insomnia Archives - Primary Care Psychiatry Foundation

Managing the Stigma of Mental Illness in the Office

Stigma is an attribute, behavior or reputation which is socially discrediting in a particular way. It is a potent, insidious, and negative force which grows like a weed. It strangles the forward movement of psychiatric treatment unless identified, “outted”, extracted by the roots on a daily basis. Those of us working in primary care and psychiatry need to become the “weed-eaters” of stigma.

The power of stigma surrounds us. The 50-year-old businessman with depression who admits to taking 20 years to come for treatment. The ADHD child whose parents simultaneously point the finger at one another when asked about family psychiatric history. The psychiatrist who recalls a “complement” by an esteemed professor in training: “Why are you wasting your talents in the halls of Freud?” The psychiatrist who’s internist friend states: “We know you guys that go into psychiatry are a little crazy yourselves”. Many patients are willing to endure considerable psychic pain to avoid treatment. A high achieving high-school graduate (GPA above 4.0) about to enter university with severe anxiety heaped on more difficult to identify, ADHD-inattentive subtype has compensated for her short attention span, distractibility, and procrastination by being driven by fear. Why has she avoided treatment? “Because if I need treatment I am flawed. Because if I need treatment I am weak. Because my family taught me that these are secrets not to be shared.”

Patients are often ambivalent about treatment. They start treatment, feel better, stop treatment, feel worse, and then wonder why treatment is ineffective. Ambivalent patients and families usually assume they will be the recipient of the “dreaded” prescription. Prescription pad aside! Giving voice to the patient’s ambivalence demands that the patient commit himself to, or against, treatment. “Why not continue as you are? What is so bad about the life you are leading now? You won’t have to explain treatment to others, or keep it a secret. Yet you want to decrease your pain and improve your functioning! Saying “no” to treatment gives you a better chance of saying “yes” when the time is right!” Supporting a patient’s ambivalence often makes it easier for the patient to move forward with treatment. Minimize pharmacologic expectations and maximize patient ownership of the treatment process. Patients worry they will “become a zombie, become dependent on the medicine, not do the work myself, be weaker. If medicine is like a shovel, it does not dig the hole itself…you have to do the digging. If you have severe social anxiety and do not expose yourself to anxiety-provoking situations, medicine alone will not do the job for you.”

A 9-year-old boy diagnosed with ADHD refused to take his stimulant medication “because I did not want it to make me do my homework”. Medicine, he thought, would force him to grip the pencil against his will and complete all of his homework which he desperately did not want to do. Medication refusal often comes up in families where stigma remains the elephant in the room. A child may be asked to take a medication that a parent would not be willing to take. A parent may not show himself in the office because he does not “believe in mental health treatment”. It is often what is unsaid and unseen that is most powerful. Empathizing with the child helps parents see the child’s impossible bind. By identifying stigma in the office, we help patients confront one of the largest obstacles to successful treatment and empower them to work towards physical and mental health.

(Joshua Lowinsky, MD Adolescent and Adult Psychiatrist is a partner at Children’s Resource Group in Indianapolis, a consultant to the Indianapolis Public Schools, and Co-founder of the Primary Care Psychiatry Foundation)

Hypnotics or not?

Insomnia is very common – nearly everyone has it sometimes. Persistent insomnia, defined as a minimum of 1 month, is present in ~15% of the population and estimated at ~25% of patients in primary care practices; with many of these patients the duration has been years.

Despite that incidence and duration, the symptom may not be brought up during an office visit. A previous National Sleep Foundation survey found that with patients having persistent insomnia and coming in for an office visit, the insomnia is never mentioned by 2/3 of these patients.

Since insomnia has been shown to be associated with (and believed to be a cause of) insulin resistance, weight gain, hypertension and others, as well as the overall misery associated with it, there is a missed opportunity to improve the patient’s overall health.

When the symptom of insomnia is discussed, it can begin consuming a lot of time and/or may be addressed with hypnotics only, when just a few more elements in the history might be able to support a more specific treatment, including evidence-based nonpharmacological treatments.

If we could develop an organized and flexible system to sort out the causes of persistent insomnia, we could perhaps better help the patient’s sleep and general health, without steep time demands on the primary care physician.

In this entry, we will introduce an algorithm created to achieve these goals (credit also goes to Espie and others).

Central to the algorithm is the concept of the right action, at the right time and right place, by the right person. By this we mean that not everything has to be done by the physician; the medical assistant could coordinate the algorithm, even computer/EMR based if possible, with your involvement for more focused assessments and decisions as may be needed.

Such a system could also work well in a population-based health care system.

After initial determination of duration of insomnia and time allotted for sleep, the next major decision points may be determined through brief questionnaires. These can apply to Restless Legs, depression, sleepiness, apnea and others, the results of which can then direct the course to behavioral treatment, focused medical assessment, possible sleep study, or possible referral to a sleep specialist as needed or desired. Also, since insomnia is often multifactorial, the algorithm will assess progress with an identified issue, and direct to other contributors as may be needed.

In particular, initial screening also addresses the psychophysiological arousal insomnia elements, including:

increasing concern/anxiety/arousal as the patient considers sleep or gets near bedtime
being more awake after going to bed
laying awake in bed “trying” to sleep, whether reading, watching TV or other.

There is much value in screening for these behavioral elements early, and this can be done with or without an entire algorithm, and there is value in addressing the behavioral elements early, whether or not accompanied by additional pharmacological treatment.

First level behavioral interventions can include getting back up to avoid the ongoing negative conditioning of laying awake in bed, and intentionally shrinking the time allotted for sleep, initially to more closely match the actual sleep being obtained.

Sorting out the presence of behavioral contributions to persistent insomnia can enable a more personalized and complete treatment pathway. Note that several studies now show that non-pharmacological treatments for persistent insomnia can be as effective as medication treatments, or even more so.

We hope the above concepts may prove useful for you and your patients with insomnia, and are interested to hear your thoughts and experiences.

Kenneth N. Wiesert, M.D. is a Sleep Disorders Medicine specialist at the Indiana Sleep Center and the Community Westview Hospital Sleep Center. Sleep specialists work to understand and help those who can’t sleep when desired, fall asleep when not desired, have behavioral activations during sleep, and others. The following entry is intended to increase awareness of the differential diagnosis of insomnia and treatments for it.

Hypnotics or not?

Questions?

CONTACT PCPF