Dr. Grant presented, however, the staff did not follow the standard of care and was obviously negligent:

• The patient was not adequately supervised, nor were the 15-minute checks properly documented.
  
• The rigor mortis is evidence that, contrary to the staff’s report, the patient could not have been checked 5 minutes before he was found dead.
  

The level of negligence appears clear enough not to require an expert witness to testify about the standard of care.

More information is needed before determining liability, however. Did the suicidality assessment contain factual errors? Did the patient reveal suicidal thoughts? Why wasn’t he assigned to onetoone observation? If the patient denied that he was suicidal and had not previously tried to kill himself, this case would be viewed differently.

Also, did lapses in the patient’s outpatient care lead to his hospitalization? In studying 481 suicides, Desai et al¹ uncovered variables that increase suicide risk, including poor continuity of care and failure to readmit within 6 months. We need to be aware that borderline personality disorder or major depressive disorder enhances a patient’s ability to plan a suicide.²

As Dr. Grant notes, we can decrease suicide risk by identifying and minimizing risk factors, such as withholding potentially injurious material objects. Patients, however, can find many other ways to harm themselves. The patient Dr. Grant describes used a seemingly harmless object—a pillowcase—for his suicide.

Finally, as psychiatrists we find it fundamentally difficult to act on our suspiciousness, probably because of our positive countertransference toward patients and our trust in therapeutic alliances. We need to remember that acutely suicidal patients view us as obstacles to suicide, and that they probably will not give us reliable information.

Theodor Rais, MD
Assistant professor of psychiatry
Director, outpatient and partial hospitalization services
Medical University of Ohio at Toledo

Dr. Jon Grant describes a 26-year-old Texas psychiatric inpatient who suffocated himself with cellophane wrap and a pillowcase (Malpractice Verdicts, Current Psychiatry, November 2005). As a forensic psychiatrist, let me offer some insights regarding this case.

A psychiatrist expects that hospitalization will prevent a patient’s suicide. Based on the facts Dr. Grant presented, however, the staff did not follow the standard of care and was obviously negligent:

• The patient was not adequately supervised, nor were the 15-minute checks properly documented.
  
• The rigor mortis is evidence that, contrary to the staff’s report, the patient could not have been checked 5 minutes before he was found dead.
  

The level of negligence appears clear enough not to require an expert witness to testify about the standard of care.

More information is needed before determining liability, however. Did the suicidality assessment contain factual errors? Did the patient reveal suicidal thoughts? Why wasn’t he assigned to onetoone observation? If the patient denied that he was suicidal and had not previously tried to kill himself, this case would be viewed differently.

Also, did lapses in the patient’s outpatient care lead to his hospitalization? In studying 481 suicides, Desai et al¹ uncovered variables that increase suicide risk, including poor continuity of care and failure to readmit within 6 months. We need to be aware that borderline personality disorder or major depressive disorder enhances a patient’s ability to plan a suicide.²

As Dr. Grant notes, we can decrease suicide risk by identifying and minimizing risk factors, such as withholding potentially injurious material objects. Patients, however, can find many other ways to harm themselves. The patient Dr. Grant describes used a seemingly harmless object—a pillowcase—for his suicide.

Finally, as psychiatrists we find it fundamentally difficult to act on our suspiciousness, probably because of our positive countertransference toward patients and our trust in therapeutic alliances. We need to remember that acutely suicidal patients view us as obstacles to suicide, and that they probably will not give us reliable information.

Theodor Rais, MD
Assistant professor of psychiatry
Director, outpatient and partial hospitalization services
Medical University of Ohio at Toledo

History: A tortured past

Ms. A, age 46, is referred to us by her primary care physician for a psychiatric evaluation. The patient endorses longstanding depression but has never seen a psychiatrist. She also reports that she was raped several years ago.

Ms. A meets DSM-IV-TR criteria for major depressive disorder, recurrent moderate; and posttraumatic stress disorder (PTSD). She complains of depressed mood, lack of energy, poor concentration and memory, anxiety, feelings of hopelessness and worthlessness, insomnia, and poor appetite. She has nightmares, flashbacks of her rape, and decreased interest in activities. She says she tries to avoid thoughts associated with her rape, feels detached from others, is easily startled, and at times is irritable.

Approximately 8 years ago—shortly after she started taking bupropion, 150 mg/d, to help her quit smoking—Ms. A suffered her first seizure-like episode. A neurologist diagnosed her with epilepsy based on EEG findings. He started her on carbamazepine, 200 mg bid, and titrated the dosage to 900 mg/d. After 2 years, however, her spells continued. Usually, she would black out for a few minutes and forget what she was doing. During some spells she would jerk her hands and feet, stare into space, repeat words over and over, and/or fumble with her hands.

After changing health insurance plans, Ms. A saw another neurologist who switched her to divalproex, 250 mg bid. She began having nausea, vomiting, and alopecia, so she stopped taking divalproex after 2 weeks. The neurologist switched her to topiramate, 25 mg bid, and titrated the dosage to 400 mg/d over 8 weeks with no side effects but minimal response. Reducing topiramate to 200 mg/d and adding phenytoin, 300 mg/d, produced little improvement.

Ms. A says these spells now come once or twice daily. She denies aura, loss of consciousness, tongue biting, or incontinence during seizures.

Medical history. Ms. A has undergone posterior fossa decompression for Arnold-Chiari type I malformation, right nephrectomy for renal cell carcinoma, a complete hysterectomy, an appendectomy, and bilateral breast implants. She has also had venous angiomas with head and neck pain.

Ms. A is frustrated over her lack of independence, her limited social life, and her inability to drive because of her seizure disorder. Once employed full-time for 12 years in a doctor’s office, she now gets by on disability benefits, which she finds degrading. She feels hopeless and helpless, as antiepileptics have not worked.

poll here

The authors’ observations

Ms. A complained of depression, sleep problems secondary to depression and PTSD, poor appetite, underlying anxiety, and decreased concentration, energy, and interest. We decided to address these symptoms with mirtazapine. Because she is thin (126 lb, body mass index 19.2 kg/m²), potential for weight gain with mirtazapine was not a concern.

We gauged Ms. A’s response to mirtazapine and her seizure history at our next visit, during which we customarily continue taking the patient’s history.

Treatment: Marriage by force?

Ms. A begins taking mirtazapine, 15 mg/d. At her next appointment the following week, she says she has stopped it because it has increased her appetite, which she fears will cause weight gain. She says her seizures, which usually occur at home, have continued with the same frequency.

Upon exploring her history further, we discover that Ms. A’s father was rarely around, and when he was he physically abused her. As a child she struggled with dyslexia, for which she received special education. She became pregnant while finishing high school and feels her mother forced her to marry her first husband.

Ms. A added that her three former husbands were physically and/or emotionally abusive toward her. About 10 years ago, she says, her third husband raped her.

We begin to suspect that Ms. A might not have epilepsy because of the seizures’ distinct nature, her vague symptoms, minimal or no response to antiepileptics, and comorbid mood and anxiety disorders. We refer her to another neurologist for video EEG (VEEG). She reluctantly agrees to the test, unwilling to believe that her seizures might have a psychiatric cause.

poll here

The authors’ observations

Recurrent seizures characteristic of epilepsy can significantly impair quality of life. Although the diagnosis often is straightforward, distinguishing epilepsy from psychogenic nonepileptic seizures (PNES) can be difficult.

PNES are sudden, episodic changes in behavior, perception, thinking, or feeling. These changes resemble epileptic events but are not prompted by abnormal brain electrical discharges as measured by EEG.¹

Formerly called pseudoseizures, PNES can have a physiologic or psychological cause (Table 1). They often are a somatic response to unbearable past events and/or current psychological tension or conflict. Most patients with PNES cite domestic abuse or family conflicts as key stressors.²

 

Few systematic studies have addressed how life events contribute to PNES. Associated life events—described mostly in case reports—fall into three general categories:

• childhood and adult trauma
  
• bereavement or loss
  
• acute or situational stressors.³
  

PNES diagnosis has become progressively refined over the last three decades. VEEG is used to diagnose PNES. Neuropsychological evaluation and VEEG are used together if PNES is believed to coexist with epilepsy or psychiatric disorders.^4,5

Table 1

Physiologic and psychological causes of nonepileptic seizures

Physiologic
Autonomic disorders
Cerebrovascular disease
Cardiac disorders
Vasovagal syncope
Ischemic heart disease
Valvular heart disease
Arrythmias
Drug toxicity
Endocrine disturbance
Metabolic disorders
Migraines
Paroxysmal movement disorder
Sleep disorder
Psychological
Anxiety disorders
Conversion disorder
Dissociative disorder
Factitious disorder
Malingering
Victim of physical, emotional, or sexual abuse
Posttraumatic stress disorder
Psychotic disorder
Somatoform disorder
Substance abuse/dependence

Continued treatment: Wasted years

Two weeks after our referral, Ms. A reports that the neurologist discontinued topiramate and phenytoin after VEEG showed no epileptic activity.

Ms. A now realizes she does not have epilepsy. She is angry that her first neurologist had misdiag-nosed her, effectively sentencing her to 8 years of needless dependency and disability.

We prescribe escitalopram, starting at 10 mg/d and titrating to 20 mg/d, to address Ms. A’s depressive/PTSD symptoms. We also refer her to a psychotherapist, who schedules twice-weekly supportive psychotherapy sessions. The therapist plans to teach her coping techniques and provide ego support and encouragement.

Ms. A’s psychotherapy progresses slowly at first, but by the fourth session she sets goals, which include getting off disability as soon as possible. With careful ego strengthening, she resumes driving and searches for a job. During one session, she tells her therapist she has long wanted to become a nurse, so she is encouraged to see a nursing school counselor for advice on selecting prerequisite nursing classes.

The authors’ observations

As with Ms. A, an erroneous epilepsy diagnosis can cause physical, psychosocial, and socioeconomic grief for the patient and can lead to needless restrictions, unemployment or underemployment, and dependence on disability benefits. After the misdiagnosis, Ms. A lost control of her future and considered her life a burden, leading to depression and anxiety. Her seizures caused most of her physical and psychological disturbances and diminished her overall function.

PNES are often mistaken for epileptic seizures, and 26% of seizure patients experience both.⁶ In a study of 50 patients, between 5% and 20% of patients evaluated for epilepsy and 10% to 40% of patients referred to comprehensive epilepsy centers were later found to have PNES.⁷

Like Ms. A, many patients with undiagnosed PNES receive antiepileptics to treat apparent epilepsy. These medications can cause troublesome side effects—from GI problems, to respiratory arrest in patients with pseudostatus, to potential teratogenicity.

In addition, comorbid epilepsy often goes undetected in patients with PNES. This could lead to inadequate treatment, increasing the patient’s morbidity and mortality risk.⁸

poll here

The authors’ observations

Patient history. Take a thorough history for patients with a history of seizures.

Too often, doctors assume a previous epilepsy diagnosis is correct, especially if rendered by a neurologist. In the United Kingdom, 20% to 31% of epilepsy diagnoses are incorrect because of incomplete history and misinterpreted EEG findings.⁸ When taking a patient’s seizure history, clinicians often do not get:

• a detailed history of seizures or seizurelike events, including onset, frequency, observations from family or friends, and seizure duration
  
• information on whether the patient remembers seizure details; has had prespell aura or loss of consciousness, or cries during the spells
  
• history of physical and/or sexual abuse.
  

Multiple daily seizures, repeated hospitalizations or emergency room visits, minimal response to antiepileptics, and no history of injury after seizures could suggest nonepileptic seizures. Seizures may be psychogenic if the patient was sexually abused, has a comorbid psychiatric disorder, or suffers attacks only when alone or only in public (Table 2).

Refer patients with features that may suggest PNES to a neurologist for VEEG to confirm or rule out epilepsy, because roughly one-quarter of seizure patients can have both.

Table 2

Patient features that suggest nonepileptic seizures

Comorbid psychiatric disorder(s)
Events occur only in presence of others or only when alone
Lack of concern or excessive emotional response to seizures
Minimal or no response to antiepileptics
Multiple daily seizures
No history of injury resulting from seizures
Normal neurologic history and examination
Repeated hospitalizations or emergency room visits
Unremarkable EEG and MRI findings
Victim of sexual abuse

Finding psychological causes. Psychological investigations become paramount after physiologic causes for nonepileptic seizures are ruled out.

The Minnesota Multiphasic Personality Inventory (MMPI) is often used to discriminate PNES from epilepsy. Wilkus et al⁹ reported significant differences in scores of MMPI hypochondriasis, hysteria, and schizophrenia scales among patients with PNES and epilepsy. Patients with PNES may have higher MMPI hypochondriasis, hysteria, schizophrenia, and psychopathic deviate scores than do patients with epilepsy.

 

Other authors, however, have found more variable MMPI results when using the test to distinguish PNES from epilepsy. Thus, the MMPI may provide supportive data for PNES diagnosis but is not a definitive tool.

Explaining the findings. Getting the patient to accept that the epilepsy is “in your head” is crucial to engaging him or her in treatment. The clinician needs to be honest with the patient while projecting a positive approach to the diagnosis. Tell the patient that not having epilepsy is “good news,” that antiepileptics are not needed, and that he or she can gain better control once stress or emotional issues are resolved.¹⁰

Follow-up: A learning experience

Within 4 months of her last seizure, Ms. A showed dramatic improvement. She began driving, working part-time and enrolled in nursing school. Her disability benefits program provided tuition assistance.

Ms. A has now been seizure-free for 1 year. Motivated and determined, she is taking up to 8 credit hours per semester and earning As and Bs but at times is anxious and fears failure. She needs much support and encouragement. Multiple therapy techniques—including direct teaching, admiring her progress, offering support, explaining, and ego strengthening—have produced good results. She is still taking escitalopram, 20 mg/d, and sees her therapist every 2 weeks.

