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Association of Varicella Zoster Virus (VZV) with a considerable variety of complications has been well documented throughout literature. Primary infection, most often seen in children, is generally characterized by mild symptoms, as opposed to the more severe presentations in adult and immunocompromised populations. Manifestations of disseminated VZV include dermatologic, pulmonary, neurologic, and ocular involvement. Vascular and hematologic complications are also reported and sometimes pose serious health threat. We present an interesting case of disseminated VZV infection, complicated by meningitis, encephalitis, and bilateral pulmonary embolism in an otherwise immunocompetent 52-year-old man with no prior chicken pox exposure.

Insomnia is defined as a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment. A comprehensive history and physical examination differentiate the subtypes of insomnia: acute, chronic, and associated with comorbid disorders. Evaluation of insomnia entails understanding the predisposing, precipitating, and perpetuating factors of insomnia unique to each person. Effective treatment is incomplete without implementing cognitive-behavioral therapy for behaviors nonconducive to sleep as monotherapy or in combination with pharmacotherapy. Setting realistic goals and expectations of quality and quantity of sleep required to feel rested determine treatment success and outcomes. This article reviews the prevalence, symptoms, subtypes, and diagnosis and management of insomnia, particularly in women with emotional and hormonal changes of symptomatic premenstrual syndrome, pregnancy, and menopause. [ Psychiatr Ann. 2019;49(12):518–523.]

Iron deficiency is a well-known cause of anemia. However, it is an under-recognized cause of venous thromboembolism (VTE). Iron deficiency predisposes to VTE mainly by inducing thrombocytosis, which can lead to a hypercoagulable state. Identifying iron deficiency as a possible cause of thromboembolic phenomena has clinical significance since this is a potentially avoidable risk factor. This case report serves as a reminder that iron deficiency is an important risk factor for VTE that should be considered in the evaluation of patients. This is particularly true in patients like ours who have recurrent venous thromboembolic disease.

COVID-19 infection causes considerable morbidity and mortality, especially to those who are aged, have impaired renal function and are obese. We propose to examine the potential utility of oral activated charcoal with the hypothesis that such treatment would lower absorption of microbiome derived toxins and ameliorate systemic oxidant stress and inflammation.

Sleep medicine is a multidisciplinary field with growth potential. Sleep and psychiatric disorders are comorbid. Many psychiatrists were at the forefront during the earlier years of the field and played significant roles during critical developments of the field. Today there is a shortage of psychiatrists trained in sleep medicine in the United States, with many psychiatry residents not knowing that subspecialty training in sleep medicine is an option. Psychiatrists trained in sleep medicine can bridge the gap between nonpsychiatric and mental health providers to increase awareness of the impact sleep disorders have on mental health and improve care of the patients. [ Psychiatr Ann . 2018;48(11):520–523.]

Breathing-related sleep disorders (BRSD) include obstructive sleep apnea (OSA), central sleep apnea, and sleep-related hypoventilation. The prevalence of BRSD increases with age and contributes to morbidity in the elderly. OSA, the most common BRSD, is characterized by an intermittent decrease in or cessation of airflow during sleep due to a collapsed airway. Clinical features of OSA include loud snoring, daytime sleepiness, choking spells, and documented episodes of hypopnea/apnea on polysomnography. OSA is a risk factor for cardiovascular disease, hypertension, atrial fibrillation, and cognitive problems. This review provides an overview of OSA in the elderly and its relationship with other medical disorders. [ Psychiatr Ann. 2018;48(6):287–291.]

Although often underdiagnosed, sleep disorders can significantly add to morbidity in neurodegenerative illnesses. Early detection and management can not only improve sleep, but also alleviate caregiver burden and assist with future prognosis. In this article, we discuss various sleep disturbances noted in neurodegenerative disorders in the aging population. Characteristics and changes in sleep architecture with normal aging are described. Various types of sleep disturbances including insomnia, hypersomnia, sleep-related movement disorders, and parasomnias associated with major neuropathological categories of synucleinopathies and tauopathies are discussed. [ Psychiatr Ann. 2018;48(6):296–302.]

