Did you ever notice how often the media uses the term “senseless” to describe an unanticipated tragedy, especially one committed by a fellow human being? It is as if we have to use the defense mechanism of denial to handle the horror of what we are capable of. It happened once again after the local Waukesha Christmas Parade, where 6 people were killed, including Dancing Grannies, and dozens injured as the perpetrator ran his SUV through the crowd on Sunday, November 21st. In an otherwise inspiring follow-up article in the 

 on November 24th, “‘The love is so overwhelming:’ People at Waukesha Parade responded quickly, and continue to offer help and support,” the author described it as “senseless violence.”

To call such a tragedy senseless is to go against all of psychiatry’s expertise. Our field has always tried to explain why and how something like this can occur. How else can we prevent it, treat the perpetrator, and soothe the victims as much as possible without some understanding of how it happened? Indeed, much is already coming out about the perpetrator and circumstances that may provide some sense, including that the perpetrator had apparently suffered from mental health issues, for which he was supposed to be taking medication. We do know that those with mental illness only become more at risk for perpetrating violence if they are not in helpful treatment.

We in psychiatry owe it to the public to advocate for trying to make sense of such tragedies. The explanation can be tentative and reveal itself slowly, and in rare situations be inconclusive with our current state of knowledge, but there are bio-psycho-social-spiritual considerations to explore. The only senselessness would be to quickly and readily conclude that there is no sense.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He is an advocate for mental health issues relate to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Hendrickson S. ‘The love is so overwhelming:’ People at Waukesha Parade responded quickly, and continue to offer help and support. 

. November 24, 2021. Accessed November 30, 2021. 

https://www.jsonline.com/story/communities/2021/11/24/waukesha-strong-help-arrived-moment-and-subsequent-days/8733928002/

Articles

“Senseless” is not the proper term to describe tragedies or violence.   

Tragedies Should Not Be Deemed Senseless

Aducanumab’s recent approval by the US Food and Drug Administration (FDA) for Alzheimer disease has been controversial. In response, the American Academy of Neurology (AAN) issued a position statement for mental health professionals, covering decisions with patients and families regarding aducanumab in the treatment of Alzheimer disease, strongly recommending consent.

, yet since it has been approved by the FDA, patients are asking their doctors if this is an option for them,” said one of the authors, Winston Chiong, MD, PhD, of the University of California San Francisco and a member of the AAN’s Ethics, Law, and Humanities Committee. “This is a high-cost drug that was approved by the FDA without convincing evidence of benefits and with known harms.”

The AAN position statement stresses that it is ethically important to communicate that 

 does not restore cognitive function. Although aducanumab reduces beta-amyloid plaques that are markers of Alzheimer disease in the brain, it remains unclear whether beta-amyloid plaque reduction provides any meaningful benefits to patients. Additionally, there are insufficient grounds to warrant offering it to patients with moderate or advanced dementia, or to those without evidence of beta-amyloid in the brain.

“It is understandable why a new drug for Alzheimer disease generates so much interest, because while its approval has been controversial, it still offers a glimmer of hope to patients and their families,” said Orly Avitzur, MD, MBA, FAAN, President of the American Academy of Neurology. “By using ethical principles to create this position statement, the American Academy of Neurology aims to help neurologists and other physicians transparently counsel patients and their families with a goal of providing the highest quality patient-centered care.”

The position statement notes that there is a risk of amyloid-related imaging abnormalities with 

, including brain bleeds. During research, aducanumab was associated with brain inflammation and bleeds in a third of the individuals who received the FDA-approved dose. Physicians need to communicate potential adverse effects when discussing this treatment option with patients.

Another ethical concern the position statement noted is the absence of racial and ethnic diversity in the clinical trials of aducanumab. Minority populations are thus deprived of relevant information about the benefits and harms of the drug for their specific populations.

 may cause financial harm to patients receiving the drug, depending on how Medicare decides to address individual patient costs. With a price of $56,000 a year—not including costs of infusing the drug, repeated imaging, and medical management—aducanumab could end up costing patients and families significant amounts annually. The position statement recommends physicians discuss how full costs of treatment may not be covered by Medicare.