Related resources

• Adetunji B, Mathews M, Williams A, Verma S. Psychogenic or epileptic seizures? How to clinch the diagnosis. Current Psychiatry 2004;3(11):25-35.
  
• Privitera MD. EEGs and epilepsy: When seizures mimic psychiatric illness. Current Psychiatry 2002;1(9):14-21.
  

Drug brand names

• Bupropion • Wellbutrin, Zyban
  
• Carbamazepine • Tegretol
  
• Divalproex sodium • Depakote
  
• Escitalopram • Lexapro
  
• Mirtazapine • Remeron
  
• Phenytoin • Dilantin
  
• Topiramate • Topamax
  

Disclosure

Dr. Khan is a speaker for Pfizer and Wyeth.

Drs. Aziz and Syed report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

History: A tortured past

Ms. A, age 46, is referred to us by her primary care physician for a psychiatric evaluation. The patient endorses longstanding depression but has never seen a psychiatrist. She also reports that she was raped several years ago.

Ms. A meets DSM-IV-TR criteria for major depressive disorder, recurrent moderate; and posttraumatic stress disorder (PTSD). She complains of depressed mood, lack of energy, poor concentration and memory, anxiety, feelings of hopelessness and worthlessness, insomnia, and poor appetite. She has nightmares, flashbacks of her rape, and decreased interest in activities. She says she tries to avoid thoughts associated with her rape, feels detached from others, is easily startled, and at times is irritable.

Approximately 8 years ago—shortly after she started taking bupropion, 150 mg/d, to help her quit smoking—Ms. A suffered her first seizure-like episode. A neurologist diagnosed her with epilepsy based on EEG findings. He started her on carbamazepine, 200 mg bid, and titrated the dosage to 900 mg/d. After 2 years, however, her spells continued. Usually, she would black out for a few minutes and forget what she was doing. During some spells she would jerk her hands and feet, stare into space, repeat words over and over, and/or fumble with her hands.

After changing health insurance plans, Ms. A saw another neurologist who switched her to divalproex, 250 mg bid. She began having nausea, vomiting, and alopecia, so she stopped taking divalproex after 2 weeks. The neurologist switched her to topiramate, 25 mg bid, and titrated the dosage to 400 mg/d over 8 weeks with no side effects but minimal response. Reducing topiramate to 200 mg/d and adding phenytoin, 300 mg/d, produced little improvement.

Ms. A says these spells now come once or twice daily. She denies aura, loss of consciousness, tongue biting, or incontinence during seizures.

Medical history. Ms. A has undergone posterior fossa decompression for Arnold-Chiari type I malformation, right nephrectomy for renal cell carcinoma, a complete hysterectomy, an appendectomy, and bilateral breast implants. She has also had venous angiomas with head and neck pain.

Ms. A is frustrated over her lack of independence, her limited social life, and her inability to drive because of her seizure disorder. Once employed full-time for 12 years in a doctor’s office, she now gets by on disability benefits, which she finds degrading. She feels hopeless and helpless, as antiepileptics have not worked.

poll here

The authors’ observations

Ms. A complained of depression, sleep problems secondary to depression and PTSD, poor appetite, underlying anxiety, and decreased concentration, energy, and interest. We decided to address these symptoms with mirtazapine. Because she is thin (126 lb, body mass index 19.2 kg/m²), potential for weight gain with mirtazapine was not a concern.

We gauged Ms. A’s response to mirtazapine and her seizure history at our next visit, during which we customarily continue taking the patient’s history.

Treatment: Marriage by force?

Ms. A begins taking mirtazapine, 15 mg/d. At her next appointment the following week, she says she has stopped it because it has increased her appetite, which she fears will cause weight gain. She says her seizures, which usually occur at home, have continued with the same frequency.

Upon exploring her history further, we discover that Ms. A’s father was rarely around, and when he was he physically abused her. As a child she struggled with dyslexia, for which she received special education. She became pregnant while finishing high school and feels her mother forced her to marry her first husband.

Ms. A added that her three former husbands were physically and/or emotionally abusive toward her. About 10 years ago, she says, her third husband raped her.

We begin to suspect that Ms. A might not have epilepsy because of the seizures’ distinct nature, her vague symptoms, minimal or no response to antiepileptics, and comorbid mood and anxiety disorders. We refer her to another neurologist for video EEG (VEEG). She reluctantly agrees to the test, unwilling to believe that her seizures might have a psychiatric cause.

poll here

The authors’ observations

Recurrent seizures characteristic of epilepsy can significantly impair quality of life. Although the diagnosis often is straightforward, distinguishing epilepsy from psychogenic nonepileptic seizures (PNES) can be difficult.

PNES are sudden, episodic changes in behavior, perception, thinking, or feeling. These changes resemble epileptic events but are not prompted by abnormal brain electrical discharges as measured by EEG.¹

Formerly called pseudoseizures, PNES can have a physiologic or psychological cause (Table 1). They often are a somatic response to unbearable past events and/or current psychological tension or conflict. Most patients with PNES cite domestic abuse or family conflicts as key stressors.²

 

Few systematic studies have addressed how life events contribute to PNES. Associated life events—described mostly in case reports—fall into three general categories:

• childhood and adult trauma
  
• bereavement or loss
  
• acute or situational stressors.³
  

PNES diagnosis has become progressively refined over the last three decades. VEEG is used to diagnose PNES. Neuropsychological evaluation and VEEG are used together if PNES is believed to coexist with epilepsy or psychiatric disorders.^4,5

Table 1

Physiologic and psychological causes of nonepileptic seizures

Physiologic
Autonomic disorders
Cerebrovascular disease
Cardiac disorders
Vasovagal syncope
Ischemic heart disease
Valvular heart disease
Arrythmias
Drug toxicity
Endocrine disturbance
Metabolic disorders
Migraines
Paroxysmal movement disorder
Sleep disorder
Psychological
Anxiety disorders
Conversion disorder
Dissociative disorder
Factitious disorder
Malingering
Victim of physical, emotional, or sexual abuse
Posttraumatic stress disorder
Psychotic disorder
Somatoform disorder
Substance abuse/dependence

Continued treatment: Wasted years

Two weeks after our referral, Ms. A reports that the neurologist discontinued topiramate and phenytoin after VEEG showed no epileptic activity.

Ms. A now realizes she does not have epilepsy. She is angry that her first neurologist had misdiag-nosed her, effectively sentencing her to 8 years of needless dependency and disability.

We prescribe escitalopram, starting at 10 mg/d and titrating to 20 mg/d, to address Ms. A’s depressive/PTSD symptoms. We also refer her to a psychotherapist, who schedules twice-weekly supportive psychotherapy sessions. The therapist plans to teach her coping techniques and provide ego support and encouragement.

Ms. A’s psychotherapy progresses slowly at first, but by the fourth session she sets goals, which include getting off disability as soon as possible. With careful ego strengthening, she resumes driving and searches for a job. During one session, she tells her therapist she has long wanted to become a nurse, so she is encouraged to see a nursing school counselor for advice on selecting prerequisite nursing classes.

The authors’ observations

As with Ms. A, an erroneous epilepsy diagnosis can cause physical, psychosocial, and socioeconomic grief for the patient and can lead to needless restrictions, unemployment or underemployment, and dependence on disability benefits. After the misdiagnosis, Ms. A lost control of her future and considered her life a burden, leading to depression and anxiety. Her seizures caused most of her physical and psychological disturbances and diminished her overall function.

PNES are often mistaken for epileptic seizures, and 26% of seizure patients experience both.⁶ In a study of 50 patients, between 5% and 20% of patients evaluated for epilepsy and 10% to 40% of patients referred to comprehensive epilepsy centers were later found to have PNES.⁷

Like Ms. A, many patients with undiagnosed PNES receive antiepileptics to treat apparent epilepsy. These medications can cause troublesome side effects—from GI problems, to respiratory arrest in patients with pseudostatus, to potential teratogenicity.

In addition, comorbid epilepsy often goes undetected in patients with PNES. This could lead to inadequate treatment, increasing the patient’s morbidity and mortality risk.⁸

poll here

The authors’ observations

Patient history. Take a thorough history for patients with a history of seizures.

Too often, doctors assume a previous epilepsy diagnosis is correct, especially if rendered by a neurologist. In the United Kingdom, 20% to 31% of epilepsy diagnoses are incorrect because of incomplete history and misinterpreted EEG findings.⁸ When taking a patient’s seizure history, clinicians often do not get:

• a detailed history of seizures or seizurelike events, including onset, frequency, observations from family or friends, and seizure duration
  
• information on whether the patient remembers seizure details; has had prespell aura or loss of consciousness, or cries during the spells
  
• history of physical and/or sexual abuse.
  

Multiple daily seizures, repeated hospitalizations or emergency room visits, minimal response to antiepileptics, and no history of injury after seizures could suggest nonepileptic seizures. Seizures may be psychogenic if the patient was sexually abused, has a comorbid psychiatric disorder, or suffers attacks only when alone or only in public (Table 2).

Refer patients with features that may suggest PNES to a neurologist for VEEG to confirm or rule out epilepsy, because roughly one-quarter of seizure patients can have both.

Table 2

Patient features that suggest nonepileptic seizures

Comorbid psychiatric disorder(s)
Events occur only in presence of others or only when alone
Lack of concern or excessive emotional response to seizures
Minimal or no response to antiepileptics
Multiple daily seizures
No history of injury resulting from seizures
Normal neurologic history and examination
Repeated hospitalizations or emergency room visits
Unremarkable EEG and MRI findings
Victim of sexual abuse

Finding psychological causes. Psychological investigations become paramount after physiologic causes for nonepileptic seizures are ruled out.

The Minnesota Multiphasic Personality Inventory (MMPI) is often used to discriminate PNES from epilepsy. Wilkus et al⁹ reported significant differences in scores of MMPI hypochondriasis, hysteria, and schizophrenia scales among patients with PNES and epilepsy. Patients with PNES may have higher MMPI hypochondriasis, hysteria, schizophrenia, and psychopathic deviate scores than do patients with epilepsy.

 

Other authors, however, have found more variable MMPI results when using the test to distinguish PNES from epilepsy. Thus, the MMPI may provide supportive data for PNES diagnosis but is not a definitive tool.

Explaining the findings. Getting the patient to accept that the epilepsy is “in your head” is crucial to engaging him or her in treatment. The clinician needs to be honest with the patient while projecting a positive approach to the diagnosis. Tell the patient that not having epilepsy is “good news,” that antiepileptics are not needed, and that he or she can gain better control once stress or emotional issues are resolved.¹⁰

Follow-up: A learning experience

Within 4 months of her last seizure, Ms. A showed dramatic improvement. She began driving, working part-time and enrolled in nursing school. Her disability benefits program provided tuition assistance.

Ms. A has now been seizure-free for 1 year. Motivated and determined, she is taking up to 8 credit hours per semester and earning As and Bs but at times is anxious and fears failure. She needs much support and encouragement. Multiple therapy techniques—including direct teaching, admiring her progress, offering support, explaining, and ego strengthening—have produced good results. She is still taking escitalopram, 20 mg/d, and sees her therapist every 2 weeks.

Related resources

• Adetunji B, Mathews M, Williams A, Verma S. Psychogenic or epileptic seizures? How to clinch the diagnosis. Current Psychiatry 2004;3(11):25-35.
  
• Privitera MD. EEGs and epilepsy: When seizures mimic psychiatric illness. Current Psychiatry 2002;1(9):14-21.
  

Drug brand names

• Bupropion • Wellbutrin, Zyban
  
• Carbamazepine • Tegretol
  
• Divalproex sodium • Depakote
  
• Escitalopram • Lexapro
  
• Mirtazapine • Remeron
  
• Phenytoin • Dilantin
  
• Topiramate • Topamax
  

Disclosure

Dr. Khan is a speaker for Pfizer and Wyeth.

Drs. Aziz and Syed report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

History: A tortured past

Ms. A, age 46, is referred to us by her primary care physician for a psychiatric evaluation. The patient endorses longstanding depression but has never seen a psychiatrist. She also reports that she was raped several years ago.

Ms. A meets DSM-IV-TR criteria for major depressive disorder, recurrent moderate; and posttraumatic stress disorder (PTSD). She complains of depressed mood, lack of energy, poor concentration and memory, anxiety, feelings of hopelessness and worthlessness, insomnia, and poor appetite. She has nightmares, flashbacks of her rape, and decreased interest in activities. She says she tries to avoid thoughts associated with her rape, feels detached from others, is easily startled, and at times is irritable.

Approximately 8 years ago—shortly after she started taking bupropion, 150 mg/d, to help her quit smoking—Ms. A suffered her first seizure-like episode. A neurologist diagnosed her with epilepsy based on EEG findings. He started her on carbamazepine, 200 mg bid, and titrated the dosage to 900 mg/d. After 2 years, however, her spells continued. Usually, she would black out for a few minutes and forget what she was doing. During some spells she would jerk her hands and feet, stare into space, repeat words over and over, and/or fumble with her hands.

After changing health insurance plans, Ms. A saw another neurologist who switched her to divalproex, 250 mg bid. She began having nausea, vomiting, and alopecia, so she stopped taking divalproex after 2 weeks. The neurologist switched her to topiramate, 25 mg bid, and titrated the dosage to 400 mg/d over 8 weeks with no side effects but minimal response. Reducing topiramate to 200 mg/d and adding phenytoin, 300 mg/d, produced little improvement.

Ms. A says these spells now come once or twice daily. She denies aura, loss of consciousness, tongue biting, or incontinence during seizures.

Medical history. Ms. A has undergone posterior fossa decompression for Arnold-Chiari type I malformation, right nephrectomy for renal cell carcinoma, a complete hysterectomy, an appendectomy, and bilateral breast implants. She has also had venous angiomas with head and neck pain.