Insomnia disorder in older adults is associated with dissatisfaction with quality or quantity of sleep and is also associated with difficulty falling asleep, maintaining sleep, or early morning awakening. It is frequently associated with an age-related decrease in restorative stage 3 of nonrapid eye movement sleep as well as advance phase shift leading to early morning awakening. Sleep disturbances in older adults, as in younger patients, have a bidirectional relationship with many medical and psychiatric disorders as well as polypharmacy. The health consequences of insomnia in the elderly may also include manifestation or magnification of cognitive deficits. Diagnosis of insomnia is based on history from the patient, the bed partner, self-administered questionnaire or sleep diary, comprehensive evaluation for comorbid medical/psychiatric disorders, and comprehensive medication history. Both nonpharmacological and pharmacological strategies are effective in the management of insomnia. Cognitive-behavioral therapy for insomnia (CBT-I) should be considered as an initial intervention for chronic insomnia. Pharmacological treatment with short-acting hypnotics is a valuable adjunct to CBT-I for acute insomnia for a brief period followed by a slow taper. Any treatment intervention should be in collaboration with the patient and/or family and include a discussion of the risks, benefits, and costs. [ Psychiatr Ann. 2018;48(6):279–286.]

The United States population continues to become more geographically, linguistically, and culturally diverse. Health care professionals, including psychiatrists, have to manage an increasing number of patients from a variety of cultural backgrounds. In addition to language barriers, cultural issues are becoming increasingly important in assessing and treating patients from different cultures including those suffering from trauma-related illnesses. With the persistence of domestic and international conflicts and terroristic incidents all over the world, posttraumatic stress disorder and trauma-related illness rates may continue to rise. Psychiatrists and mental health professionals need to be familiar with how the effects of trauma and trauma-related illness present across different cultures and how assessment and treatment will need to differ in these different populations. The American Psychiatric Association has responded to these challenges by including a section on “Cultural Formulation” in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition ( DSM-5 ). This article focuses on examining various aspects of the presentation of trauma-related illness in different cultures with specific emphasis on culturally sensitive assessment and treatment along the lines advised in DSM-5 . The article also includes guidelines for clinicians on how to incorporate culture-specific approaches and tools in their day-to-day practice to achieve optimal outcomes for patients and their families. [ Psychiatr Ann . 2017;47(3):128–133.]

Excessive daytime sleepiness (EDS) is one of the leading reasons that patients present to sleep clinics. Approximately 10% to 14% of the adults report that excessive sleepiness interferes with their daily lives. Common causes of EDS include obstructive sleep apnea, sleep deprivation, circadian rhythm disorders, medication effects, psychiatric conditions especially depression, and primary hypersomnia such as narcolepsy or central idiopathic hypersomnia. Vitamin B(12) deficiency is a rare cause of EDS. We are presenting a case of severe vitamin B(12) deficiency as an unusual and rare cause of hypersomnia. CITATION: Khawaja I, Yingling K, Bukamur H, Abusnina W. Vitamin B(12) deficiency: a rare cause of excessive daytime sleepiness. J Clin Sleep Med. 2019;15(9):1365–1367.

Chronic obstructive pulmonary disease or COPD is one of the conditions that physicians frequently see in both the hospital and outpatient setting. In order to improve diagnostic and treatment outcomes, the Global Strategy for the Diagnosis, Management and Prevention of COPD, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was created in 2001. Every year, a new report is generated based on an analysis of published studies which attempts to improve the way physicians handle COPD. GOLD reports are considered to be essential evidence-based reference tools for the implementation of effective management plans, and represent the current best practices for the care of patients with COPD. The 2017 report greatly revised the guidelines and added a few components that changed the system of COPD diagnosis and treatment. This review article addresses those changes, explains the current guidelines, and draws attention to areas that still require improvement.

Extracorporeal membrane oxygenation (ECMO) therapy has been around since the 1970s and has completely changed how critical care physicians view supportive therapy for certain patients. ECMO therapy is a supportive therapy provided by a mechanical extracorporeal circuit that is able to directly oxygenate and remove carbon dioxide from the blood. By performing this, ECMO can provide cardiac, respiratory, or combined cardiopulmonary supportive therapy in cases of failure. ECMO therapy also places less emphasis on invasive mechanical ventilation, which prevents barotrauma and gives rest to the lungs. Therefore, they are used for several different conditions. This review article focuses on the definition, principles, types, and practical applications of ECMO therapy.

Transthoracic echocardiography (TTE) is an incredibly valuable tool in today's emergency rooms and intensive care units (ICUs). It has the ability to provide a complete evaluation of the structure and function of the heart, the valves, stroke volume, ejection fraction, and much more. Previous academic studies have also determined that point-of-care TTE done by non-cardiologist physicians can also provide higher accuracy in patient assessment and management, with potential prognostic impact by assessing the severity of cardiac dysfunction and response to treatment. The aim of this review article is to examine further these point-of-care evaluations, what they entail, their benefits, and where further research would better our own understanding.