Helen Lavretsky, MD, MS, a professor in-residence in the Department of Psychiatry at the University of California, Los Angeles, and 

 editorial board member, concurred with the AAN. “I am very much in agreement with the very cautious statement that emphasizes the limited evidence for significant cognitive or functional improvement, the lack of promise to reverse or even slow Alzheimer disease progression, the very high cost of the drug and monitoring protocols, and the exuberant cost of the drug to the Medicare that would triple the cost of AD care, even if only 10% [of individuals] with Alzheimer disease receive the drug, along with the lack of data on long-term safety outcomes warrant a very careful approach and recommendation for the patients and families.”

“The decision should be made by doctors together with patients and [after] full disclosure of incurring costs of treatment, most often not covered by the insurances, that can only offer limited benefits for cognition along with high likelihood of brain inflammation, and complicated protocols for safety monitoring with costly expensive brain scans. The administration of the drug will also require collaborative care model between primary care and geriatric neurology and psychiatry,” said Lavretsky further.

Lavretsky also wished to draw attention to a viewpoint by Salloway and Cummings,

 who noted that the approval and implementation of aducanumab is justified and will open a new era in the treatment of Alzheimer disease.

The full statement is published in the online issue of 

1. Chiong W, Tolchin BD, Bonnie RJ, et al. Decisions with patients and families regarding aducanumab in Alzheimer disease, with recommendations for consent: AAN position statement. 

November 17, 2021. Accessed November 22, 2021. 

https://n.neurology.org/content/early/2021/11/17/WNL.0000000000013053

Aducanumab, amyloid lowering, and slowing of Alzheimer disease.

The American Academy of Neurology issued a position statement for mental health professionals, warning them to carefully discuss the benefits and known harms of aducanumab. 

Aducanumab: A Tentative Position

Thanksgiving Day has just passed, but that does not mean, of course, that we should stop being thankful. In fact, at its best, Thanksgiving reminds us to be more thankful in terms of gratitude.

In Memoriam: Charles Atkins, MD, aka Caleb James

Gratitude may be thought of as the essence of positive psychology and psychiatry. Why? Other than genetics, it seems to be the most important and powerful contributor to happiness and positive relationships.

Thankfully, gratitude is an attitude that can also be developed. So, even if your Thanksgiving was tarnished by family conflict, loneliness, or something else, you can still be grateful for what you had, have, and hopefully will have.

But how do you get to such ongoing gratitude if you do not have it already? Find some ritual gratitude practice. It also would not be out of the question to be grateful and compassionate to yourself for challenging achievements.

 article “Giving thanks during a pandemic: ‘We learn to appreciate things when we lose them,’” conveyed, difficult times are one with Thanksgiving Day historically.

 It was first celebrated in our country after a harsh winter and death of many pilgrims. It became a national holiday during our Civil War. The current date of our Thanksgiving holiday came to be in the middle of the Depression.

We know that for our patients, grabbing gratitude may be an even greater challenge. Depression in particular increase negativity, which is where the positive reframing of cognitive behavioral therapy comes in.

In this spirit of gratitude, let me in the very least thank anybody who reads this and especially those who comment, the editors who helped post it, 

 for their appreciation of all that goes into psychiatry, and, as always—and most importantly—my family and friends.

1. della Cava M. Giving thanks during a pandemic: ‘We learn to appreciate things when we lose them.’ 

 November 22, 2021. Accessed November 29, 2021. 

https://www.usatoday.com/story/life/health-wellness/2021/11/22/thanksgiving-pandemic-era-gratitude/8658809002/

Gratitude: the essence of psychology and psychiatry. 