Ms. A is frustrated over her lack of independence, her limited social life, and her inability to drive because of her seizure disorder. Once employed full-time for 12 years in a doctor’s office, she now gets by on disability benefits, which she finds degrading. She feels hopeless and helpless, as antiepileptics have not worked.

poll here

The authors’ observations

Ms. A complained of depression, sleep problems secondary to depression and PTSD, poor appetite, underlying anxiety, and decreased concentration, energy, and interest. We decided to address these symptoms with mirtazapine. Because she is thin (126 lb, body mass index 19.2 kg/m²), potential for weight gain with mirtazapine was not a concern.

We gauged Ms. A’s response to mirtazapine and her seizure history at our next visit, during which we customarily continue taking the patient’s history.

Treatment: Marriage by force?

Ms. A begins taking mirtazapine, 15 mg/d. At her next appointment the following week, she says she has stopped it because it has increased her appetite, which she fears will cause weight gain. She says her seizures, which usually occur at home, have continued with the same frequency.

Upon exploring her history further, we discover that Ms. A’s father was rarely around, and when he was he physically abused her. As a child she struggled with dyslexia, for which she received special education. She became pregnant while finishing high school and feels her mother forced her to marry her first husband.

Ms. A added that her three former husbands were physically and/or emotionally abusive toward her. About 10 years ago, she says, her third husband raped her.

We begin to suspect that Ms. A might not have epilepsy because of the seizures’ distinct nature, her vague symptoms, minimal or no response to antiepileptics, and comorbid mood and anxiety disorders. We refer her to another neurologist for video EEG (VEEG). She reluctantly agrees to the test, unwilling to believe that her seizures might have a psychiatric cause.

poll here

The authors’ observations

Recurrent seizures characteristic of epilepsy can significantly impair quality of life. Although the diagnosis often is straightforward, distinguishing epilepsy from psychogenic nonepileptic seizures (PNES) can be difficult.

PNES are sudden, episodic changes in behavior, perception, thinking, or feeling. These changes resemble epileptic events but are not prompted by abnormal brain electrical discharges as measured by EEG.¹

Formerly called pseudoseizures, PNES can have a physiologic or psychological cause (Table 1). They often are a somatic response to unbearable past events and/or current psychological tension or conflict. Most patients with PNES cite domestic abuse or family conflicts as key stressors.²

 

Few systematic studies have addressed how life events contribute to PNES. Associated life events—described mostly in case reports—fall into three general categories:

• childhood and adult trauma
  
• bereavement or loss
  
• acute or situational stressors.³
  

PNES diagnosis has become progressively refined over the last three decades. VEEG is used to diagnose PNES. Neuropsychological evaluation and VEEG are used together if PNES is believed to coexist with epilepsy or psychiatric disorders.^4,5

Table 1

Physiologic and psychological causes of nonepileptic seizures

Physiologic
Autonomic disorders
Cerebrovascular disease
Cardiac disorders
Vasovagal syncope
Ischemic heart disease
Valvular heart disease
Arrythmias
Drug toxicity
Endocrine disturbance
Metabolic disorders
Migraines
Paroxysmal movement disorder
Sleep disorder
Psychological
Anxiety disorders
Conversion disorder
Dissociative disorder
Factitious disorder
Malingering
Victim of physical, emotional, or sexual abuse
Posttraumatic stress disorder
Psychotic disorder
Somatoform disorder
Substance abuse/dependence

Continued treatment: Wasted years

Two weeks after our referral, Ms. A reports that the neurologist discontinued topiramate and phenytoin after VEEG showed no epileptic activity.

Ms. A now realizes she does not have epilepsy. She is angry that her first neurologist had misdiag-nosed her, effectively sentencing her to 8 years of needless dependency and disability.

We prescribe escitalopram, starting at 10 mg/d and titrating to 20 mg/d, to address Ms. A’s depressive/PTSD symptoms. We also refer her to a psychotherapist, who schedules twice-weekly supportive psychotherapy sessions. The therapist plans to teach her coping techniques and provide ego support and encouragement.

Ms. A’s psychotherapy progresses slowly at first, but by the fourth session she sets goals, which include getting off disability as soon as possible. With careful ego strengthening, she resumes driving and searches for a job. During one session, she tells her therapist she has long wanted to become a nurse, so she is encouraged to see a nursing school counselor for advice on selecting prerequisite nursing classes.

The authors’ observations

As with Ms. A, an erroneous epilepsy diagnosis can cause physical, psychosocial, and socioeconomic grief for the patient and can lead to needless restrictions, unemployment or underemployment, and dependence on disability benefits. After the misdiagnosis, Ms. A lost control of her future and considered her life a burden, leading to depression and anxiety. Her seizures caused most of her physical and psychological disturbances and diminished her overall function.

PNES are often mistaken for epileptic seizures, and 26% of seizure patients experience both.⁶ In a study of 50 patients, between 5% and 20% of patients evaluated for epilepsy and 10% to 40% of patients referred to comprehensive epilepsy centers were later found to have PNES.⁷

Like Ms. A, many patients with undiagnosed PNES receive antiepileptics to treat apparent epilepsy. These medications can cause troublesome side effects—from GI problems, to respiratory arrest in patients with pseudostatus, to potential teratogenicity.

In addition, comorbid epilepsy often goes undetected in patients with PNES. This could lead to inadequate treatment, increasing the patient’s morbidity and mortality risk.⁸

poll here

The authors’ observations

Patient history. Take a thorough history for patients with a history of seizures.

Too often, doctors assume a previous epilepsy diagnosis is correct, especially if rendered by a neurologist. In the United Kingdom, 20% to 31% of epilepsy diagnoses are incorrect because of incomplete history and misinterpreted EEG findings.⁸ When taking a patient’s seizure history, clinicians often do not get:

• a detailed history of seizures or seizurelike events, including onset, frequency, observations from family or friends, and seizure duration
  
• information on whether the patient remembers seizure details; has had prespell aura or loss of consciousness, or cries during the spells
  
• history of physical and/or sexual abuse.
  

Multiple daily seizures, repeated hospitalizations or emergency room visits, minimal response to antiepileptics, and no history of injury after seizures could suggest nonepileptic seizures. Seizures may be psychogenic if the patient was sexually abused, has a comorbid psychiatric disorder, or suffers attacks only when alone or only in public (Table 2).

Refer patients with features that may suggest PNES to a neurologist for VEEG to confirm or rule out epilepsy, because roughly one-quarter of seizure patients can have both.

Table 2

Patient features that suggest nonepileptic seizures

Comorbid psychiatric disorder(s)
Events occur only in presence of others or only when alone
Lack of concern or excessive emotional response to seizures
Minimal or no response to antiepileptics
Multiple daily seizures
No history of injury resulting from seizures
Normal neurologic history and examination
Repeated hospitalizations or emergency room visits
Unremarkable EEG and MRI findings
Victim of sexual abuse

Finding psychological causes. Psychological investigations become paramount after physiologic causes for nonepileptic seizures are ruled out.

The Minnesota Multiphasic Personality Inventory (MMPI) is often used to discriminate PNES from epilepsy. Wilkus et al⁹ reported significant differences in scores of MMPI hypochondriasis, hysteria, and schizophrenia scales among patients with PNES and epilepsy. Patients with PNES may have higher MMPI hypochondriasis, hysteria, schizophrenia, and psychopathic deviate scores than do patients with epilepsy.

 

Other authors, however, have found more variable MMPI results when using the test to distinguish PNES from epilepsy. Thus, the MMPI may provide supportive data for PNES diagnosis but is not a definitive tool.

Explaining the findings. Getting the patient to accept that the epilepsy is “in your head” is crucial to engaging him or her in treatment. The clinician needs to be honest with the patient while projecting a positive approach to the diagnosis. Tell the patient that not having epilepsy is “good news,” that antiepileptics are not needed, and that he or she can gain better control once stress or emotional issues are resolved.¹⁰

Follow-up: A learning experience

Within 4 months of her last seizure, Ms. A showed dramatic improvement. She began driving, working part-time and enrolled in nursing school. Her disability benefits program provided tuition assistance.

Ms. A has now been seizure-free for 1 year. Motivated and determined, she is taking up to 8 credit hours per semester and earning As and Bs but at times is anxious and fears failure. She needs much support and encouragement. Multiple therapy techniques—including direct teaching, admiring her progress, offering support, explaining, and ego strengthening—have produced good results. She is still taking escitalopram, 20 mg/d, and sees her therapist every 2 weeks.

Related resources

• Adetunji B, Mathews M, Williams A, Verma S. Psychogenic or epileptic seizures? How to clinch the diagnosis. Current Psychiatry 2004;3(11):25-35.
  
• Privitera MD. EEGs and epilepsy: When seizures mimic psychiatric illness. Current Psychiatry 2002;1(9):14-21.
  

Drug brand names

• Bupropion • Wellbutrin, Zyban
  
• Carbamazepine • Tegretol
  
• Divalproex sodium • Depakote
  
• Escitalopram • Lexapro
  
• Mirtazapine • Remeron
  
• Phenytoin • Dilantin
  
• Topiramate • Topamax
  

Disclosure

Dr. Khan is a speaker for Pfizer and Wyeth.

Drs. Aziz and Syed report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Careful investigation can often reveal insomnia’s cause¹—whether a medical or psychiatric condition or poor sleep habits. Understanding why patients can’t sleep is key to effective therapy.

Insomnia is associated with increased risk of accidents, work-related difficulties, and relationship problems.² Long-term sleeplessness may even increase risk of new psychiatric disorders—most notably major depression.³

Primary Insomnia

DSM-IV-TR criteria for primary insomnia include:⁴

• For at least 1 month, the patient’s main complaint has been trouble going to sleep, staying asleep, or feeling unrested.
  
• The insomnia or resulting daytime fatigue causes clinically important distress or impairs work, social, or personal functioning.
  
• The insomnia does not occur solely in the course of a breathing-related or circadian rhythm sleep disorder, a parasomnia, or as part of another mental disorder such as delirium, generalized anxiety disorder, or major depressive disorder.
  

The International Classification of Sleep Disorders outlines discrete insomnia types that are unrelated to other medical, mental, or sleep disorders.⁵ These include, among others, adjustment sleep disorder and psychophysiologic insomnia.

Adjustment sleep disorder. Acute emotional stressors—such as bereavement, job loss, or hospitalization—can cause insomnia or daytime sleepiness. Symptoms typically remit soon after the stressors abate, so this insomnia usually lasts a few days (acute) to a few months (short-term). It can also become chronic, lasting³ months or longer.

Psychophysiologic insomnia. Once insomnia begins—regardless of its cause—sleep problems may persist well after precipitating factors resolve. The mechanism may be related to somatized tension and learned sleep-preventing associations (trying too hard to sleep and conditioned arousal to the bedroom). Thus, short-term insomnia may develop into long-term, chronic difficulty with recurring episodes or a constant, daily pattern of insomnia.

Treatment for both adjustment sleep disorder and psychophysiologic insomnia with behavioral therapies and hypnotics⁶ is warranted if:

• sleepiness and fatigue interfere with daytime function
  
• the patient is significantly distressed
  
• a pattern of recurring episodes develops.⁵
  

Psychiatric Disorders and Insomnia

Depression. Up to 80% of depressed persons experience insomnia, although no one sleep pattern seems typical.⁷ Depression may be associated with:

• difficulties in falling asleep
  
• interrupted nocturnal sleep
  
• early morning awakening.
  

Anxiety disorders. Generalized anxiety disorder (GAD), panic attacks, and posttraumatic stress disorder (PTSD) are associated with disrupted sleep. Patients with GAD experience prolonged sleep latency and fragmented sleep, similar to those with primary insomnia.

Some patients experience panic symptoms while sleeping, possibly in association with mild hypercapnia. Those patients tend to have earlier onset of panic disorder and a higher likelihood of comorbid mood and other anxiety disorders.⁸

In patients with PTSD, disturbed sleep continuity and increased REM phasic activity—such as eye movements—are directly correlated with PTSD symptom severity. Nightmares and disturbed REM sleep are hallmarks of PTSD.⁹

Workup of Sleep Complaints

The patient history is an important part of the evaluation and treatment of insomnia and other sleep disturbances (Algorithm).¹²

Acute. Many short-term insomnias—lasting a few weeks or less—are caused by situational stressors, circadian rhythm changes, or poor sleep hygiene (Table 1).¹ A logical approach is to begin sleep hygiene measures and explore the patient’s life situation to uncover what might be causing the insomnia. Hypnotic agents may be considered if insomnia is associated with daytime sleepiness or occupational impairment or if it seems to be escalating and your assessment indicates that it is a primary condition.

Chronic. For longer-term insomnias—lasting more than a few months—consider a more thorough evaluation, including medical and psychiatric history, physical examination, and mental status examination. A differential assessment can be made on the basis of whether a patient has difficulty falling or staying asleep (Table 1). Ask about cardinal symptoms of disorders associated with insomnia, including:

• snoring or breathing pauses during sleep (sleep apnea syndrome)
  
• restlessness or twitching in the lower extremities (PLMD/RLS).
  

If possible, question the patient’s bed partner, who may be more aware of such symptoms than the patient.

Carefully review the patient’s weekday and weekend sleep patterns, bedtime habits, sleep hygiene habits, and substance and medication use.

Sleep clinic referrals. Consider an evaluation by a sleep disorders center when the diagnosis remains unclear or treatment of the presumed condition fails after a reasonable time.