The use of a central line or central venous catheterization was brought to attention in 1929 when Dr. Werner Forssmann self-inserted a ureteric catheter through his cubital vein and into the right side of his heart. Since that time the central line technique has developed further and has become essential for the treatment of decompensating patients. Central lines are widely used for anything from rapid fluid resuscitation, to drug administration, to parenteral nutrition, and even for administering hemodialysis. Central lines come in different sizes, types, and sites of administration. Sometimes their use can be associated with complications as well. The following review article addresses these parameters of central lines and goes into detail regarding their complications.

Obstructive sleep apnea (OSA) is caused by intermittent episodes of partial or complete closure of the upper airway, leading to apneic episodes while the patient is asleep. Atrial fibrillation (AF) leads to more than 750,000 hospitalizations per year and accounts for an estimated 130,000 deaths each year. The death rate from AF as the primary or a contributing cause of death has been rising for more than two decades. The material reviewed in this paper focuses on the association between OSA and arrhythmias. It goes into the details of the epidemiology, pathophysiology, and types of arrhythmias and the therapies seen in association with OSA.

Lung ultrasonography has a tailored diagnostic and therapeutic approach in the critical care setting. Lung ultrasonography in critically ill (LUCI) is a helpful modality for the early detection and assessment of various lung pathologies and guides the management protocol for the same. The aim of this review was to highlight the basics of an ultrasound machine, the fundamentals of a lung ultrasound and the importance of lung artifacts in detecting the anatomy and pathology of the lung disease. In addition, we have also discussed regarding the effective approach to lung ultrasonography through the two protocols: the Bedside Lung Ultrasound in Emergency (BLUE) protocol and the Fluid Administration Limited by Lung Sonography (FALLS) protocol.

Post-traumatic stress disorder (PTSD) and nightmares are major psychiatric problems among veterans with combat experience. Veterans who have obstructive sleep apnea (OSA) have increased nightmares while sleeping on their back. Treatment of sleep apnea with a continuous positive airway pressure (CPAP) device lessens the arousals from sleep, and patients do not remember their nightmares as they sleep through their dreams. The case report describes a veteran who had severe nightmares especially when sleeping on his back. He was diagnosed with sleep apnea and treated with auto CPAP. During the follow-up visit, the patient reported a dramatic improvement in his PTSD symptoms, nightmares frequency, and intensity. He also reported feeling better, less sleepy, and more energetic during the day. Besides, he reported experiencing no nightmares when using CPAP and improvement in his quality of sleep. He also reported an improvement in daytime functioning and quality of life.

Narcolepsy is a chronic neurological disease with five domains of symptoms including excessive daytime sleepiness (EDS), cataplexy, hypnagogic/hypnopompic hallucinations, sleep paralysis, and sleep fragmentation. Several overlapping symptoms of schizophrenia and narcolepsy often make it challenging to differentiate between the two conditions. A 23-year-old African American female was diagnosed with schizophrenia based on a two-year history of auditory and visual hallucinations. The patient was referred to a sleep physician for excessive daytime sleepiness. She has been sleepy since her teenage years taking 1–2 naps daily (Epworth sleepiness scale (ESS) was 14). She also complained of occasional sudden loss of muscle tone, which was triggered by strong emotions. In addition, she had episodes of inability to move her body in the morning, feeling as if someone was sitting on her chest. A full “hypersomnia workup” was scheduled including a nocturnal polysomnography (PSG) followed by a multiple sleep latency test (MSLT). The MSLT was positive for narcolepsy with cataplexy, or type 1 narcolepsy. She was prescribed modafinil 200 mg daily for EDS and venlafaxine 75 mg was added for cataplexy. In two weeks her ESS improved from 14 to 8. This case illustrates the potential of narcolepsy being misdiagnosed as schizophrenia in patients who have excessive daytime sleepiness and symptoms mimicing psychosis.

Schizophrenia is a chronic, disabling condition that significantly impacts social and occupational functioning. Sleep problems are common to the illness, but are often overlooked. Patients with schizophrenia often have a combination of subjective sleep complaints and objective findings on polysomnographic testing. As a group, people with schizophrenia have a higher prevalence of common sleep disorders. This article reviews sleep abnormalities and disorders in schizophrenia and provides an overview of treatment options. [ Psychiatr Ann . 2016;46(3):192–196.]

