is a sixth-year medical student at Universidad Peruana Cayetano Heredia in Lima, Peru. She aspires to become a neurologist and to continue advocating through research and policymaking for the transgender community.

 (@MPLerario) is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community. Their work has been published in 

 Journal of Speech Language and Hearing Research, 

Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse

Being well versed in correct terminology is fundamental to building affirming clinical environments and psychosocial rapport with patients. Physicians are not expected to get everything right, but to take responsibility for their education and apologize in the event a mistake is made.

 a key distinction to make is between sex and gender. Sex is assigned at birth by a medical professional most often based on biological criteria, such as external genitalia. Gender refers to a person’s internal sense of self, which can be expressed through a diverse range of social, cultural, physical, and behavioral cues, such as clothing, pronouns, and physical embodiment. The Figure defines these terms and their key differences.

 neither sex nor gender are binary, as evidenced by the existence of intersex and TGD individuals. And neither sex nor gender are categorical. Someone’s gender identity can change through their life, and someone’s sex can, too (eg, a person can change their gender expression, sex hormone levels, and the appearance of their genitalia).

 another common misconception is that gender identity is the same as sexual orientation, which refers to the gender(s) of the individuals to whom a person is attracted. This includes asexual people, who do not experience sexual attraction. Many TGD individuals identify as “straight,” or heterosexual. Self-disclosing a TGD identity does not necessarily mean that the person is “gay/lesbian,” or homosexual.

 terminology changes depending on geography and demography. For example, in Latin America, terms such as transexual and travesti are used as synonyms for transgender. However, these may be considered derogatory in the United States and Europe due to their medical implications.

is a sixth-year medical student at Universidad Peruana Cayetano Heredia in Lima, Peru. She aspires to become a neurologist and to continue advocating through research and policymaking for the transgender community. 

 is a board-certified neurologist and graduate student of social service at Fordham University, where they perform activism and research for the transgender community.

Articles

Covering the Basics: LGBTQ+ Terminology

The data is clear: We should expect an increasing number of 

 and gender diverse (TGD) youth presenting to our practices over the coming years.

 We must ask ourselves: Are we prepared to treat these patients and their families with the most affirming, evidence-based treatment available?

For discussion purposes, consider a prototypical case of “Bar,” an 11-year-old child who presents to your office accompanied by his parents. Bar was assigned female at birth but recently began identifying with “he/him” pronouns; he is scared to face impending puberty. Bar’s father informs you that he is afraid Bar will be “bullied for being gay.”

Recent qualitative studies suggest that the caregivers’ response and adjustment to their TGD child’s identity development is critical to the child’s mental health.

 An integrative family therapy approach should affirm and support the TGD child in an equal partnership between the caregivers and the child.

 Addressing attunement and attachment is important for the family system, as there is likely longstanding 

 from adoption of rigid, binary gender norms.

 Families should prioritize building psychosocial support for, and affirming the gender identity of, the TGD child, rather than focus on worries like “Is this my fault?” “What went wrong?” or “Is this just a phase?” The family may express grief due to the loss of an expected future they associated with the assigned sex of a transitioning child.

Distress tolerance and interpersonal relationship dynamics can be tested during a gender transition

 may be misdiagnosed with personality disorders.

 Dialectical behavioral therapy is a good therapeutic option for these patients.

 It is important that group therapy options provide affirming environments for transgender group members. This includes the facilitator’s role modeling of appropriate usage of pronouns and chosen names during therapy sessions.

Disclosing a shared identity with a patient can aid the therapeutic alliance by displaying understanding and empathy for the patient’s experience, which can facilitate trust and reciprocity.

 It is vital that providers reflect on whether self-disclosure is being done with the intent of improving patient care, and peer supervision around this can be of value.

Psychiatrists should model inclusive environments to their TGD patients within their offices and clinical spaces.

 Patients and their families should feel safe to give feedback to the psychiatrist when they fail to produce an affirming patient experience.

 In these situations, the administrative response should be transparent and timely, and it should address the root cause of the issue. Psychiatrists should collaborate and advocate with the family and other community and mental health professionals, such as school psychologists and counselors, to create affirming environments within the child’s home and school life.

 It is imperative that work with TGD patients involves ongoing feedback and participation from affected community members throughout the learning and healing process.

To create a more affirming environment for a TGD child, psychiatrists should collaborate with the family, school, and community. For example, using noninvasive and empowering language can be a great first step in establishing not only a good environment, but also a therapeutic alliance. See 

Recommended Psychoeducational Approach for Families of a Transgender or Gender-Diverse Child

Psychiatric Terminology: Is the Field Doing Enough?

Gender Dysphoria and Its Significance in the TGD Community

Gender dysphoria is a term that originated within psychiatry. The DSM-5-TR defines gender dysphoria as “the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity.” Gender euphoria is an accepted term used in the TGD community that recently entered the peer-reviewed literature.

 It is defined as a “joyful feeling of rightness” and the “powerfully positive emotions” that comes from one’s gender. See 

 for more details on gender dysphoria and euphoria.

Gender dysphoria is caused by repeated exposure to gender-nonaffirming environments, which can result in higher rates of 

, anxiety, trauma and stress disorders, rumination, somatization, and suicidality in TGD individuals.

 The mismatch between a person’s self-identified gender and invalidating environments can occur within multiple domains, including online, home, school, athletic, employment, carceral, and health care settings.

 Access to affirming environments and health care improves mental health outcomes

; on the other hand, nonaffirming environments and barriers to health care increase disparities for TGD individuals.

 Due to recent attempts to criminalize evidence-based affirming health care for TGD individuals, psychiatrists should expect to see an increase in patients presenting with gender dysphoria in the near future.