Table 1

Possible causes of sleep complaints

Acute, transient	Recent or recurring stress
	Change in sleeping environment
	Acute illness or injury
	New medications
	Jet lag or shift change
Chronic	Difficulty staying asleep	Difficulty falling asleep
	Medications	Poor sleep hygiene
	Drug or alcohol use	Conditioned insomnia
	Psychiatric disorder	Restless legs syndrome
	Medical disorder	Circadian rhythm disorder
	Sleep-disordered breathing	Advanced sleep-phase syndrome
	Periodic limb movement disorder
	Restless legs syndrome
Source: Adapted and reprinted with permission from reference 13

Behavioral Treatments

Behavioral treatments—with or without hypnotics—are appropriate for many insomnia complaints, including adjustment sleep disorder and psychophysiologic insomnia. Behavioral measures may work more slowly than drug therapy, but their effects have been shown to last longer in patients with primary insomnia. It may be useful to start with both hypnotic and behavioral treatments and withdraw the hypnotic after behavioral measures take effect.

 

Sleep hygiene. Many individuals unknowingly engage in habits that impair sleep. Those with insomnia, for example, often try to compensate for lost sleep by staying in bed later in the morning or by napping, which further fragment nocturnal sleep. Advise these patients to adhere to a regular awakening time—regardless of how long they slept the night before—and to avoid naps. Other tips for getting a good night’s sleep are outlined in Table 2.¹⁴

Caffeine has a plasma half-life of 3 to 7 hours, although individual sensitivity varies widely and caffeine’s erratic absorption can prolong its effects. Advise patients with insomnia to avoid caffeine-containing beverages—including coffee, tea, and soft drinks—after noon.

Relaxation training. Muscle tension can be reduced through techniques such as electromyography (EMG) biofeedback, abdominal breathing exercises, or progressive muscle relaxation. Relaxation training is usually effective within a few weeks.

Psychological counseling. Counseling can help identify and dispel tension-producing thoughts that may be disrupting sleep, such as preoccupation with unpleasant work experiences or school examinations. Reassurance may help patients overcome fears about sleeplessness; suggest that they deal with anxiety-producing thoughts during counseling sessions and at times other than bedtime.

Table 2

How to get a good night’s sleep

Maintain a regular waking time, regardless of amount of sleep the night before Avoid excessive time in bed Avoid naps, except if a shift worker or elderly Spend time in bright light while awake Use the bed only for sleeping and sex Avoid nicotine, caffeine, and alcohol Exercise regularly early in the day Do something relaxing before bedtime Don’t watch the clock Eat a light snack before bedtime if hungry

Prescribing Hypnotics

Sedative-hypnotics are indicated primarily for short-term insomnia management. Most are used at bedtime until insomnia dissipates or the physician advises the patient to take a break.

Treatment principles. Because many insomnias are recurrent, prolonged hypnotic treatment given in short bouts is often optimal. Longer treatment—months to years—is clearly needed by a few patients with chronic insomnia. In these cases, carefully monitor for tolerance, as manifested by dosage escalation. Hypnotic treatment is generally not suitable for patients with drug abuse or dependence histories.

Although chloral hydrate and barbiturates are effective hypnotics, adverse effects limit their safety and usefulness. Benzodiazepines and more recently introduced agents have milder side-effect profiles (Table 3). Choose agents based on the patient’s situation, preferences, and effects of prior trials with similar agents. Guidelines for hypnotics discourage chronic use to minimize abuse, misuse, and habituation (Table 4).

Elimination half-life is one of the most important pharmacological properties that differentiates the hypnotics from each other:¹⁵

• longer half-life: flurazepam, quazepam
  
• intermediate half-life: estazolam, temazepam, eszopiclone
  
• short half-life: triazolam, zolpidem, zolpidem ER, zaleplon, ramelteon.
  

Hypnotic agents with relatively longer halflives tend to be associated with greater potential for residual daytime effects such as sedation, motor incoordination, amnesia, and slowed reflexes. These effects may impair performance and increase the risk of auto accidents and injuries, especially hip fractures in the elderly.

Benzodiazepine receptor agonists. Of the all the drugs in class, zalepon—because of its ultra-short half-life—is least likely to cause residual daytime effects when administered at bedtime. At 10-mg doses, its side effects seem to last no more than 4 hours after administration. Zaleplon can be safely taken after nocturnal awakenings if the patient remains in bed 4 hours or longer after taking it.¹⁷

An ultra-short half life is less desirable for patients with difficulty with sleep initiation and discontinuous sleep throughout the night. For them, longer elimination half-life agents—such as zolpidem, zolpidem extended release (ER), and eszopiclone—may be more predictably effective for the entire night.¹⁸

Short half-life hypnotics do not offer anxiolysis for patients with daytime anxiety, as the longer half-life agents do.

Zolpidem ER and eszopiclone do not have a limitation imposed on duration of use. Although zolpidem ER has not been investigated in controlled trials greater than 3 weeks, eszopiclone was evaluated during a 6-month study that demonstrated lack of tolerance during the entire period, and lack of rebound after rapid discontinuation.¹⁹ Eszopiclone is the only hypnotic indicated for long-term (lasting > 3 weeks) insomnia.

Melatonin receptor agonists. Ramelteon’s activity at MT1 and MT2 receptors is believed to contribute to its sleep-promoting properties. This agent has been found to reduce sleep latency,^20,21 and it is indicated to treat insomnia characterized by sleep-onset delays. Although controlled, longterm studies are lacking, ramelteon does not have a limit on duration of use. It demonstrated a lack of abuse liability when compared with triazolam and placebo in subjects with a history of sedative/hypnotic or anxiolytic drug abuse.²²

Tolerance and rebound. Tolerance can develop after repeated dosing with benzodiazepines—primarily triazolam—and rebound insomnia can follow abrupt discontinuation. Both can be minimized by using benzodiazepines at the lowest effective dosages and for brief periods. Gradual tapering when discontinuing the drug can help control rebound.

 

Tolerance and rebound seem to be less of a concern with the newer hypnotics than with benzodiazepines, as shown by controlled studies of eszopiclone¹⁹, zolpidem²³, and zaleplon.²⁴ However, periodic re-evaluation is still the prudent clinical standard for hypnotics prescribed over long periods of time.

Table 3

Actions and available doses of common hypnotics

Class/drug	Onset of action	Half-life (hrs)	Active metabolites	Doses (mg)
Benzodiazepines
Flurazepam	Rapid	40 to 250	Yes	15, 30
Quazepam	Rapid	40 to 250	Yes	7.5, 15
Estazolam	Rapid	10 to 24	Yes	0.5, 1, 2
Temazepam	Intermediate	8 to 22	No	7.5, 15
Triazolam	Rapid		No	0.125, 0.25, 0.5
Imidazopyridine
Zolpidem	Rapid	2.5	No	5, 10
Zolpidem ER	Rapid	2.5	No	6.25, 12.5
Pyrazolopyrimidines
Zaleplon	Rapid	1	No	5, 10, 20
Cyclopyrrolone
Eszopiclone	Rapid	6	Minor	2,3
Melatonin receptor agonist
Ramelteon	Rapid	1 to 2.6	No	8

Table 4

Guidelines for safe use of hypnotics

Define a clear indication and treatment goal Prescribe the lowest effective dose Individualize the dose for each patient Use lower doses with a CNS depressant or alcohol Consider dose adjustment in the elderly and in patients with hepatic or renal disease Avoid in patients with sleep apnea syndrome, pregnancy, and history of abuse Limit duration of use Consider intermittent therapy for patients who need longer-term treatment Taper doses to avoid abrupt discontinuation Re-evaluate drug treatment regularly; assess both efficacy and adverse effects

Nonhypnotic Sleep AIDS

Sedating antidepressants. Some physicians prescribe low doses of sedating antidepressants to control insomnia, a practice supported by controlled clinical trials of some tricyclic antidepressants (TCAs) such as doxepin,²⁵ trazodone,²⁶ and trimipramine.²⁷ Some physicians also advocate using more-sedating antidepressants—at dosages needed to treat depression—to control insomnia in depressed patients.

Evening dosing can minimize daytime sedation. If you choose an activating antidepressant, the potential side effect of insomnia can be managed by judicious use of hypnotic agents. Little is known about antidepressants’ effects on sleep quality after the first 6 to 8 weeks of treatment.²⁸

Although possibly helpful as sleep aids, TCAs are associated with anticholinergic effects such as dry mouth, urinary flow difficulties, and cardiac dysrhythmias.

Alcohol. Patients with insomnia sometimes selfmedicate with alcohol at bedtime because it enhances sleepiness and induces a more rapid sleep onset.²⁹ Drinking a “nightcap” is a poor choice, however, because alcohol can impair sleep quality, resulting in daytime somnolence. Alcohol is also associated with rapid development of tolerance.

Antihistamines and over-the-counter products whose main active ingredients are antihistamines—such as doxylamine and diphenhydramine—are used for insomnia and may help individuals fall asleep and stay asleep. However, antihistamine use is complicated by unpredictable efficacy and side effects such as daytime sedation, confusion, and systemic anticholinergic effects.³⁰

Melatonin is a nonprescription dietary supplement used in dosages of 0.5 to 3,000 mg. Anecdotal reports indicate it may be efficacious in certain subtypes of insomnia—such as shift work, jet lag, blindness, delayed sleep phase syndrome—and in older patients with sleep complaints.

Melatonin’s efficacy has not been established conclusively, however, and concerns have been expressed regarding the purity of over-the-counter preparations and possible coronary artery tissue stimulation, as observed in animal studies.

Related resources

• American Academy of Sleep Medicine. Sleep logs, patient education materials. www.aasmnet.org
  
• American Sleep Apnea Association. National Sleep Foundation. www.sleepapnea.org
  

Drug brand names

• Doxepin • Inequan
  
• Estazolam • Prosom
  
• Eszopiclone • Lunesta
  
• Flurazepam • Dalmane
  
• Quazepam • Doral
  
• Ramelteon • Rozerem
  
• Temazepam • Restoril
  
• Trazodone • Desyrel
  
• Triazolam • Halcion
  
• Trimipramine • Surmontil
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Doghramji receives research grant support from Cephalon, GlaxoSmithKline, Merck & Co., and Sanofi-Synthelabo

Careful investigation can often reveal insomnia’s cause¹—whether a medical or psychiatric condition or poor sleep habits. Understanding why patients can’t sleep is key to effective therapy.

Insomnia is associated with increased risk of accidents, work-related difficulties, and relationship problems.² Long-term sleeplessness may even increase risk of new psychiatric disorders—most notably major depression.³

Primary Insomnia

DSM-IV-TR criteria for primary insomnia include:⁴

• For at least 1 month, the patient’s main complaint has been trouble going to sleep, staying asleep, or feeling unrested.
  
• The insomnia or resulting daytime fatigue causes clinically important distress or impairs work, social, or personal functioning.
  
• The insomnia does not occur solely in the course of a breathing-related or circadian rhythm sleep disorder, a parasomnia, or as part of another mental disorder such as delirium, generalized anxiety disorder, or major depressive disorder.
  

The International Classification of Sleep Disorders outlines discrete insomnia types that are unrelated to other medical, mental, or sleep disorders.⁵ These include, among others, adjustment sleep disorder and psychophysiologic insomnia.

Adjustment sleep disorder. Acute emotional stressors—such as bereavement, job loss, or hospitalization—can cause insomnia or daytime sleepiness. Symptoms typically remit soon after the stressors abate, so this insomnia usually lasts a few days (acute) to a few months (short-term). It can also become chronic, lasting³ months or longer.

Psychophysiologic insomnia. Once insomnia begins—regardless of its cause—sleep problems may persist well after precipitating factors resolve. The mechanism may be related to somatized tension and learned sleep-preventing associations (trying too hard to sleep and conditioned arousal to the bedroom). Thus, short-term insomnia may develop into long-term, chronic difficulty with recurring episodes or a constant, daily pattern of insomnia.

Treatment for both adjustment sleep disorder and psychophysiologic insomnia with behavioral therapies and hypnotics⁶ is warranted if:

• sleepiness and fatigue interfere with daytime function
  
• the patient is significantly distressed
  
• a pattern of recurring episodes develops.⁵
  

Psychiatric Disorders and Insomnia

Depression. Up to 80% of depressed persons experience insomnia, although no one sleep pattern seems typical.⁷ Depression may be associated with:

• difficulties in falling asleep
  
• interrupted nocturnal sleep
  
• early morning awakening.
  

Anxiety disorders. Generalized anxiety disorder (GAD), panic attacks, and posttraumatic stress disorder (PTSD) are associated with disrupted sleep. Patients with GAD experience prolonged sleep latency and fragmented sleep, similar to those with primary insomnia.

Some patients experience panic symptoms while sleeping, possibly in association with mild hypercapnia. Those patients tend to have earlier onset of panic disorder and a higher likelihood of comorbid mood and other anxiety disorders.⁸

In patients with PTSD, disturbed sleep continuity and increased REM phasic activity—such as eye movements—are directly correlated with PTSD symptom severity. Nightmares and disturbed REM sleep are hallmarks of PTSD.⁹

Workup of Sleep Complaints

The patient history is an important part of the evaluation and treatment of insomnia and other sleep disturbances (Algorithm).¹²

Acute. Many short-term insomnias—lasting a few weeks or less—are caused by situational stressors, circadian rhythm changes, or poor sleep hygiene (Table 1).¹ A logical approach is to begin sleep hygiene measures and explore the patient’s life situation to uncover what might be causing the insomnia. Hypnotic agents may be considered if insomnia is associated with daytime sleepiness or occupational impairment or if it seems to be escalating and your assessment indicates that it is a primary condition.

Chronic. For longer-term insomnias—lasting more than a few months—consider a more thorough evaluation, including medical and psychiatric history, physical examination, and mental status examination. A differential assessment can be made on the basis of whether a patient has difficulty falling or staying asleep (Table 1). Ask about cardinal symptoms of disorders associated with insomnia, including:

• snoring or breathing pauses during sleep (sleep apnea syndrome)
  
• restlessness or twitching in the lower extremities (PLMD/RLS).
  