Sleep disturbances are common in adults with posttraumatic stress disorder (PTSD) and range from insomnia and nightmares to periodic leg movements and disruptive nocturnal behaviors. Together, these findings suggest profound disturbances in rapid eye movement (REM) and non-REM sleep, although there is a lack of consensus regarding a distinct profile of objective sleep disturbances associated with PTSD. Prospective longitudinal studies have established that sleep disturbances represent a risk factor for the development and course of PTSD, suggesting that sleep is an important neurobiologic mechanism in the etiology and maintenance of this disorder. This research highlights the importance of early identification and treatment of sleep disturbances in at-risk and trauma-exposed populations. A number of psychologic and pharmacologic treatments are effective at treating sleep disturbances in PTSD. Additional research is needed to further develop clinical guidelines informing when and how to integrate sleep-specific treatment with PTSD-focused clinical care. [ Psychiatr Ann . 2016;46(3):173–176.]

Obstructive sleep apnea (OSA) is a common sleep disorder associated with several medical conditions, increased rates of motor vehicle accidents, and higher overall health care expenditure. There is a higher prevalence of depression in people with sleep-disordered breathing in clinical and community samples. Depression and OSA share many symptoms, which may explain the underdiagnosis of OSA in depressed patients. OSA may be responsible for treatment resistance in depression. The relationship between depression and OSA is complex and remains unclear; however, several pathophysiologic mechanisms could be involved. Increased understanding of the relationship between these two disorders will likely improve clinical outcomes. [ Psychiatr Ann . 2016;46(3):187–191.]

Autism spectrum disorder (ASD) is characterized by early-onset socialization and communication difficulties associated with restricted interests and behavioral rigidities. Recent epidemiologic studies show that 1 in 68 children has autism. This complex condition is among the least-understood developmental disorders of childhood but there is a growing body of research on ASD, making it critically important that clinicians are well informed about these conditions. Recent changes in the Diagnostic and Statistical Manual of Mental Disorders , fifth edition, regarding ASD criteria can affect how the diagnosis is made. Various comorbidities can have a huge impact on assessment and management. There are various behavioral and pharmacologic strategies focusing on cluster symptoms of hyperactivity/inattention, irritability, aggression, self-injurious behaviors, and ritualistic behaviors. In the past few years, the US Food and Drug Administration has approved psychotropic medications for treating irritability associated with autism. Speech and language assessment and interventions, parent education, and appropriate educational programs are integral parts of management. [ Psychiatr Ann . 2016;46(1):58–62.]

Sleep problems are common among children and adolescents, with up to 50% of children experiencing sleep difficulties and as many as 4% receiving a formal sleep disorder diagnosis. Early identification of sleep problems may prevent negative consequences, such as daytime sleepiness, misdiagnosis, learning difficulties, or poor academic performance. This article provides an overview of common sleep disorders in children and adolescents, including common presenting symptoms, diagnosis, and treatment. [ Psychiatr Ann . 2016;46(1):39–44.]

Parasomnias are a group of sleep disorders characterized by abnormal, unpleasant motor verbal or behavioral events that occur during sleep or wake to sleep transitions. Parasomnias can occur during non-rapid eye movement (NREM) and rapid eye movement (REM) stages of sleep and are more commonly seen in children than the adult population. Parasomnias can be distressful for the patient and their bed partners and most of the time, these complaints are brought up by their bed partners because of the possible disruption in their quality of sleep. As clinicians, it is crucial to understand the characteristics of various parasomnias and address them with detailed sleep history and essential diagnostic approach for proper evaluation. The review aims to highlight the epidemiology, pathophysiology and clinical features of various types of parasomnias along with the appropriate diagnostic and pharmacological approach.

The overlap syndrome (OS) was first coined by David C. Flenley in 1985 to describe the coexistence of obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD). Patients with OS experience more profound nocturnal oxygen desaturation (NOD) than patients with OSA or COPD alone. This underlying hypoxia in OS increases the risk of cardiovascular disease including atrial fibrillation, right heart failure, and pulmonary hypertension, thereby increasing the mortality associated with the disease. Keeping in mind the risk of mortality, it is crucial for clinicians to clinically evaluate the patients with OSA or COPD for the occurrence of OS and provide effective treatment options for the same. This review aims to highlight the pathophysiology and the risks associated with the OS along with early detection and appropriate management protocols to reduce the mortality associated with it.