Thanksgiving and Thankfulness

My uncle, who has schizophrenia, was shot by police in summer 2000. After decades of living in the streets, jail cells, and hospital beds across the country, he had finally procured housing and was living in an apartment alone. He was also disconnected from any meaningful mental health services, off his psychiatric medication, and spiraling into a paranoid psychotic state. As my uncle was noticeably sick and carrying a knife, his apartment manager called 911 after seeing my uncle staring out of his window, spinning the blade in his hand. Although the apartment manager felt threatened, he also knew that my uncle had schizophrenia and gave this information in his 911 call.

Two policemen responded, and after a few minutes of talking through the doorway, my uncle opened the door, and they muscled their way in. He backed into his kitchen and was pepper-sprayed by one of the officers. Depending on who is asked, he either dropped the knife or threw it in their direction. Either way, as soon as the knife left his hand, the other officer shot him. My aunt, tasked with cleaning up the horrific scene, remembers how the blood on the linoleum floor stood in stark contrast to the spotless apartment that my uncle otherwise kept. Decades later, when recounting the familial pain, it is chilling images like these that most vividly remain.

“I’m not a quitter, Sam,” my uncle reassures me with his smoky voice, not only about surviving being shot, but also regarding his recent hospitalization with COVID-19. With a twisted sense of justice, after recovering from multiple surgeries and a lengthy medical hospitalization, my uncle was ultimately arrested for assault against a police officer and spent the next several years between prison and state forensic psychiatric facilities. Framed as both the victim and the perpetuator of what is ostensibly the crime of having a serious mental illness, he embodies the violent and criminalized fate of our brothers and sisters suffering from these diseases. Although tragic, I have little doubt that had my uncle been black or brown, the police would not have stopped with 1 bullet and the outcome would have been deadlier.

Approximately 25% of fatal police shootings involve someone in a mental health crisis.

 Police encounters are 16 times more likely to result in someone’s death if the individual has an untreated mental illness.

 This risk is highest among Black men, who, even without mental illness, have a 1 in 1000 chance of being killed by police over their lifetime.

 Decades of relying on police as mental health first responders have led to generations of communities suffering unnecessary prison time, injuries, and death.

Motivated to help people with struggles similar to those of my uncle, I am now in my third year of psychiatry residency training in Brooklyn. I regularly hear from families who fear police response to mental health emergencies. Crippled by the horror stories they have heeded or lived, these families wait until their son or daughter’s illness becomes more life-threatening than calling for help. It is an impossible situation, in which the structural violence has not just eroded the trust in our health care system—it has prevented people from getting treatment at all.

This narrative, however, may be changing. Large cities like New York City, Pittsburgh, San Francisco, and others are starting pilot programs where mobile crisis teams comprised of mental health professionals will be dispatched as first responders to behavioral health calls instead of police.

 As a result of the American Rescue Plan, the Centers for Medicare and Medicaid Services (CMS) awarded $15 million in planning grants to 20 states and their Medicaid agencies to expand their crisis services, including mobile crisis teams.

A nationwide intervention is also near implementation. This will be a new 3-digit mental health crisis number, 988, and it will become operational by July 2022.

 The 988 number should allow mental health emergency calls to initially bypass police response. Thanks in part to advocacy efforts by the American Psychiatric Association (APA), the US House of Representatives passed several appropriation bills to increase funding for these and other mental health initiatives, some at unprecedented levels. However, as the reconciliation process continues, this funding is still in jeopardy.

As passed by the House, these bills would invest, for the first time ever, in creating a $100 million pilot program to support mental health mobile crisis response in lieu of police. It would also double the Federal Mental Health Block Grant for crisis services and expand funding for the Suicide Lifeline by $87 million to assist with the 988 transition.

 While these are small amounts compared to the billions of dollars being debated in increased spending for mental health and substance use disorder treatment and research, this funding, if fought to fruition, would indicate that the need for non-police response to mental health crises is being realized and pursued.