If possible, question the patient’s bed partner, who may be more aware of such symptoms than the patient.

Carefully review the patient’s weekday and weekend sleep patterns, bedtime habits, sleep hygiene habits, and substance and medication use.

Sleep clinic referrals. Consider an evaluation by a sleep disorders center when the diagnosis remains unclear or treatment of the presumed condition fails after a reasonable time.

Table 1

Possible causes of sleep complaints

Acute, transient	Recent or recurring stress
	Change in sleeping environment
	Acute illness or injury
	New medications
	Jet lag or shift change
Chronic	Difficulty staying asleep	Difficulty falling asleep
	Medications	Poor sleep hygiene
	Drug or alcohol use	Conditioned insomnia
	Psychiatric disorder	Restless legs syndrome
	Medical disorder	Circadian rhythm disorder
	Sleep-disordered breathing	Advanced sleep-phase syndrome
	Periodic limb movement disorder
	Restless legs syndrome
Source: Adapted and reprinted with permission from reference 13

Behavioral Treatments

Behavioral treatments—with or without hypnotics—are appropriate for many insomnia complaints, including adjustment sleep disorder and psychophysiologic insomnia. Behavioral measures may work more slowly than drug therapy, but their effects have been shown to last longer in patients with primary insomnia. It may be useful to start with both hypnotic and behavioral treatments and withdraw the hypnotic after behavioral measures take effect.

 

Sleep hygiene. Many individuals unknowingly engage in habits that impair sleep. Those with insomnia, for example, often try to compensate for lost sleep by staying in bed later in the morning or by napping, which further fragment nocturnal sleep. Advise these patients to adhere to a regular awakening time—regardless of how long they slept the night before—and to avoid naps. Other tips for getting a good night’s sleep are outlined in Table 2.¹⁴

Caffeine has a plasma half-life of 3 to 7 hours, although individual sensitivity varies widely and caffeine’s erratic absorption can prolong its effects. Advise patients with insomnia to avoid caffeine-containing beverages—including coffee, tea, and soft drinks—after noon.

Relaxation training. Muscle tension can be reduced through techniques such as electromyography (EMG) biofeedback, abdominal breathing exercises, or progressive muscle relaxation. Relaxation training is usually effective within a few weeks.

Psychological counseling. Counseling can help identify and dispel tension-producing thoughts that may be disrupting sleep, such as preoccupation with unpleasant work experiences or school examinations. Reassurance may help patients overcome fears about sleeplessness; suggest that they deal with anxiety-producing thoughts during counseling sessions and at times other than bedtime.

Table 2

How to get a good night’s sleep

Maintain a regular waking time, regardless of amount of sleep the night before Avoid excessive time in bed Avoid naps, except if a shift worker or elderly Spend time in bright light while awake Use the bed only for sleeping and sex Avoid nicotine, caffeine, and alcohol Exercise regularly early in the day Do something relaxing before bedtime Don’t watch the clock Eat a light snack before bedtime if hungry

Prescribing Hypnotics

Sedative-hypnotics are indicated primarily for short-term insomnia management. Most are used at bedtime until insomnia dissipates or the physician advises the patient to take a break.

Treatment principles. Because many insomnias are recurrent, prolonged hypnotic treatment given in short bouts is often optimal. Longer treatment—months to years—is clearly needed by a few patients with chronic insomnia. In these cases, carefully monitor for tolerance, as manifested by dosage escalation. Hypnotic treatment is generally not suitable for patients with drug abuse or dependence histories.

Although chloral hydrate and barbiturates are effective hypnotics, adverse effects limit their safety and usefulness. Benzodiazepines and more recently introduced agents have milder side-effect profiles (Table 3). Choose agents based on the patient’s situation, preferences, and effects of prior trials with similar agents. Guidelines for hypnotics discourage chronic use to minimize abuse, misuse, and habituation (Table 4).

Elimination half-life is one of the most important pharmacological properties that differentiates the hypnotics from each other:¹⁵

• longer half-life: flurazepam, quazepam
  
• intermediate half-life: estazolam, temazepam, eszopiclone
  
• short half-life: triazolam, zolpidem, zolpidem ER, zaleplon, ramelteon.
  

Hypnotic agents with relatively longer halflives tend to be associated with greater potential for residual daytime effects such as sedation, motor incoordination, amnesia, and slowed reflexes. These effects may impair performance and increase the risk of auto accidents and injuries, especially hip fractures in the elderly.

Benzodiazepine receptor agonists. Of the all the drugs in class, zalepon—because of its ultra-short half-life—is least likely to cause residual daytime effects when administered at bedtime. At 10-mg doses, its side effects seem to last no more than 4 hours after administration. Zaleplon can be safely taken after nocturnal awakenings if the patient remains in bed 4 hours or longer after taking it.¹⁷

An ultra-short half life is less desirable for patients with difficulty with sleep initiation and discontinuous sleep throughout the night. For them, longer elimination half-life agents—such as zolpidem, zolpidem extended release (ER), and eszopiclone—may be more predictably effective for the entire night.¹⁸

Short half-life hypnotics do not offer anxiolysis for patients with daytime anxiety, as the longer half-life agents do.

Zolpidem ER and eszopiclone do not have a limitation imposed on duration of use. Although zolpidem ER has not been investigated in controlled trials greater than 3 weeks, eszopiclone was evaluated during a 6-month study that demonstrated lack of tolerance during the entire period, and lack of rebound after rapid discontinuation.¹⁹ Eszopiclone is the only hypnotic indicated for long-term (lasting > 3 weeks) insomnia.

Melatonin receptor agonists. Ramelteon’s activity at MT1 and MT2 receptors is believed to contribute to its sleep-promoting properties. This agent has been found to reduce sleep latency,^20,21 and it is indicated to treat insomnia characterized by sleep-onset delays. Although controlled, longterm studies are lacking, ramelteon does not have a limit on duration of use. It demonstrated a lack of abuse liability when compared with triazolam and placebo in subjects with a history of sedative/hypnotic or anxiolytic drug abuse.²²

Tolerance and rebound. Tolerance can develop after repeated dosing with benzodiazepines—primarily triazolam—and rebound insomnia can follow abrupt discontinuation. Both can be minimized by using benzodiazepines at the lowest effective dosages and for brief periods. Gradual tapering when discontinuing the drug can help control rebound.

 

Tolerance and rebound seem to be less of a concern with the newer hypnotics than with benzodiazepines, as shown by controlled studies of eszopiclone¹⁹, zolpidem²³, and zaleplon.²⁴ However, periodic re-evaluation is still the prudent clinical standard for hypnotics prescribed over long periods of time.

Table 3

Actions and available doses of common hypnotics

Class/drug	Onset of action	Half-life (hrs)	Active metabolites	Doses (mg)
Benzodiazepines
Flurazepam	Rapid	40 to 250	Yes	15, 30
Quazepam	Rapid	40 to 250	Yes	7.5, 15
Estazolam	Rapid	10 to 24	Yes	0.5, 1, 2
Temazepam	Intermediate	8 to 22	No	7.5, 15
Triazolam	Rapid		No	0.125, 0.25, 0.5
Imidazopyridine
Zolpidem	Rapid	2.5	No	5, 10
Zolpidem ER	Rapid	2.5	No	6.25, 12.5
Pyrazolopyrimidines
Zaleplon	Rapid	1	No	5, 10, 20
Cyclopyrrolone
Eszopiclone	Rapid	6	Minor	2,3
Melatonin receptor agonist
Ramelteon	Rapid	1 to 2.6	No	8

Table 4

Guidelines for safe use of hypnotics

Define a clear indication and treatment goal Prescribe the lowest effective dose Individualize the dose for each patient Use lower doses with a CNS depressant or alcohol Consider dose adjustment in the elderly and in patients with hepatic or renal disease Avoid in patients with sleep apnea syndrome, pregnancy, and history of abuse Limit duration of use Consider intermittent therapy for patients who need longer-term treatment Taper doses to avoid abrupt discontinuation Re-evaluate drug treatment regularly; assess both efficacy and adverse effects

Nonhypnotic Sleep AIDS

Sedating antidepressants. Some physicians prescribe low doses of sedating antidepressants to control insomnia, a practice supported by controlled clinical trials of some tricyclic antidepressants (TCAs) such as doxepin,²⁵ trazodone,²⁶ and trimipramine.²⁷ Some physicians also advocate using more-sedating antidepressants—at dosages needed to treat depression—to control insomnia in depressed patients.

Evening dosing can minimize daytime sedation. If you choose an activating antidepressant, the potential side effect of insomnia can be managed by judicious use of hypnotic agents. Little is known about antidepressants’ effects on sleep quality after the first 6 to 8 weeks of treatment.²⁸

Although possibly helpful as sleep aids, TCAs are associated with anticholinergic effects such as dry mouth, urinary flow difficulties, and cardiac dysrhythmias.

Alcohol. Patients with insomnia sometimes selfmedicate with alcohol at bedtime because it enhances sleepiness and induces a more rapid sleep onset.²⁹ Drinking a “nightcap” is a poor choice, however, because alcohol can impair sleep quality, resulting in daytime somnolence. Alcohol is also associated with rapid development of tolerance.

Antihistamines and over-the-counter products whose main active ingredients are antihistamines—such as doxylamine and diphenhydramine—are used for insomnia and may help individuals fall asleep and stay asleep. However, antihistamine use is complicated by unpredictable efficacy and side effects such as daytime sedation, confusion, and systemic anticholinergic effects.³⁰

Melatonin is a nonprescription dietary supplement used in dosages of 0.5 to 3,000 mg. Anecdotal reports indicate it may be efficacious in certain subtypes of insomnia—such as shift work, jet lag, blindness, delayed sleep phase syndrome—and in older patients with sleep complaints.

Melatonin’s efficacy has not been established conclusively, however, and concerns have been expressed regarding the purity of over-the-counter preparations and possible coronary artery tissue stimulation, as observed in animal studies.

Related resources

• American Academy of Sleep Medicine. Sleep logs, patient education materials. www.aasmnet.org
  
• American Sleep Apnea Association. National Sleep Foundation. www.sleepapnea.org
  

Drug brand names

• Doxepin • Inequan
  
• Estazolam • Prosom
  
• Eszopiclone • Lunesta
  
• Flurazepam • Dalmane
  
• Quazepam • Doral
  
• Ramelteon • Rozerem
  
• Temazepam • Restoril
  
• Trazodone • Desyrel
  
• Triazolam • Halcion
  
• Trimipramine • Surmontil
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Doghramji receives research grant support from Cephalon, GlaxoSmithKline, Merck & Co., and Sanofi-Synthelabo

Careful investigation can often reveal insomnia’s cause¹—whether a medical or psychiatric condition or poor sleep habits. Understanding why patients can’t sleep is key to effective therapy.

Insomnia is associated with increased risk of accidents, work-related difficulties, and relationship problems.² Long-term sleeplessness may even increase risk of new psychiatric disorders—most notably major depression.³

Primary Insomnia

DSM-IV-TR criteria for primary insomnia include:⁴

• For at least 1 month, the patient’s main complaint has been trouble going to sleep, staying asleep, or feeling unrested.
  
• The insomnia or resulting daytime fatigue causes clinically important distress or impairs work, social, or personal functioning.
  
• The insomnia does not occur solely in the course of a breathing-related or circadian rhythm sleep disorder, a parasomnia, or as part of another mental disorder such as delirium, generalized anxiety disorder, or major depressive disorder.
  

The International Classification of Sleep Disorders outlines discrete insomnia types that are unrelated to other medical, mental, or sleep disorders.⁵ These include, among others, adjustment sleep disorder and psychophysiologic insomnia.

Adjustment sleep disorder. Acute emotional stressors—such as bereavement, job loss, or hospitalization—can cause insomnia or daytime sleepiness. Symptoms typically remit soon after the stressors abate, so this insomnia usually lasts a few days (acute) to a few months (short-term). It can also become chronic, lasting³ months or longer.

Psychophysiologic insomnia. Once insomnia begins—regardless of its cause—sleep problems may persist well after precipitating factors resolve. The mechanism may be related to somatized tension and learned sleep-preventing associations (trying too hard to sleep and conditioned arousal to the bedroom). Thus, short-term insomnia may develop into long-term, chronic difficulty with recurring episodes or a constant, daily pattern of insomnia.

Treatment for both adjustment sleep disorder and psychophysiologic insomnia with behavioral therapies and hypnotics⁶ is warranted if:

• sleepiness and fatigue interfere with daytime function
  
• the patient is significantly distressed
  
• a pattern of recurring episodes develops.⁵
  

Psychiatric Disorders and Insomnia

Depression. Up to 80% of depressed persons experience insomnia, although no one sleep pattern seems typical.⁷ Depression may be associated with:

• difficulties in falling asleep
  
• interrupted nocturnal sleep
  
• early morning awakening.
  

Anxiety disorders. Generalized anxiety disorder (GAD), panic attacks, and posttraumatic stress disorder (PTSD) are associated with disrupted sleep. Patients with GAD experience prolonged sleep latency and fragmented sleep, similar to those with primary insomnia.

Some patients experience panic symptoms while sleeping, possibly in association with mild hypercapnia. Those patients tend to have earlier onset of panic disorder and a higher likelihood of comorbid mood and other anxiety disorders.⁸

In patients with PTSD, disturbed sleep continuity and increased REM phasic activity—such as eye movements—are directly correlated with PTSD symptom severity. Nightmares and disturbed REM sleep are hallmarks of PTSD.⁹

Workup of Sleep Complaints

The patient history is an important part of the evaluation and treatment of insomnia and other sleep disturbances (Algorithm).¹²

Acute. Many short-term insomnias—lasting a few weeks or less—are caused by situational stressors, circadian rhythm changes, or poor sleep hygiene (Table 1).¹ A logical approach is to begin sleep hygiene measures and explore the patient’s life situation to uncover what might be causing the insomnia. Hypnotic agents may be considered if insomnia is associated with daytime sleepiness or occupational impairment or if it seems to be escalating and your assessment indicates that it is a primary condition.