Objective To examine the correlations between obstructive sleep apnea (OSA) and psychiatric disorders such as major depressive disorder (MDD), posttraumatic stress disorder (PTSD), or bipolar disorder (BD) and whether comorbid psychiatric diagnosis increases the risk of OSA. Methods This retrospective chart review study included all patients (N = 413) seen within a randomly selected 4-month period (August 2014 to November 2014) in a Veterans Administration outpatient psychiatry clinic. Patients were screened for symptoms of OSA with the STOP-BANG Questionnaire. Those with a positive screen were referred to the sleep clinic for confirmation of the diagnosis by polysomnogram (PSG). Frequency of PSG-confirmed OSA was correlated with different psychiatric disorders and comorbid psychiatric diagnoses. Results The study showed a high prevalence of OSA in psychiatric patients, particularly with MDD (37.8%) and PTSD (35.5%) and less so with BD (16.7%). Among all patients with OSA (n = 155), those with comorbid BD and PTSD had a significantly higher rate of OSA than those with BD alone (χ² = 7.28, P < .05) but not with PTSD alone. We also found a statistically significant higher incidence of OSA in male veterans with either MDD comorbid with PTSD (χ² = 3.869, P < .05) or BD comorbid with PTSD (χ² = 6.631, P < .05) compared with either mood disorder or PTSD alone. Conclusions The study showed a high prevalence of OSA in psychiatric patients, particularly in those with PTSD and MDD and less so with BD. There was a statistically significant increase in the incidence of OSA in male veterans with either BD with comorbid PTSD or MDD with comorbid PTSD.​​.

Most psychotropics are currently given a US Food and Drug Adminstration (FDA) drug rating of category C, meaning there is evidence of potential risk to a fetus. Some psychotropics, however, have a higher degree of risk to the fetus than others, and this article discusses the use of those psychotropics for which caution is warranted based on currently available evidence and clinical opinion. The psychotropics that will be highlighted here include paroxetine, monoamine oxidase inhibitors, lithium, valproate, carbamazepine, and benzodiazepines. We suggest caution with regards to their routine use or as a first-line treatment in pregnancy. Five benzodiazepines are category X according to the FDA and are therefore contraindicated in pregnancy. For all these medications it is important not to overlook the benefits of psychiatric stability from continued treatment and the harms of discontinuation, which include increased risk of relapse of the illness. [ Psychiatr Ann. 2015;45(2):71–76.]

Parasomnias comprise a category of sleep disorders that includes behavioral and emotional disturbances occurring during any stage of sleep or during states of mixed sleep and wakefulness. These disorders can range from having vocalizations and minor movements to very complex and aggressive behaviors that result in serious injury and disruption of sleep for the patients and the bed partners. Parasomnias need careful clinical history-taking often followed by a sleep lab study to rule out other sleep disorders. Parasomnias can frequently be mistaken as nocturnal manifestations of psychiatric disorders, which makes it very important for psychiatrists to have a proper understanding of these sleep disorders. [ Psychiatr Ann . 2015;45(1):30–34.]

Obstructive sleep apnea (OSA) is a common breathing disorder during sleep that has many implications beyond disrupted sleep. The Diagnostic and Statistical Manual of Mental Disorders , fifth edition recognizes three sleep-related breathing disorders—OSA, central sleep apnea, and sleep-related hypoventilation. OSA has many overlapping symptoms with depression, and is increasingly recognized as an independent risk factor for hypertension and cardiovascular disease. It is crucial for mental health providers to remain vigilant in recognizing patients with signs and symptoms consistent with OSA. This review focuses on updates in terminology and testing, complications of untreated OSA, and its relationship with mental disorders. [ Psychiatr Ann . 2015;45(1):19–24.]

A case is reported of recurrent, injurious self-biting during sleep, requiring surgical interventions, in a 55-year-old obese man with a 20-year history of violent complex parasomnia, with greatly increased frequency and severity of episodes induced by work stress during the preceding 3 years. After clinical evaluation and overnight, hospital-based video-polysomnography, the cause of the chronic injurious parasomnia was deemed to be a non-rapid eye movement (NREM) sleep parasomnia comorbid with severe obstructive sleep apnea. Therapy with bedtime clonazepam and bilevel positive airway pressure was effective, with injurious parasomnia relapse occurring with cessation of either or both of these therapies. The differential diagnosis of sleep-related biting should now include NREM sleep parasomnia (with or without comorbid obstructive sleep apnea), besides previously reported cases of REM sleep behavior disorder (RBD), sleep-related dissociative disorder, sleep-related rhythmic movement disorder and anticipated cases of parasomnia overlap disorder (RBD + NREM sleep parasomnia), sleep-related biting seizures, and sleep-related eating disorder. CITATION: Danish N, Khawaja IS, Schenck CH. Violent parasomnia with recurrent biting and surgical interventions: case report and differential diagnosis. J Clin Sleep Med. 2018;14(5):889–891.