For my uncle and my patients, it will take years to create a sense of safety when calling for help. Whether or not we decide to fully invest in these programs will determine if our family members, friends, and patients with mental illness will continue to be criminalized and killed, or if they will have a chance towards recovery. Here lies the great opportunity for all of us: to demand support for these programs and to be aggressive advocates at every step in the process. Our voices matter and are making a difference.

is a resident in the Department of Psychiatry & Behavioral Services at SUNY Downstate Health Sciences University. 

 is director of public psychiatry education at SUNY Downstate Health Sciences University and medical officer at the US Department of Health and Human Services.

Effectiveness of police crisis intervention training programs

Decoupling crisis response from policing—a step toward equitable psychiatric emergency services

Risk of being killed by police use of force in the United States by age, race-ethnicity, and sex

Biden-Harris Administration awards $15 million to 20 states for mobile crisis intervention

. News Release. Centers for Medicare & Medicaid Services. September 20, 2021. Accessed November 15, 2021.

SAMHSA awards vibrant emotional health the grant to administer 988 dialing code for the National Suicide Prevention Lifeline

. Substance Abuse and Mental Health Services Administration. News Release. June 16, 2021. Accessed October 15, 2021.

APA statement on House passage of FY22 appropriations bill providing needed increases for mental health and substance use disorder programs

. American Psychiatric Association. News Release. July 29, 2021. Accessed October 15, 2021.

Can we save lives by dispatching mental health professionals as first responders to behavioral health calls?

Investing in Recovery: The Case for Supporting Non-Police Crisis Response

Smartphone©HaveANiceDayPhoto/Adobe Stock

From preparing for the holiday season to clinical updates and psychiatric perspectives on social issues and contemporary events, 

 covered important topics this week. Top articles included:

Holidays are joyous for some, but not for everyone. How can you help patients with mood disorders navigate the difficulties of the holidays?

COVID-19, Cognition, and Dementias: What Role Has the Pandemic Played?

How does COVID-19 contribute to cognitive impairment in older adults and future cases of dementia?

Shedding Light on the Shadow Brain Pandemic: The Devastating Effects of Gendered Violence-Related Acquired Brain Injury

In honor of the International Day for the Elimination of Violence against Women, let’s consider the impact of IPV on the neuropsychiatric health of women.

A Humanity Lesson From the Mouths of Babes

A child’s perspective, innocent and honest, serves as a good reminder of our biases.

Be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

It’s been a full week of interesting stories, commentaries, and more on a variety of topics at psychiatrictimes.com.

In Case You Missed It: November 22 to 26

is an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine, Greenville. He served on the American Psychiatric Association’s Task Force to Address Structural Racism Throughout Psychiatry, and he currently serves as the Diversity and Inclusion section editor and advisory board member for

A Black psychiatrist's reflections and dreams on what true allyship would look like in a country that remains divided.





Authentic Allyship

Sleep complaints are common among older adults.

 Such complaints may reflect their concerns about normative age-related changes in sleep, such as reduced total sleep time, lighter sleep, and increased wakefulness at night,

 as well as the prevalence of common sleep disorders in late life, including sleep-disordered breathing and chronic insomnia. 

 displays common sleep disorders in older adults and associated risk factors and correlates.

Sleep-disordered breathing describes respiratory events that occur during sleep, ranging from simple snoring to pathological hypopneas (decreased air flow) and/or apneas (temporary breathing cessation). Obstructive sleep apnea (OSA) is defined as the apnea-hypopnea index (average hypopnea and apnea events rate per hour) being above 5. The general prevalence rate of OSA is approximately 22% in men and 17% in women, and it increases with age.

 Chronic insomnia, characterized by difficulties initiating and maintaining sleep, is also prevalent in the older population, with estimates of insomnia symptoms close to 50%, although estimates of insomnia diagnosis are variable.

Caring for Older Adults With Mental Health Disorders During the Pandemic

Eric E. Brown, MD, MSc; Tarek K. Rajji, MD; and Benoit H. Mulsant, MD, MS

PTSD in Late Life: An Update on Clinical Issues

Joan M. Cook, PhD; Bret R. Rutherford, MD; and Ron Acierno, PhD

Both OSA and chronic insomnia are linked with various psychiatric concerns. OSA is associated with increased risks of vascular dementia, Alzheimer disease,

 Insomnia is also associated with the onset of depression, anxiety, alcohol abuse, and psychosis.