Chronic. For longer-term insomnias—lasting more than a few months—consider a more thorough evaluation, including medical and psychiatric history, physical examination, and mental status examination. A differential assessment can be made on the basis of whether a patient has difficulty falling or staying asleep (Table 1). Ask about cardinal symptoms of disorders associated with insomnia, including:

• snoring or breathing pauses during sleep (sleep apnea syndrome)
  
• restlessness or twitching in the lower extremities (PLMD/RLS).
  

If possible, question the patient’s bed partner, who may be more aware of such symptoms than the patient.

Carefully review the patient’s weekday and weekend sleep patterns, bedtime habits, sleep hygiene habits, and substance and medication use.

Sleep clinic referrals. Consider an evaluation by a sleep disorders center when the diagnosis remains unclear or treatment of the presumed condition fails after a reasonable time.

Table 1

Possible causes of sleep complaints

Acute, transient	Recent or recurring stress
	Change in sleeping environment
	Acute illness or injury
	New medications
	Jet lag or shift change
Chronic	Difficulty staying asleep	Difficulty falling asleep
	Medications	Poor sleep hygiene
	Drug or alcohol use	Conditioned insomnia
	Psychiatric disorder	Restless legs syndrome
	Medical disorder	Circadian rhythm disorder
	Sleep-disordered breathing	Advanced sleep-phase syndrome
	Periodic limb movement disorder
	Restless legs syndrome
Source: Adapted and reprinted with permission from reference 13

Behavioral Treatments

Behavioral treatments—with or without hypnotics—are appropriate for many insomnia complaints, including adjustment sleep disorder and psychophysiologic insomnia. Behavioral measures may work more slowly than drug therapy, but their effects have been shown to last longer in patients with primary insomnia. It may be useful to start with both hypnotic and behavioral treatments and withdraw the hypnotic after behavioral measures take effect.

 

Sleep hygiene. Many individuals unknowingly engage in habits that impair sleep. Those with insomnia, for example, often try to compensate for lost sleep by staying in bed later in the morning or by napping, which further fragment nocturnal sleep. Advise these patients to adhere to a regular awakening time—regardless of how long they slept the night before—and to avoid naps. Other tips for getting a good night’s sleep are outlined in Table 2.¹⁴

Caffeine has a plasma half-life of 3 to 7 hours, although individual sensitivity varies widely and caffeine’s erratic absorption can prolong its effects. Advise patients with insomnia to avoid caffeine-containing beverages—including coffee, tea, and soft drinks—after noon.

Relaxation training. Muscle tension can be reduced through techniques such as electromyography (EMG) biofeedback, abdominal breathing exercises, or progressive muscle relaxation. Relaxation training is usually effective within a few weeks.

Psychological counseling. Counseling can help identify and dispel tension-producing thoughts that may be disrupting sleep, such as preoccupation with unpleasant work experiences or school examinations. Reassurance may help patients overcome fears about sleeplessness; suggest that they deal with anxiety-producing thoughts during counseling sessions and at times other than bedtime.

Table 2

How to get a good night’s sleep

Maintain a regular waking time, regardless of amount of sleep the night before Avoid excessive time in bed Avoid naps, except if a shift worker or elderly Spend time in bright light while awake Use the bed only for sleeping and sex Avoid nicotine, caffeine, and alcohol Exercise regularly early in the day Do something relaxing before bedtime Don’t watch the clock Eat a light snack before bedtime if hungry

Prescribing Hypnotics

Sedative-hypnotics are indicated primarily for short-term insomnia management. Most are used at bedtime until insomnia dissipates or the physician advises the patient to take a break.

Treatment principles. Because many insomnias are recurrent, prolonged hypnotic treatment given in short bouts is often optimal. Longer treatment—months to years—is clearly needed by a few patients with chronic insomnia. In these cases, carefully monitor for tolerance, as manifested by dosage escalation. Hypnotic treatment is generally not suitable for patients with drug abuse or dependence histories.

Although chloral hydrate and barbiturates are effective hypnotics, adverse effects limit their safety and usefulness. Benzodiazepines and more recently introduced agents have milder side-effect profiles (Table 3). Choose agents based on the patient’s situation, preferences, and effects of prior trials with similar agents. Guidelines for hypnotics discourage chronic use to minimize abuse, misuse, and habituation (Table 4).

Elimination half-life is one of the most important pharmacological properties that differentiates the hypnotics from each other:¹⁵

• longer half-life: flurazepam, quazepam
  
• intermediate half-life: estazolam, temazepam, eszopiclone
  
• short half-life: triazolam, zolpidem, zolpidem ER, zaleplon, ramelteon.
  

Hypnotic agents with relatively longer halflives tend to be associated with greater potential for residual daytime effects such as sedation, motor incoordination, amnesia, and slowed reflexes. These effects may impair performance and increase the risk of auto accidents and injuries, especially hip fractures in the elderly.

Benzodiazepine receptor agonists. Of the all the drugs in class, zalepon—because of its ultra-short half-life—is least likely to cause residual daytime effects when administered at bedtime. At 10-mg doses, its side effects seem to last no more than 4 hours after administration. Zaleplon can be safely taken after nocturnal awakenings if the patient remains in bed 4 hours or longer after taking it.¹⁷

An ultra-short half life is less desirable for patients with difficulty with sleep initiation and discontinuous sleep throughout the night. For them, longer elimination half-life agents—such as zolpidem, zolpidem extended release (ER), and eszopiclone—may be more predictably effective for the entire night.¹⁸

Short half-life hypnotics do not offer anxiolysis for patients with daytime anxiety, as the longer half-life agents do.

Zolpidem ER and eszopiclone do not have a limitation imposed on duration of use. Although zolpidem ER has not been investigated in controlled trials greater than 3 weeks, eszopiclone was evaluated during a 6-month study that demonstrated lack of tolerance during the entire period, and lack of rebound after rapid discontinuation.¹⁹ Eszopiclone is the only hypnotic indicated for long-term (lasting > 3 weeks) insomnia.

Melatonin receptor agonists. Ramelteon’s activity at MT1 and MT2 receptors is believed to contribute to its sleep-promoting properties. This agent has been found to reduce sleep latency,^20,21 and it is indicated to treat insomnia characterized by sleep-onset delays. Although controlled, longterm studies are lacking, ramelteon does not have a limit on duration of use. It demonstrated a lack of abuse liability when compared with triazolam and placebo in subjects with a history of sedative/hypnotic or anxiolytic drug abuse.²²

Tolerance and rebound. Tolerance can develop after repeated dosing with benzodiazepines—primarily triazolam—and rebound insomnia can follow abrupt discontinuation. Both can be minimized by using benzodiazepines at the lowest effective dosages and for brief periods. Gradual tapering when discontinuing the drug can help control rebound.

 

Tolerance and rebound seem to be less of a concern with the newer hypnotics than with benzodiazepines, as shown by controlled studies of eszopiclone¹⁹, zolpidem²³, and zaleplon.²⁴ However, periodic re-evaluation is still the prudent clinical standard for hypnotics prescribed over long periods of time.

Table 3

Actions and available doses of common hypnotics

Class/drug	Onset of action	Half-life (hrs)	Active metabolites	Doses (mg)
Benzodiazepines
Flurazepam	Rapid	40 to 250	Yes	15, 30
Quazepam	Rapid	40 to 250	Yes	7.5, 15
Estazolam	Rapid	10 to 24	Yes	0.5, 1, 2
Temazepam	Intermediate	8 to 22	No	7.5, 15
Triazolam	Rapid		No	0.125, 0.25, 0.5
Imidazopyridine
Zolpidem	Rapid	2.5	No	5, 10
Zolpidem ER	Rapid	2.5	No	6.25, 12.5
Pyrazolopyrimidines
Zaleplon	Rapid	1	No	5, 10, 20
Cyclopyrrolone
Eszopiclone	Rapid	6	Minor	2,3
Melatonin receptor agonist
Ramelteon	Rapid	1 to 2.6	No	8

Table 4

Guidelines for safe use of hypnotics

Define a clear indication and treatment goal Prescribe the lowest effective dose Individualize the dose for each patient Use lower doses with a CNS depressant or alcohol Consider dose adjustment in the elderly and in patients with hepatic or renal disease Avoid in patients with sleep apnea syndrome, pregnancy, and history of abuse Limit duration of use Consider intermittent therapy for patients who need longer-term treatment Taper doses to avoid abrupt discontinuation Re-evaluate drug treatment regularly; assess both efficacy and adverse effects

Nonhypnotic Sleep AIDS

Sedating antidepressants. Some physicians prescribe low doses of sedating antidepressants to control insomnia, a practice supported by controlled clinical trials of some tricyclic antidepressants (TCAs) such as doxepin,²⁵ trazodone,²⁶ and trimipramine.²⁷ Some physicians also advocate using more-sedating antidepressants—at dosages needed to treat depression—to control insomnia in depressed patients.

Evening dosing can minimize daytime sedation. If you choose an activating antidepressant, the potential side effect of insomnia can be managed by judicious use of hypnotic agents. Little is known about antidepressants’ effects on sleep quality after the first 6 to 8 weeks of treatment.²⁸

Although possibly helpful as sleep aids, TCAs are associated with anticholinergic effects such as dry mouth, urinary flow difficulties, and cardiac dysrhythmias.

Alcohol. Patients with insomnia sometimes selfmedicate with alcohol at bedtime because it enhances sleepiness and induces a more rapid sleep onset.²⁹ Drinking a “nightcap” is a poor choice, however, because alcohol can impair sleep quality, resulting in daytime somnolence. Alcohol is also associated with rapid development of tolerance.

Antihistamines and over-the-counter products whose main active ingredients are antihistamines—such as doxylamine and diphenhydramine—are used for insomnia and may help individuals fall asleep and stay asleep. However, antihistamine use is complicated by unpredictable efficacy and side effects such as daytime sedation, confusion, and systemic anticholinergic effects.³⁰

Melatonin is a nonprescription dietary supplement used in dosages of 0.5 to 3,000 mg. Anecdotal reports indicate it may be efficacious in certain subtypes of insomnia—such as shift work, jet lag, blindness, delayed sleep phase syndrome—and in older patients with sleep complaints.

Melatonin’s efficacy has not been established conclusively, however, and concerns have been expressed regarding the purity of over-the-counter preparations and possible coronary artery tissue stimulation, as observed in animal studies.

Related resources

• American Academy of Sleep Medicine. Sleep logs, patient education materials. www.aasmnet.org
  
• American Sleep Apnea Association. National Sleep Foundation. www.sleepapnea.org
  

Drug brand names

• Doxepin • Inequan
  
• Estazolam • Prosom
  
• Eszopiclone • Lunesta
  
• Flurazepam • Dalmane
  
• Quazepam • Doral
  
• Ramelteon • Rozerem
  
• Temazepam • Restoril
  
• Trazodone • Desyrel
  
• Triazolam • Halcion
  
• Trimipramine • Surmontil
  
• Zaleplon • Sonata
  
• Zolpidem • Ambien
  

Disclosures

Dr. Doghramji receives research grant support from Cephalon, GlaxoSmithKline, Merck & Co., and Sanofi-Synthelabo

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.
  

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.
  

Burnout develops slowly and insidiously; there are no fire alarms, no smoke. It is easy to ignore the warning signs. As psychiatrists, we are at high risk for burnout, and the consequences can be devastating. We have:

• suicide rates 2 to 3 times higher than those of the general population
  
• higher rates of divorce and substance abuse compared with other physicians and non-physicians (Table 1).^1-12
  

Burnout affects 25% to 57% of our profession at any given time,¹³ yet we seldom address it. Despite vast literature on burnout in family medicine and other medical specialties, psychiatric burnout is grossly under-recognized. It’s as if we aren’t supposed to burn out; after all, aren’t we the experts others come to when they are burned out?

If you think you may be heading toward burnout, we offer practical, evidence-based information to help you:

• prevent burnout
  
• diagnose burnout, “brownout,” and “compassion fatigue”
  
• begin to make immediate changes to over-come burnout and reclaim your life.
  

Table 1

Relative rates of divorce, suicide, and substance abuse among psychiatrists

Event	Psychiatrists	Other physicians	General population
Divorce*	50% (2.7 times risk of other physicians)3	22% to 24% in internists and pediatricians3	10% to 20% less than among physicians4
Suicide	28 to 40/100,0001 (2 to 3 times rate in general population)	May be similar to rate among psychiatrists† Equal rates in male and female physicians	12/100,000
		Rate in female physicians is 2 to 4 times that of women in general population1,2,5
Substance abuse6-10
Benzodiazepine use (past year)6	26.3%	7% to 16% (11.4% across all specialties)
Lifetime abuse/dependence6	14.3%	7.9%
Alcohol only	7.9%	4.2%
* Divorce risk across 30 years
† Some but not all evidence indicates psychiatrists have higher rates of suicide than other physicians1,2,11,12

Case: ‘Something in me had died’

I (PB) was 50 years old, racing along, seeing patients 45 hours a week, and keeping a full schedule of teaching and writing. Psychotherapy was my primary training and my love, but monitoring medications for other therapists—without getting to know the patients—had become unsatisfying. My practice group had exploded from 5 mental health professionals to more than 20, creating unexpected stresses and conflicts. At the same time, my marriage was failing.