Objective: To develop a standardized validated version of the Hamilton Rating Scale for Depression (HAM-D) in Urdu. Methods: After translation of the HAM-D into the Urdu language following standard guidelines, the final Urdu version (HAM-D-U) was administered to 160 depressed outpatients. Inter-item correlation was assessed by calculating Cronbach alpha. Correlation between HAM-D-U scores at baseline and after a 2-week interval was evaluated for test-retest reliability. Moreover, scores of two clinicians on HAM-D-U were compared for inter-rater reliability. For establishing concurrent validity, scores of HAM-D-U and BDI-U were compared by using Spearman correlation coefficient. The study was conducted at Mayo Hospital, Lahore, from May to December 2014. Results: The Cronbach alpha for HAM-D-U was 0.71. Composite scores for HAM-D-U at baseline and after a 2-week interval were also highly correlated with each other (Spearman correlation coefficient 0.83, p-value < 0.01) indicating good test-retest reliability. Composite scores for HAM-D-U and BDI-U were positively correlated with each other (Spearman correlation coefficient 0.85, p < 0.01) indicating good concurrent validity. Scores of two clinicians for HAM-D-U were also positively correlated (Spearman correlation coefficient 0.82, p-value < 0.01) indicated good inter-rater reliability. Conclusion: The HAM-D-U is a valid and reliable instrument for the assessment of Depression. It shows good inter-rater and test-retest reliability. The HAM-D-U can be a tool either for clinical management or research.

Sleep disturbances and psychiatric illness often coexist. Chronic sleep loss and sleep disorders impose an immense public health burden since up to 50–70 million Americans suffer from a chronic disorder of sleep and wakefulness, hindering daily functioning and adversely affecting health. Insomnia is the most common sleep disorder, followed by sleep apnea and restless legs syndrome (RLS). Obstructive sleep apnea (OSA) is by far the most common form of sleep-disordered breathing. OSA causes excessive daytime sleepiness, mood problems, poor neurocognitive performance and potentially serious organ system dysfunction including a variety of adverse cardiovascular and metabolic effects. OSA is often comorbid with severe mental illness including major depression and anxiety disorders. These illnesses share some common neurotransmitter pathways and often need to be treated concurrently for optimal relief.

Obstructive sleep apnea syndrome (OSAS) is characterized by repeated cessations of breathing during sleep. Most patients suffering from OSAS are treated with continuous positive airway pressure (CPAP) as the first line of therapy. Overall, noncompliance to CPAP can range from 29-83%. In this study of 135 patients, we aimed to evaluate the role of sleep clinics in factors improving adherence to CPAP. Initially, patients had a compliance of 72.6%, but after one year or more overall compliance was 85.9%. Remarkably, the most significant difference was seen in the Medicaid population, whose compliance increased by 26.6%. Considering the well-established benefits of CPAP in patients with OSAS, we determined that a close follow up in a dedicated sleep clinic improves overall compliance especially in the Medicaid population. CPAP mask change was the most successful intervention that improved compliance.

Pharmacologic interventions are often prescribed for insomnia disorder.To assess the benefits, harms, and comparative effectiveness of pharmacologic treatments for adults with insomnia disorder.Several electronic databases (2004-September 2015), reference lists, and U.S. Food and Drug Administration (FDA) documents.35 randomized, controlled trials of at least 4 weeks' duration that evaluated pharmacotherapies available in the United States and that reported global or sleep outcomes; 11 long-term observational studies that reported harm information; FDA review data for nonbenzodiazepine hypnotics and orexin receptor antagonists; and product labels for all agents.Data extraction by single investigator confirmed by a second reviewer; dual-investigator assessment of risk of bias; consensus determination of strength of evidence.Eszopiclone, zolpidem, and suvorexant improved short-term global and sleep outcomes compared with placebo, although absolute effect sizes were small (low- to moderate-strength evidence). Evidence for benzodiazepine hypnotics, melatonin agonists, and antidepressants, and for most pharmacologic interventions in older adults, was insufficient or low strength. Evidence was also insufficient to compare efficacy within or across pharmacotherapy classes or versus behavioral therapy. Harms evidence reported in trials was judged insufficient or low strength; observational studies suggested that use of hypnotics for insomnia was associated with increased risk for dementia, fractures, and major injury. The FDA documents reported that most pharmacotherapies had risks for cognitive and behavioral changes, including driving impairment, and other adverse effects, and they advised dose reduction in women and in older adults.Most trials were small and short term and enrolled individuals meeting stringent criteria. Minimum important differences in outcomes were often not established or reported. Data were scant for many treatments.Eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known. Pharmacotherapies for insomnia may cause cognitive and behavioral changes and may be associated with infrequent but serious harms.Agency for Healthcare Research and Quality. (CRD42014009908).