 Sleep disturbances may potentiate symptoms of mental illness via several mechanisms: disruptions of memory consolidation processes that normally occur during sleep; increases in irritability and fatigue; and negative impacts on cognitive function.

It is important to note the bidirectional relationship between sleep disorders and psychiatric disorders in older adults. That is, psychiatric disorders can be both the cause and consequence of sleep disturbances. Therefore, the challenge is to determine whether sleep disruption should be the primary target for intervention or whether there are also comorbid psychiatric symptoms that need to be addressed for treatment to be successful.

It is helpful to start with a detailed history regarding the nature of the patient’s sleep complaints, other areas of functioning, and any other comorbid conditions that might be impacting their sleep. It can be helpful to walk through a typical 24-hour period to review sleep problems in greater detail, including onset, duration, frequency of disturbances, and possible contributions of sleep environment (eg, temperature, noise, etc). A sleep diary can also provide a sampling of a typical week of sleep. Reported sleep difficulties often have daytime consequences, so it is important to ask about their daytime behaviors (eg, napping, canceling plans) used to counteract or cope with perceived and real sleep loss. This information sheds light on the patient’s relationship with their sleep, including whether sleep impacts their ability to function and their level of concern surrounding the possible downstream effects of sleep loss. The 

Medical conditions, medications, pain level, and alcohol or drug use should be discussed, as these factors can adversely affect sleep. 

 shares screening measures that are useful for gathering information about other contributing factors to poor sleep, including possible comorbid sleep disorders.

 For example, the Pittsburgh Sleep Quality Index, a global measure of sleep quality, may help identify the presence of potential sleep disturbance due to medical comorbidities (eg, pain, waking to use bathroom), psychiatric comorbidities (eg, nightmares), and use of sleep medications, including over-the-counter sleep medications. Furthermore, assessment of daytime sleepiness and screening for sleep apnea may be helpful to determine whether a sleep study is needed.

To make a diagnosis of OSA, home study (level 3 study) or in-lab polysomnography (PSG; level 1 sleep study) are required. In-lab polysomnography is considered a gold-standard sleep study; home study is less accurate because fewer sensors are involved.

 Home study is usually indicated for the confirmation of OSA diagnosis in patients with a high pretest probability of OSA. In-lab PSG is recommended for patients with comorbidities such as congestive heart failure, chronic lung disease, or neurologic conditions.

Finally, it is crucial to ask the patient what they are currently doing to manage their symptoms and their level of optimism around efforts to help. This information will be helpful in designing a treatment plan that not only improves the quality and quantity of their sleep, but also addresses the psychological impact through psychoeducation, support, and problem solving.

Obstructive sleep apnea. Positive airway pressure (PAP), a device that helps keep the airway open during sleep through a stream of compressed air, is the first-line medical treatment for moderate or severe sleep apnea. Several types of PAP devices exist; the most commonly used is continuous PAP, and other advanced options include bilevel PAP. For individuals with difficulty adhering to PAP use, other treatment options can be considered, including oral appliances (eg, mandibular advancement devices) and surgical options (either soft or hard tissue surgery or implantation of a nerve stimulation device). Improvements in sleep quality, daytime symptoms, and cognitive functions are often observed when OSA is adequately addressed.

Chronic insomnia: pharmacological approaches. There are several US Food and Drug Administration-approved prescription hypnotics for insomnia, including benzodiazepines (eg, estazolam, temazepam), nonbenzodiazepines (eg, eszopiclone, zolpidem), melatonin receptor agonists (eg, ramelteon), orexin/hypocretin receptor antagonists (eg, suvorexant), and an antihistamine (doxepin). Other pharmacological drugs with sedating effects that are commonly prescribed for sleep include trazodone, mirtazapine, gabapentin; other sedative antipsychotics include quetiapine. However, many sedative hypnotics have negative side effects. Benzodiazepines, in particular, are not recommended for late-life insomnia due to their increased risks of cognitive impairment and falls.