Increasingly overextended, I lost my good humor. I became irritable and short with everyone, and—worse—I felt resentful and burdened by my patients. Once eager for challenges, I avoided new consults and referrals. Every hour was filled with dread, and I struggled to get through the day. Empty, numb, and miserable, I had burned out but did not realize it. I only knew that something in me had died.

I started fantasizing about retiring from clinical work, but what would I do then? What if this was the end of my career?

Burnout is a ‘heart attack’

Most burnout definitions include three features: emotional exhaustion, depersonalization, and diminished feelings of personal accomplishment.¹⁴ Some writers describe it as a state of mourning: “A grief syndrome due to loss of our dreams or sense of purpose or mission, leading to the experience of emotional depletion…expectations clash with an imposing reality.”¹⁵

Burnout represents a loss of meaning. It resembles a “spiritual heart attack,” with “referred pain” that affects our work, our relationships, and our soul. We become members of the “coronary club” (Box 1).¹⁶

Box 1

External causes. Burnout causes include the usual suspects: external factors such as increased paperwork, managed care hassles, lower reimbursement rates, and fears of litigation. In psychiatry, we also face occupational hazards associated with continuous exposure to depressed, violent, suicidal, and personality-disordered individuals.

The “15-minute” medication check is probably the most demoralizing hazard. Pressure from managed care to focus on brief contact with patients only for medication management is dispiriting, resulting in:

• little time for empathic connection
  
• loss of professional autonomy
  
• fear of greater liability risk than when we handle psychotherapy and medication
  
• fear of lost income if we opt not to accept medication-only referrals.^17-21
  

In a 1998 survey of 100 Manhattan psychiatrists assessing the impact of managed care on their practices, 70% of respondents said they “would not recommend a career in private practice to a graduating psychiatry resident.”²²

Internal causes. Approximately 60% of job satisfaction is related to internal determinants: attitudes, beliefs, lifestyle, and coping techniques. Burnout is not simply the result of overwork, underpay, or increasing demands of a changing medical culture. If all managed care hassles disappeared tomorrow—if paperwork went away and reimbursements flowed freely—burnout would continue because it is the loss of a dream. Freuden-berger²³ refers to it as a loss of idealism; a loss of expected goals.

 

Psychiatry is about intimate human relationships, connectedness, and accompanying our patients over the complex terrain of the human condition. Often, burnout develops when something disrupts the physician-patient bond. As Irvin Yalom reminds us, “It’s the relationship that heals.” That relationship is healing to the physician as well as to the patient.²⁴

Burnout comes from decreased quality of fulfillment we derive from our efforts. It concerns intangible phenomena such as losing our sense of purpose or feeling we are not making a difference. We wonder: Am I doing what I was born to do? Burnout is suffering that goes beyond a worn-down body and approaches “erosion of the soul.”²⁵

Diversify your portfolio

Physician-author Rachel Naomi Remen, MD, clinical professor of family and community medicine at the University of California, San Francisco, reminds us, “Service in medicine is the work of the heart and the soul.”²⁶ To heal ourselves, we must by nurturing and cultivating our inner life. By plumbing these depths, you may rediscover your sense of purpose.

You may need to “diversify your portfolio” with reflective and regenerative activities. These may be as varied as reading poetry, paddling canoes, spiritual practices, gardening, hiking, or visiting art museums.

More importantly, you may need to re-examine and deepen your relationships with:

• your partner (Are you spending enough time together? Is your relationship growing?)
  
• your patients (Are you getting to know your patients as people?)
  
• your sense of purpose or spirituality (Do you see a higher or transcendent meaning in your life?)
  
• the community, the world. (Are you making them better?).
  

What’s your diagnosis?

How do you know if you have brownout (mild depression; a prodromal phase), classic burnout (severe depression), or compassion fatigue (a form of burnout)?

Brownout vs burnout (Table 2). Look for depressive symptoms: sad mood, lack of pleasure, low energy or motivation, poor concentration or memory, or insomnia. In addition, you may experience a “deadness” at work, as well as “marital deadness.” The “helper’s high” has become the “helper’s low.” You may anger quickly and have tensions with your family or co-workers. Signs of burnout include disorganization and chronic lateness, absenteeism, or “presenteeism” (physically present, spiritually and go beyond the mind and body to address the soul emotionally absent).

Irritability and lack of time for family can cause extensive collateral damage:

• Wife of a burned-out doctor: “My husband wasn’t there for our son’s 6th birthday, and he missed our daughter’s high-school graduation. He’s missed half their childhoods.”
  
• Husband of a burned-out psychiatrist: “I’m miserable. She’s not the same woman I married. She’s such a workaholic, she’s got nothing left for us.”
  
• A psychiatrist’s 13-year-old daughter: “He helps his patients have a good life; why can’t he do that with us?”
  

Table 2

Are you suffering from brownout or burnout?

Brownout (mild depression)	Burnout (severe depression)
I feel tired	I feel exhausted, listless
I’m having less fun and feeling less satisfied	I feel grumpy and joyless
I’m drinking more caffeine and eating more junk food	I’m drinking more alcohol, taking more medications, or using illicit drugs
I feel less interested and less caring about my patients, residents, and coworkers	I want to leave patient care, and I don’t care about my co-workers
I am dissatisfied, troubled	I am impaired

Compassion fatigue (Table 3) typically affects disaster relief caregivers. The term arose in the early 1990s,²⁷ when caring for sick and dying AIDS patients overwhelmed health care workers.

Table 3

Is it burnout or compassion fatigue?

Burnout	Compassion fatigue
Evolves gradually	Reaction to extreme circumstances or suddenly increased work demands, such as disaster relief, crisis work
Loss of meaning, unmet expectations	Vicarious suffering of others’ trauma (“emotional contagion”)
Diminished work capacity (depression, withdrawal)	Increased, relentless work effort (ignore physical health, work-‘til-you-drop mentality, obsessive-compulsive behavior)

Intensive care for burnout

Treating or preventing burnout requires individual solutions, peer strategies, and group/organizational techniques. The first five suggestions below relate to individual steps, and the last two to peer approaches and organizational strategy.

Stop doing what you’re doing. In her book, The Joy of Burnout, Dina Glouberman, PhD, says, “Burn-out is life catching up with us…. Stop doing, and start listening to ourselves in a completely new way, to make space for our true self.”²⁸ Better time management is not the answer; you cannot give what you do not have.

Take time off. Most experts recommend at least 1 month off to rethink things, and 6 months off to renew. I (PB) took 6 months off to recover from my burnout and needed every minute of it.

Take a serious inventory of your life and priorities, and set limits (Box 2). One psychiatrist decided he didn’t want to be on three medical society committees, two hospital committees, and a church task force. His wife had threatened to divorce him, and he was always exhausted.

 

Box 2

Confide in someone you trust. Avoid the empty complaining, “Ain’t it awful.” Ventilate your concerns and feelings, and look for honest feedback. Be open to suggestions for action.

Get professional counseling. Burnout is moderate or major depression. Practice what you preach.

Join a support group. Let go of, “Real doctors handle things on their own.” Focus on introspection and solutions.

Consider stress management. Options include seminars or retreats and individual, practice-oriented, and organizational consultations (see Related resources).

Burnout as opportunity

Viewing burnout as an opportunity for transformation gives you a chance to:

Re-evaluate your life and priorities. What is most important to you: Money? Family? Making your community a better place? Spiritual growth? If you knew you had only 1 year to live, how would you be living?

Renew/reinvent yourself. One burned-out psychiatrist moved from Denver to San Francisco, where he started over with no expectations or image to uphold. This made it easier to try new professional and personal ventures.

“The geographical solution” is not necessary, however, and can add stress at a vulnerable time. You can “bloom where you’re planted” and renew yourself wherever you are.

Rediscover your passion. Teaching? Art? Part-time practice and run a bed-and-breakfast? Surfing? Guitar lessons? We know physicians who used each of these to help revitalize themselves.

Case continued: recovery

As my life got worse—a drawn-out divorce, two daughters in private universities, and by now a greatly reduced income—I felt trapped and spent. I had to change or die emotionally (possibly even physically).

Not knowing what to do, I took a leap. I cashed in my retirement fund and resigned. I took a 6-month unpaid sabbatical. With no schedule to keep, I had time to read and think. I resumed my own psychotherapy, went through deep reflection, and re-evaluated my priorities and values. I took up acting for fun and started keeping a gratitude journal.

Eventually I remarried. I started changing my workaholic tendencies, limited my practice to 20 hours a week, and established that my priorities were family, friends, and the joy of helping patients and colleagues. I re-discovered my enthusiasm for teaching, including teaching others about preventing burnout.

Preventative medicine

To prevent burnout, we must learn to recognize and address brownout. This is a much better choice than trying to recover from full-fledged burnout: less disruptive, less costly, less damaging interpersonally.

How do we prevent burnout? Several approaches are particularly useful for psychiatrists:

Self-care. Take time off, but beware of “The Vacation Solution”—psychiatrists’ most popular strategy. As one put it: “I work until I’m ready to drop, then I take 2 weeks off.” This is unhealthy:

• physically (gradually wears you down)
  
• emotionally (we all know the risk of repeated mild depressions, or brownout)
  
• interpersonally (our family members and colleagues suffer as we get exhausted).
  

Get a personal physician to maximize your health; only about one-third of physicians do. You are playing medical roulette if you treat your-self or manage with only informal chats with colleagues and medication samples. Suffer a coronary or stroke or slip into excessive alcohol use or obesity, and your best-laid plans can be derailed.

Give and get affirmation and support. Isolating yourself socially is one of the surest roads to burnout. Compared with solo practitioners, psychiatrists working at community mental health centers often report greater career satisfaction. Although they may have difficult case loads and systemic challenges, group practitioners are supported by nurses, social workers, and case managers. The team helps dilute the stress of caring for the most difficult patients.

If you have a solo practice, try to connect and commiserate with other mental health practitioners by joining a professional organization or forming your own process group. If you prefer not to socialize professionally, consider a book club, temple, or church group.

Take time to interact meaningfully: practice appreciating others at least 3 times a day. Saying, “I really admire how you handled that situation,” or “How are you doing?” takes less than 10 seconds. Appreciate your own efforts, too. Write down—now, as you read this—the names of three people you will affirm or offer support to today. Include one person you usually wouldn’t acknowledge.

Find/create meaning in your work life. When you get tired or frustrated, remind yourself that practicing psychiatry is a privilege. We make a difference with people (service) through intimate emotional connection (relationship). Altruism confers benefits to the giver and the recipient. Some psychiatrists derive meaning by seeing our profession as fulfilling a mission or higher purpose, even as a calling.

 

Be grateful. Gratitude can reduce depression and boost happiness and life satisfaction.^29,30 For the next month, try keeping a “gratitude journal,” writing 3 to 5 things you are grateful for each day. It can produce a positive shift in mood, even after a frustrating or demanding workday.³¹ Start now, by writing what you are grateful for today.

Live fully in this moment. Avoid the “someday” game, waiting to be happy until… you’re caught up with your work, your children are in (or out) of school, you’re wealthy/old enough to retire, etc. Live right now, with this patient, this colleague, this family member. Focus 100% on the person or task of the moment.

Don’t let the task get between us.³² If your spouse or friend wants to visit or share feelings, make the time, even if you’re “busy.” If your patient wants an “extra minute” to thank you for your help or to show you a picture, make time happily.

Play a little every day. Take mini-vacations: walk outside, listen to or make music (a colleague next door lightens my day playing his guitar). Call your spouse or give him/her a funny greeting card, wear a light-hearted tie, bring flowers to your nurses or receptionist. Play with your patients: read poetry; have them bring in pictures of themselves when they were young to help them remember their vitality and spirit. Create your own change of pace (Box 3).

Box 3

Related resources

• Institute for Healing in Society and Medicine. Martin Sullivan, MD. www.healinginmedicine.org
  
• Center for Professional Well-Being. John-Henry Pfifferling, PhD. www.cpwb.org
  
• Renew. Linda Clever, MD. www.renewnow.org
  
• WorkLife Design. Kernan Manion, MD. www.worklifedesign.org
  
• Menninger Clinic. Professionals in Crisis Program. www.menningerclinic.com
  
• Rachel Naomi Remen. Author of Kitchen Table Wisdom: Stories That Heal. www.rachelremen.com.
  

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.

National Guard and Army Reserve troops constitute an estimated 30% to 40% of the 1 million-plus U.S. military personnel deployed in Iraq and Afghanistan.^1-3 Many of these civilian soldiers—once considered “weekend warriors”—are serving a first combat tour, returning home, and being redeployed for additional tours of duty.

Because of these unprecedented deployment policies, civilian psychiatrists will likely play a greater role in treating combat-related mental health problems than in any previous U.S. war. You may need to provide initial and long-term psychiatric care for reservists and Guard members returning to your community during 2006 and beyond.

To help you prepare, we discuss the combat situations these soldiers are experiencing, types of psychiatric problems they are reporting in anonymous surveys, and their attitudes about seeking psychiatric care. We also offer practical resources on combat-related posttraumatic stress disorder (PTSD) for nonmilitary or Veterans Administration clinicians.

A soldier’s story: ‘He’s always jumpy’

Mr. L, age 39, is supervisor for a local construction company and a sergeant first class with 18 years of Army Reserve service who returned from Iraq 7 months ago. He tells you, “My wife made me come see you—I didn’t want to.”

Though he does not think he needs a psychiatrist, his irritability and poor sleep worry his wife. “He isn’t the same anymore,” she says. “He’s always jumpy.”

Reported psychiatric problems

Stress-related symptoms. Within 4 months of returning home from Iraq or Afghanistan, 3 in 10 soldiers have developed “stress-related mental health problems” such as anxiety, depression, nightmares, anger, and concentration difficulties, reports Army Surgeon General Lt. Gen. Kevin Kiley.⁴ An unknown smaller percentage were reportedly diagnosed with PTSD.