Sleep-related abnormal sexual behaviors (sexsomnia) are classified as a subtype of non-rapid eye movement sleep parasomnias. There are reported cases of control of sexsomnia with treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure. We present a case of sexsomnia controlled with the treatment of OSA with a mandibular advancement device.

Study Objectives: American Academy of Sleep Medicine (AASM) practice parameters indicate that split-night polysomnograms (SN-PSG) may be performed when the apnea hypopnea index (AHI) is ≥ 20 to 40, depending on clinical factors. The aim of this study was to determine the diagnostic accuracy of SN-PSG, including at the lower range of AHIs.

To the Editor: Sleep disturbances commonly co-occur with mental disorders and often are sufficiently severe to warrant targeted treatment.1 Left untreated, sleep disturbances may exacerbate comorbid conditions and complicate recovery.2 Moreover, sleep disturbances are considered modifiable risk factors for onset and relapse of mental disorders.3 Numerous prospective longitudinal studies have demonstrated that the specific sleep disturbance of insomnia is a risk factor for psychiatric disorders and suicidal ideation or behavior.4–6 Very little work has been done to examine sleep disturbance as a risk factor for relapse within the context of acute psychiatric treatment within a partial hospital setting. The purpose of this retrospective chart review study was to examine the long-term follow-up over 18 months after discharge from a partial hospitalization program to determine if poor sleep quality at discharge predicts early readmission into the program. In our previous work,7 it was demonstrated that sleep improved for patients who completed this program. In this follow-up study, we examined whether patients with higher scores on the Pittsburgh Sleep Quality Index (PSQI)8 at discharge (indicating worse sleep quality) were at increased risk for rehospitalization, controlling for covariates related to mental health status. Method. The PSQI was completed by 183 patients at the time of entry into a psychiatry partial hospitalization program (typically lasting 1 month) and again at discharge. The PSQI is a self-report scale for measuring sleep quality and has shown evidence of good reliability and validity.8 A retrospective chart review was conducted to examine predictors of readmission over an 18-month follow-up period. The institutional review board of the Minneapolis VA Health Care System (Minneapolis, Minnesota) approved this study. Data were collected between November 2007 and March 2009. Results. The mean age of the patients was 48.2 years. Most participants were male (91.2%, n = 165), 152 (84.0%) were white, 56 (30.9%) were married, and 34 (18.8%) were currently employed. The mean number of mental health diagnoses (DSM-IV criteria) was 2.15. Poor sleep quality defined by a PSQI score ≥ 6 was significantly associated with readmission (P = .02), with 13.2% of patients with poor sleep quality readmitted compared to 0% with good sleep quality. As shown in Table 1, PSQI scores significantly predicted readmission over 18 months after controlling for covariates associated with mental health status, including total number of mental health diagnoses, employment status, marital status, age, and ethnicity (odds ratio = 2.10; 95% CI, 1.16–3.69). For every increase in 1 standard deviation on the PSQI, patients were twice as likely to be readmitted. Neither change in continuous PSQI scores nor change in categories based on clinical cutoffs over the course of treatment predicted readmission. Table 1. Step-Wise Multiple Logistic Regression Predicting Readmission to Psychiatry Partial Hospitalization Program 18 Months After Discharge Overall, we found that poor sleep quality at discharge is predictive of readmission to a partial hospitalization program, suggesting the need for a higher level of sleep-focused care during and following psychiatric admission. Our earlier work7 suggests that sleep disturbances did improve over the course of treatment, but change in sleep was not predictive of readmission. This study highlights the need to identify and treat patients who have poor sleep quality following intensive mental health treatment to support remission and recovery. There are several limitations to this study. First, covariates were determined from records and therefore are most likely less accurate than information obtained from diagnostic interviews. The data were also limited to dichotomous diagnoses; although this is not expected to introduce systematic bias regarding the direction and significance of the findings, it did prevent a more fine-grained analysis of continuous mental health symptom covariates for which sleep quality may be a proxy. Despite these limitations, this study is one of the first to evaluate the outcome following partial hospital treatment in those with poor sleep quality at discharge. This study highlights the importance of assessing poor sleep quality prior to discharge and incorporating behavioral or pharmacologic treatments for sleep disturbances into treatment planning.