 Nonpharmacological approaches are therefore regarded as the first line of treatment for insomnia, as they have been found to be more effective, with minimal side effects.

Nonpharmacological approaches. Cognitive behavioral therapy for insomnia (CBTI) is an evidence-based, multicomponent therapy that is recommended as the first line of treatment for insomnia, with strong empirical support for the general population

 In the context of medical and psychiatric comorbidities, CBTI was found to improve sleep and comorbid psychiatric symptoms.

 To optimize CBTI for older adults with comorbid psychiatric symptoms, 

 illustrates CBTI intervention components as well as adaptation considerations for older adults

 and modifications in the context of comorbid depression and anxiety.

For older adults with psychiatric comorbidities, additional modifications may be warranted. Depressive symptoms, such as low motivation and energy, may be associated with lower adherence in the behavioral recommendations of CBTI, highlighting the need for motivational enhancement strategies. Incorporating positive mood strategies into CBTI, such as behavioral activation (eg, daily pleasant activity scheduling), cognitive reframing (eg, thought records focusing on depression-related thoughts), and positive affirmation (eg, positive data logs and cue cards), could all help address comorbid insomnia and depression.

For older adults who have anxiety, considerations include assessing sleep anxiety, as certain CBTI strategies may become less effective among those who are significantly anxious about sleep. For example, sleep restriction, intended to promote sleep drive, may be less effective in consolidating sleep due to heightened arousal levels masking sleep drive.

 To address heightened arousal at night, there may be benefits in introducing relaxation exercises (eg, diaphragmatic breathing or progressive muscle relaxation) and other cognitive-behavioral strategies for managing anxiety (eg, constructive worry).

More research is needed to better understand whether to treat these comorbid conditions sequentially or concurrently in order to optimize treatment outcomes for both sleep and psychiatric symptoms. Recent data support further development of transdiagnostic treatments that concurrently target common cognitive, behavioral, and biological underpinnings across psychiatric disorders, such as sleep disturbances. One example is the Transdiagnostic Sleep and Circadian Intervention, a transdiagnostic treatment targeting sleep and circadian problems for individuals with comorbid psychiatric disorders.

 This approach is informed by CBTI and other circadian optimization strategies. Although more studies on transdiagnostic treatments are underway, CBTI is appropriate for older adults with comorbid insomnia and psychiatric disorders.

Sleep disturbance often co-occurs among older adults with psychiatric symptoms and disorders. A thorough assessment, looking at difficulty initiating and maintaining sleep, daytime sleepiness/dysfunction, and other physical markers (eg, snoring), will help providers identify the presence of sleep disorders, such as OSA or chronic insomnia, that co-occur with psychiatric conditions. Modifications can optimize the treatment of sleep disturbance in the presence of such psychiatric conditions as depression and anxiety.

Appropriate treatment is essential, as the long-term consequences of not addressing sleep disturbances may be severe. Interactions between sleep disruption and mental health symptoms even may set into motion a cascade of neurodegeneration that can ultimately lead to dementia.

 Mood disorders also increase risk of dementia, potentially through accelerated brain aging from stress exposure that leads to pathological changes in the brain, termed the brain-age gap. Sleep disturbances may constitute a type of stressor that increases the brain-age gap. Treatment of these common, yet complex, patients with evidenced-based methods is essential to improving their symptoms, quality of life, and brain health.

is a clinical assistant professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

is an instructor (affiliated) in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. She is a research health science specialist in the Veterans Administration (VA) Palo Alto Health Care System. 

is a clinical professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine. 

 is a clinical associate professor in the Division of Sleep Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

is associate director for education and evaluation at the VA Palo Alto Health Care System’s Geriatric Research, Education, and Clinical Center. She is also a clinical assistant professor in the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.

Dr Juang is a member of the advisory board for Koko. Dr Gould receives research funding from Meru Health, Inc. None of the other authors have any disclosures to report.