Strained marriages, suicidal thoughts/feelings, nightmares or flashbacks, and fear of losing control or injuring someone else were among problems soldiers acknowledged during post-deployment health assessments between January and August 2005. In these surveys, 28% of 193,000 returnees endorsed mental health problems, according to the Army Center for Health Promotion and Preventive Medicine (Table 1).⁵

Table 1

Mental health problems reported by troops returning from combat in Iraq*

Problem	Number among 193,000 U.S. soldiers
Nightmares or unwanted war recollections	20,000
Might “hurt or lose control” with someone else	3,700
Suicidal thoughts/feeling better off dead	1,700
* 28% of returnees reported mental health problems in post-deployment surveys between January and August 2005.
Source: Army Center for Health Promotion and Preventive Medicine, reference 5.

Low estimates? In 1997, the U.S. military began universal medical screening of troops before and after military deployments.⁶ This important step allows the military to address baseline health needs of returning soldiers and measure effects from combat. There are no comparable sources of data from previous wars.

Unfortunately, this new information may underestimate the number of returnees with psychiatric problems and the severity of those problems. In an anonymous survey of returning Army and Marine soldiers, Hoge et al⁷ found that those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis (Table 2).

Table 2

Perceived barriers to seeking mental health services cited by U.S. soldiers after combat duty in Iraq and Afghanistan*

Perceived barrier	Met screening criteria for a mental disorder?
	Yes (N=731)	No (N=5,422)
I would be seen as weak	65%	31%
My unit leadership might treat me differently	63%	33%
Members of my unit might have less confidence in me	59%	31%
I would have difficulty getting time off work for treatment	55%	22%
My leaders would blame me for the problem	51%	20%
It would harm my career	50%	24%
It is difficult to schedule an appointment	45%	17%
It would be too embarrassing	41%	18%
I don’t trust mental health professionals	38%	17%
Mental health care costs too much money	25%	10%
Mental health care doesn’t work	25%	9%
I don’t know where to get help	22%	6%
I don’t have adequate transportation	18%	6%
* Anonymous survey. Those who met criteria for psychiatric diagnoses were less likely to seek assistance because of perceived stigma and concerns about their military careers than those without a psychiatric diagnosis.
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004;351:13-22.

Female personnel. Women are overrepresented by a factor of two among personnel evacuated primarily for psychiatric reasons from combat phases the military calls Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) (unpublished data, Dr. Rundell).⁸ Women comprise 10% of returning OIF and OEF veterans and 19% of psychiatric evacuees.

Gender per se may not be the most important variable; age, number of years in the military, type of military unit, and ethnic group are also risk factors for developing a war-related psychiatric disorder. Further studies of OIF- and OEF-related psychiatric disorders are needed to determine whether female veterans’ clinical needs differ in important ways from those of male veterans.

 

PTSD in combat veterans

Every war has seen new names and descriptions for combinations of psychological and somatic symptoms resulting from war experiences (Box).^9,11 Compared with persons with PTSD from other types of trauma, combat veterans appear to have the highest rate of delayed-onset PTSD and are less responsive to treatment.⁹

Initial PTSD rates for soldiers returning from Iraq ranged from 12.2% (Marines) to 12.9% (Army), using diagnostic criteria requiring functional impairment.⁷ These rates are 2.5 times the rate observed before combat (5%) and 3 to 4 times that of the general population (3.6%), using the same methodology.¹⁰

If 12.5% of 1 million combat-exposed service members develop PTSD, 125,000 service members may be affected. This rough estimate—7 times the number of personnel officially reported as “wounded”—does not take into account the wide variability of combat exposure among deployed troops or the effects of combat stress interventions (which might decrease the rate). Nor does it consider the impact of multiple rotations and possible decreased combat simulation training in reserve troops (which might increase the rate).

Box

Resiliency and PTSD. Resiliency among service members in combat is the norm, and most will not develop PTSD. Military efforts at increasing resilience and performance include intense training with realistic combat simulation and education. A selected sample of experienced elite soldiers has been shown to have lower cortisol levels in response to simulated combat stress than younger soldiers with less training.¹¹

To develop, PTSD requires synergy between a severe stressor and a neurobiologic response. Because of genetic endowment or experience, not all persons are susceptible to the high levels of stress and associated hypothalamus-pituitary-adrenal axis activation required for the disorder to occur. Specific individual differences in coping, trauma history, and biology may predispose some individuals to PTSD.¹¹

Mr. L’s story: Detached and irritable

As a combat infantryman, Mr. L was in seven fire fights, in which three of his buddies died. In responding to your questions, he admits feeling disconnected from his children and from his old friends who did not go to Iraq. He describes frequent arguments with his wife, though they had rarely argued previously. He denies psychiatric problems before his 12-month rotation in Iraq.

Being wounded in combat, surviving multiple life-threatening events, and experiencing combat of greater intensity and duration all increase the risk of developing PTSD. Mr. L’s multiple fire fights, loss of three friends, and other combat experiences place him at high risk for developing PTSD.

Typical combat experiences in Iraq and Afghanistan reported by Army and Marine troops are outlined in Table 3.⁷ Familiarizing yourself with these experiences can help you interview combat-exposed patients after you develop trust and rapport with them.

Table 3

Combat experiences reported by U.S. troops
after deployment in Iraq or Afghanistan

Experience	Army groups		Marine group
	Afghanistan	Iraq
Being attacked or ambushed	58%	89%	95%
Receiving incoming artillery, rocket or mortar fire	84%	86%	92%
Being shot at or receiving small-arms fire	66%	93%	97%
Shooting or directing fire at the enemy	27%	77%	87%
Being responsible for death of an enemy combatant	12%	48%	65%
Being responsible for death of a noncombatant	1%	14%	28%
Seeing dead bodies or human remains	39%	95%	94%
Seeing dead or seriously injured Americans	30%	65%	75%
Knowing someone seriously injured or killed	43%	86%	87%
Participating in demining operations	16%	38%	34%
Seeing ill or injured women or children whom you were unable to help	46%	69%	83%
Being wounded or injured	5%	14%	9%
Being shot or hit, but protective gear saved you	*	8%	10%
Having a buddy who was near you shot or hit	*	22%	26%
Clearing or searching homes or buildings	57%	80%	86%
Engaging in hand-to-hand combat	3%	22%	9%
Saved the life of a soldier or civilian	6%	21%	19%
* Question not included in this survey
Source: Adapted and reprinted with permission from Hoge CW, Castro CA, Messer SC, et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N Engl J Med 2004; 351:13-22.

 

Workup of combat veterans

Military psychiatrists provide support and treatment during and immediately after combat, but they do not associate acute reactions with specific psychiatric diagnoses to avoid “pathologizing” brief reactions to combat. To provide appropriate treatment for returning troops, however, you will need to characterize clinically significant psychopathology by using DSM IV-TR criteria for acute stress disorder and PTSD.¹²

We recommend that you manage a returning service member according to usual clinical practice. This includes a thorough history and appropriate medical and laboratory workup. Because soldiers commonly minimize their symptoms and concerns—particularly if they fear full disclosure could jeopardize their military careers—consider including collateral history from the patient’s family and friends in your assessment.

Differential diagnosis of mental disorders in combat troops is broad. You will need to obtain a thorough substance abuse history, with particular attention to use of alcohol to self-medicate symptoms. It will be important to assess safety issues, including potential for suicide, homicide, and domestic violence.

Many soldiers report difficulties with re-entering family life. Marital and sexual problems may develop because of role changes that occurred during a long separation. Pre-existing marital problems may be exacerbated, and both military members and spouses may express concerns about infidelity. Separation and divorce rates may be high.

Mr. L’s story: Alcohol ‘helps me sleep’

When you ask Mr. L about his use of alcohol, he notes that he was cited for driving while intoxicated at age 28. “I used to have a problem with drinking, but after my ticket I didn’t drink ‘til I came back from Iraq,” he says. “Now it’s the only thing that calms me down and helps me sleep.”

Comorbid diagnoses associated with PTSD are the rule. Mr. L’s drinking to self-medicate his PTSD symptoms puts him at risk of redeveloping alcohol problems. Use current best practices for managing depression, anxiety disorders, and substance abuse (if present) to guide treatment.

Suicidal behavior has also been strongly associated with PTSD.¹³ Thus, address Mr. L’s access to firearms, and include suicide assessment and regular followup in any treatment plan.

Head injuries in iraq

The use of effective body armor has dramatically changed the types of wounds and injuries sustained in combat. Kevlar body armor has decreased the frequency of mortal chest and abdominal wounds, leading to an unprecedented proportion of head and neck wounds, including eye injuries. In the war in Iraq and Afghanistan, 22% of evacuated casualties have injuries to the head, neck, and face.¹⁴

At the same time, rapid treatment of open and closed head injuries—often fatal in past wars—has improved survival. As a result, the prevalence of traumatic brain injury in veteran populations is believed to be substantially higher now than in previous conflicts.¹⁵

Mr. L’s story: ‘I forget everything’

Mr. L reports that after he served 8 months in Iraq, his vehicle was destroyed by a roadside bomb. He lost consciousness and was hospitalized briefly before returning to duty and completing his tour.

“I’m having trouble concentrating at work, and it seems like I forget everything,” he says. “My boss has complained about mistakes I make when planning our construction jobs. Could that explosion be causing my problems?”

Mr. L’s loss of consciousness associated with a blast injury and his cognitive complaints suggest possible mild traumatic brain injury. Consider neuropsychological testing and brain imaging studies, along with possible referral to appropriate rehabilitation programs if needed.

Treatment resources

The Iraq War Clinician Guide¹⁶ delineates military approaches to prevention, as well as acute intervention and initial treatment after evacuation from a war zone. This guide also:

• outlines rationales for removing affected service members from combat and eventually returning them to duty or medically retiring them if severe symptoms continue to interfere with ability to function.
  
• describes the biopsychosocial approach used by the Walter Reed Army Medical Center Psychiatric Consultation Service to address the multifactorial needs of the traumatized amputee.
  

Other resources. Detailed analyses of treatment options and their efficacy, along with algorithms for treatment, are available online (Related resources). Because practice guidelines might not apply to all situations, it will be important to develop patient-specific treatment plans.

Related resources

• National Center for PTSD: The War in Iraq. www.ncptsd.va.gov/topics/war.html
  Comprehensive Web site designated by Congress to provide information for military veterans with PTSD. Clinician’s guide available, plus fact sheets for family and patients.
  
• National Center for PTSD. Iraq War Clinician Guide (2nd ed). www.ncptsd.va.gov/war/iraq_clinician_guide_v2/iraq_clinician_guide_v2.pdf
  Detailed guide for treating the soldier in combat. Includes treatment options for PTSD and the veteran with amputation.
  
• U.S. Army Center for Health Promotion and Preventive Medicine. Supporting Guidelines. www.pdhealth.mil/clinicians/support.asp
  Collection of guidelines for PTSD, major depression, and medically unexplained symptoms following combat.
  
• Military One Source. www.militaryonesource.com
  Resource for active duty and reserve soldiers and family members. Portal for support services, policies, and education. Brief confidential counseling support for soldiers and family members.
  
• Veterans Administration (VA)/Department of Defense (DOD) Clinical Practice Guideline for Management of PTSD, January 2004. www.oqp.med.va.gov/cpg/PTSD/PTSD_Base.htm
  Includes list of clinical trials, medication dosing, and evidence basis for treatment with pharmacotherapy and psychotherapy.
  
• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder. http://www.psych.org/psych_pract/treatg/pg/PTSD-PG-PartsA-B-C-New.pdf
  Background and guidelines for managing PTSD, including treatment recommendations, evidence basis, background, and areas for future research.
  

 

Disclosure

Drs. Lineberry, Bostwick, and Rundell previously served on active duty in the U.S. Air Force for 12, 5, and 23 years, respectively.

In " Tips to manage and prevent discontinuation syndromes " ( Current Psychiatry , September 2005), Dr. Sriram Ramaswamy et al state, "no discontinuation symptoms have been reported with mirtazapine, bupropion, or duloxetine."

Discontinuation symptoms with mirtazapine and bupropion—though quite rare—have been described in case reports. 1 - 4 Also, a discontinuation syndrome was observed after duloxetine was abruptly stopped in placebo-controlled clinical trials; this is noted in the package insert.

James W. Jefferson, MDMadison Institute of Medicine, Inc.Clinical professor of psychiatryUniversity of Wisconsin Medical School, Madison

In " Tips to manage and prevent discontinuation syndromes " ( Current Psychiatry , September 2005), Dr. Sriram Ramaswamy et al state, "no discontinuation symptoms have been reported with mirtazapine, bupropion, or duloxetine."

Discontinuation symptoms with mirtazapine and bupropion—though quite rare—have been described in case reports. 1 - 4 Also, a discontinuation syndrome was observed after duloxetine was abruptly stopped in placebo-controlled clinical trials; this is noted in the package insert.

James W. Jefferson, MDMadison Institute of Medicine, Inc.Clinical professor of psychiatryUniversity of Wisconsin Medical School, Madison

In " Tips to manage and prevent discontinuation syndromes " ( Current Psychiatry , September 2005), Dr. Sriram Ramaswamy et al state, "no discontinuation symptoms have been reported with mirtazapine, bupropion, or duloxetine."

Discontinuation symptoms with mirtazapine and bupropion—though quite rare—have been described in case reports. 1 - 4 Also, a discontinuation syndrome was observed after duloxetine was abruptly stopped in placebo-controlled clinical trials; this is noted in the package insert.

James W. Jefferson, MDMadison Institute of Medicine, Inc.Clinical professor of psychiatryUniversity of Wisconsin Medical School, Madison