To the Editor: We describe a case of compulsive gambling associated with the use of modafinil in a patient with idiopathic hypersomnia. Modafinil is a wakefulness-promoting agent that is approved by the US Food and Drug Administration for hypersomnolence associated with narcolepsy, obstructive sleep apnea, shift work sleep disorder, and fatigue associated with multiple sclerosis.1 Modafinil prescribing information reports psychiatric adverse experiences including mania, delusions, hallucinations, suicidal ideation, and depression.1 Tarrant and colleagues2 have described a case of a patient with minor gambling, who reported a 10-fold increase in his slot-machine use after taking modafinil. However, new-onset impairment of impulse control has been more commonly described in patients receiving dopamine agonist therapy for restless legs syndrome and Parkinson’s disease.3 Case report. A 46-year-old white woman with history of idiopathic hypersomnia diagnosed in 2005 at another sleep center presented to our sleep clinic as a transfer of care in 2010. She had history of excessive daytime sleepiness dating back to early school years. She had also experienced hypnogogic hallucinations and occasional sleep paralysis. There was no clear history of cataplexy. In 2005, her primary complaint included excessive sleepiness and snoring. She underwent diagnostic polysomnography (PSG) and a multiple sleep latency test (MSLT with 4 naps). Review of these records indicated an unremarkable PSG. Results from a MSLT performed after 8 hours of PSG-documented sleep showed a sleep latency of 4 minutes 45 seconds with no sleep-onset rapid-eye-movement periods. She was diagnosed with narcolepsy without cataplexy (based on International Classification of Sleep Disorders, second edition4), and modafinil was started at a dose of 200 mg in the morning and a 100-mg additional dose if needed for residual daytime sleepiness. She had a good response to the medication and no longer required daily naps. The patient’s hypersomnolence symptom remained stable on a dose of 200 mg of modafinil for a year when she developed impulsive gambling. She was not taking any other medications at that time. She tried to curtail her gambling, but could not, and would go to casinos and lose significant amounts of money until she was seen in our sleep center in 2010. She described losing up to $1,000 each time and reported losing $20,000 in the past 5 years prior to the visit to our clinic. She has tried behavior modifications such as talking to her husband when there was an urge to gamble, but had little success. In the year 2010, she was switched from modafinil to methylphenidate, which helped resolve gambling severity within a month. She was never restarted on modafinil after this as she did not want to risk having another episode of gambling again. On a follow-up visit the next year, she reported improvement in the compulsive gambling. She still had urges, but was able to exercise control over the impulses. In regard to her hypersomnolence symptoms, however, she had better results with modafinil. A more divided dose of methylphenidate was recommended during the visit. The patient has continued to take methylphenidate since 2010 and has had no reported side effects. She was taking a sustained dose of methylphenidate with good response. Impulse-control disorders (ICD) are characterized by excessive rumination and/or unwanted behaviors that lead to dysfunction or interference with work or social functioning.5 In a group of patients treated with dopaminergic agents, up to 17% of patients developed ICDs, of which 5% was pathological gambling. Mean time to onset of symptoms was 9.5 months.6 Modafinil is a non-amphetamine stimulant medication, and the exact mechanism of action is unknown.7 The wakefulness-promoting action useful in narcolepsy treatment could be due to activation of orexin neurons in the hypothalamus.6 In addition, modafinil has been shown to inhibit dopamine transporter and increase cortical and caudate dopamine concentrations.8 The effects of modafinil on impulse control are poorly studied. Zack and Poulos9 found that modafinil can have bidirectional effects on pathological gambling patients, ie, it can increase desire to gamble, disinhibition, and risky decision-making in low-impulsivity subjects, while decreasing these indexes in high-impulsivity subjects. In our patient, a previous history of gambling was not associated with disruption in her life. Moreover, there was no previous psychiatric comorbidity. She did not describe episodic hypersomnia, suggestive of Kleine-Levin syndrome, which commonly is associated with behavioral disturbances. However, the patient developed a new-onset pathological gambling and an inability to stop despite financial and social repercussions. Symptoms began after the use of modafinil, with significant improvement in gambling preoccupation and urges once the medication was stopped. While the majority of patients who develop ICDs while using dopaminergic agents for Parkinson’s disorder will have remission of symptoms, ICDs, particularly pathological gambling, can persist.10