Sleep disorders in the older adult – a mini-review. 

2. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. 

Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan.

Psychiatric illness and sleep in older adults: comorbidity and opportunities for intervention.

Obstructive sleep apnea is a common disorder in the population – a review on the epidemiology of sleep apnea

Epidemiology of insomnia: what we know and what we still need to learn.

8. Liguori C, Maestri M, Spanetta M, et al. 

Sleep-disordered breathing and the risk of Alzheimer’s disease.

Obstructive sleep apnea and psychiatric disorders: a systematic review.

10. Hertenstein E, Feige B, Gmeiner T, et al. 

Insomnia as a predictor of mental disorders: a systematic review and meta-analysis.

Sleep-dependent memory consolidation in healthy aging and mild cognitive impairment.

12. Buysse DJ, Reynolds CF III, Monk TH, et al. 

The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. 

Validation of the Insomnia Severity Index as an outcome measure for insomnia research. 

A new method for measuring daytime sleepiness: the Epworth sleepiness scale. 

15. Chung F, Yegneswaran B, Liao P, et al. 

STOP questionnaire: a tool to screen patients for obstructive sleep apnea.

16. Chung F, Subramanyam R, Liao P, et al. 

High STOP-Bang score indicates a high probability of obstructive sleep apnoea.

17. Kapur VK, Auckley DH, Chowdhuri S, et al. 

Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline.

18. 2019 American Geriatrics Society Beers Criteria® Update Expert Panel. 

American Geriatrics Society 2019 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults.

19. Mitchell MD, Gehrman P, Perlis M, Umscheid CA. 

Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review.

20. van der Zweerde T, Bisdounis L, Kyle SD, et al. 

Cognitive behavioral therapy for insomnia: a meta-analysis of long-term effects in controlled studies.

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. 

22. Wu JQ, Appleman ER, Salazar RD, Ong JC. 

Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis.

23. Cassidy-Eagle EL, Siebern A, Chen H, et al. Cognitive-behavioral therapy for insomnia in older adults. 

24. Sadler P, McLaren S, Klein B, et al. 

Cognitive behavior therapy for older adults with insomnia and depression: a randomized controlled trial in community mental health services.

Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders.

A transdiagnostic sleep and circadian treatment to improve severe mental illness outcomes in a community setting: study protocol for a randomized controlled trial.

27. Alfini AJ, Tzuang M, Owusu JT, Spira AP. 

Later-life sleep, cognition, and neuroimaging research: an update for 2020.

Recognizing and Addressing Psychiatric Implications of Sleep Disorders

is a board-certified internist and a board-certified psychiatrist and executive with strategic clinical leadership experience, serving as chief medical officer for Magellan Health and MagellanRx Management.

Caroline Carney, MD, MSc, discusses what clinicians can do to help children and adolescents during this difficult time. 

Videos

From April 2020 to June 2021, more than 140,000 kids lost a guardian. Children and adolescents are in a mental health crisis. What can you do to help? 

In the Midst of a Crisis: A Safe Space for Youth

The Centers for Disease Control and Prevention (CDC) recently reported that more than 100,000 people in the United States died of overdose in the 12 months ending April 2020. In response, the Drug Policy Alliance (DPA), National Harm Reduction Coalition, and People’s Action and VOCAL-NY led a group of 240 civil rights, drug policy, criminal justice reform, public health, and faith-based organizations in urging members of Congress to pass legislation that will prioritize the beating the 

They specifically urged Congress to consider evidence-based public health approaches, including critical harm reduction funding, the MAT Act, the STOP Fentanyl Act, and the Medicaid Reentry Act.

“With over 100,000 people dying of overdose in the US during the first year of the pandemic, passing these critical pieces of legislation is not only more urgent than ever before—it’s literally a matter of life and death for so many people,” said Maritza Perez, Director of the Office of National Affairs at the Drug Policy Alliance. “We are far past the point of waiting for a politically convenient time to take the necessary steps to curb this crisis and save lives. The US Government has targeted and criminalized our communities for drugs over the last 50 years as a political ploy which has only fueled the overdose crisis. With countless more lives at stake, it’s time to stop playing politics and continuing down this ill-fated path. It is absolutely imperative that policymakers change course immediately and prioritize evidence-based public health alternatives that are proven to actually save lives.”

Their statement urges Congress to enact life-saving legislation by the end of the 2022, including the following 4 items:

1. $69.5 million in funding to increase access to overdose prevention, harm reduction, and syringe service programs through the CDC’s Infectious Diseases and the Opioid Epidemic program.

2. The Mainstreaming Addiction Treatment Act, which eliminates the outdated requirement that practitioners apply for a separate waiver through the Drug Enforcement Administration to prescribe 

 for the treatment of substance use disorders.

3. The Support, Treatment, and Overdose Prevention of Fentanyl Act, or the STOP Fentanyl Act, which improves fentanyl surveillance and detection.

4. The Medicaid Reentry Act, which would allow Medicaid to cover health services during the last 30 days of incarceration and create better linkages to community-based care during reentry.

—through evidence-based, public health solutions,” said Sondra Youdelman, People’s Action Campaigns Director. “Our communities just suffered a record-breaking 100,000 preventable overdose deaths in a single year. Instead of continuing to criminalize drug use, Congress needs to take evidenced-based action now, and listen to the people who lost 100,000 loved ones.”

Jasmine Budnella, Director of Drug Policy at VOCAL-NY, echoed these sentiments: “Our nation is at a heartbreaking, infuriating watershed moment. With over 100,000 of our loved ones dying from a preventable overdose, it is a grave failure that evidence-based solutions proven to turn the tide on the overdose crisis remain out of reach. Congress must heed the calls for urgent action, and pass legislation rooted in science, harm reduction, and care before the new year. If our leaders fail to act, another year of devastating and historic overdose deaths is inevitable.”

1. Drug Policy Alliance. As overdose crisis claims record lives, coalition of 240 organizations urge Congress to pass lifesaving public health bills. News release. November 30, 2021. Accessed December 1, 2021. 

https://drugpolicy.org/press-release/2021/11/overdose-crisis-claims-record-lives-coalition-240-organizations-urge-congress

A coalition of 240 organizations came together to urge Congress to pass legislation to fight the opioid crisis. 

Stopping the Opioid Crisis: Evidence-Based Public Health Approaches 

Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

The home hospice nurses were frustrated and discouraged. My 89-year-old mother, dying of uncorrected aortic stenosis, was refusing the pain medication the nurses repeatedly offered her. Years earlier, she had declined to undergo aortic valve replacement, despite my recommendation to do so. (In my family, it is praiseworthy to raise a child to be a physician, but foolish to listen to one.) Owing to a failed operation for a bowel problem, my mother was experiencing moderate, intermittent pain. But she refused repeated offers of oxycodone or morphine because, as she put it, “I want to keep my head clear.” My mother died in her own way, stoically enduring her pain, guided by her own idea of “death with dignity.”

Shortly after 9/11, the novelist Don DeLillo wrote, “Language is inseparable from the world that provokes it.” Referring to “people falling from the towers, hand in hand,” DeLillo noted, “Before politics, before history and religion, there is the primal terror.”

 I believe that the world of death and dying—even the mere imagining of it—evokes a similar primal terror in most of us; and this, in turn, provokes a linguistic response. The ubiquitous shibboleth, “death with dignity,” represents our deep-seated wish for control, comfort, and personal autonomy. That is all entirely understandable.

But over the past several decades, death with dignity has become a kind of battle cry. Owing to the lobbying and proselytizing efforts of groups promoting physician-assisted suicide—euphemistically called, “medical aid in dying”—the phrase, death with dignity, has become nearly synonymous with the deliberate ingestion of lethal drugs, prescribed for people with terminal illnesses.

 In the marketplace of ideas, other modes of dignity in dying—and more importantly, 

Has this slogan crowded out the importance of life with dignity?