The Gender Minority Stress and Resilience Theory

The Gender Minority Stress and Resilience Theory describes the disparate impact of risk and protective factors on the experience of internalized (proximal) and external (distal) oppression in TGD communities.

 factors combine with other forms of social identity–based discrimination, such as racism and socioeconomic disadvantage. Taken together, this intersectionality is responsible for the structural pathways leading to systemic health care inequities experienced by TGD community members (ie, social determinants of health).

 provides more details on minority stress and resilience.

Minority stress models have been used to explain the increased risk for biological, psychological, and social health disparities observed in TGD communities. These biological factors include increased rates of cardiovascular disease and cancer-related outcomes, whereas psychological outcomes of minority stress include depression and suicidality.

 Among the TGD community, social disparities and structural disadvantages have been noted in increased rates of incarceration, housing instability, underinsurance, and risk behaviors, such as 

 expands on this topic and gives examples of resilience, or protective factors, that moderate the effect of minority stress.

 Resilience factors include methods to create systemic and structural changes that increase the psychosocial support and affirming environments available to TGD individuals.

 Additionally, TGD individuals can learn skills such as community building, advocacy, role modeling, and other expressions of pride, self-worth, and self-acceptance.

You diagnose Barr with gender dysphoria and provide supportive psychotherapy throughout the social transition process. You present Barr with information regarding his local community center, where Barr becomes active in peer support and social activities. You provide educational resources to Barr’s parents, who join their local PFLAG (Parents, Families, and Friends of Lesbians and Gays) chapter to speak with other parents of TGD children. You discuss the changes in pronouns with Barr’s school psychologist and work with school administration to help develop strategies for Barr to express his gender authentically within the school’s policies.

After a year of treatment, although Barr feels more confident in his masculine gender expression, he reports ongoing depression due to expected changes with puberty. As a result, you refer Barr and his parents to a gender-affirming endocrinologist to discuss options regarding potential puberty suppression and timing.

Recommended Provider, Educator, Family, and Patient Resources

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. This includes the use of sensitive and inclusive language and assisting the field in adapting to ongoing evolution of community standards of care. Similarly, it is important to integrate transition and resocialization efforts with the patient’s family, community centers, and school professionals. 

 provides a list of potential resources to help in this endeavor. Together, we can work to provide affirmative and evidence-based care for all youth, whether or not they identify within the gender binary.

1. Jones JM. LGBT identification in U.S. ticks up to 7.1%. Gallup. February 17, 2022. Accessed October 3, 2022. 

https://news.gallup.com/poll/389792/lgbt-identification-ticks-up.aspx

2. Turban J, Ferraiolo T, Martin A, Olezeski C. 

Ten things transgender and gender nonconforming youth want their doctors to know.

3. Bhattacharya N, Budge SL, Pantalone DW, Katz-Wise SL. 

Conceptualizing relationships among transgender and gender diverse youth and their caregivers.

Integrative family therapy with transgender, gender diverse, and non-binary (TGDNB) young people.

Working toward family attunement: family therapy with transgender and gender-nonconforming children and adolescents.

Treating family members of transgender and gender-nonconforming people: an interview with Eric Yarbrough, M.D.

7. Austin A, Craig SL, D’Souza S, McInroy LB. 

Suicidality among transgender youth: elucidating the role of interpersonal risk factors.

8. Goldhammer H, Crall C, Keuroghlian AS. 

Distinguishing and addressing gender minority stress and borderline personality symptoms.

9. Sloan CA, Berke DS. Dialectical behavior therapy as a treatment option for complex cases of gender dysphoria. In: Kauth MR, Shipherd JC, eds. 

Adult Transgender Care: An Interdisciplinary Approach for Training Mental Health Professionals.

 Routledge/Taylor & Francis Group; 2018:123-139.

Therapist self-disclosure of sexual orientation revisited: considerations with a case example.

11. Banerjee SC, Staley JM, Alexander K, et al. 

Encouraging patients to disclose their lesbian, gay, bisexual, or transgender (LGBT) status: oncology health care providers’ perspectives.

12. Acosta W, Qayyum Z, Turban JL, van Schalkwyk GI. 

Identify, engage, understand: supporting transgender youth in an inpatient psychiatric hospital.

13. Brown JM, Naser SC, Brown Griffin C, et al. 

A multicultural, gender, and sexually diverse affirming school-based consultation framework.

14. Katz-Wise SL, Sansfaçon AP, Bogart LM, et al. 

Lessons from a community-based participatory research study with transgender and gender nonconforming youth and their families.

15. Beischel WJ, Gauvin SEM, van Anders SM. 

“A little shiny gender breakthrough”: community understandings of gender euphoria.

16. Dhejne C, Van Vlerken R, Heylens G, Arcelus J. 

Mental health and gender dysphoria: a review of the literature.

17. Chumakov EM, Ashenbrenner YV, Petrova NN, et al. 

Anxiety and depression among transgender people: findings from a cross-sectional online survey in Russia.

18. Wanta JW, Niforatos JD, Durbak E, et al. 

Mental health diagnoses among transgender patients in the clinical setting: an all-payer electronic health record study.

19. Cardoso Silva D, Salati LR, Villas-Bôas AP, et al. 

Factors associated with ruminative thinking in individuals with gender dysphoria.

Increased prevalence of depression, anxiety, and adjustment and somatoform disorders in transsexual individuals.

Cyberbullying and LGBTQ youth: a systematic literature review and recommendations for prevention and intervention.

23. Brown C, Porta CM, Eisenberg ME, et al. 

Family relationships and the health and well-being of transgender and gender-diverse youth: a critical review.

24. Kosciw JG, Clark CM, Truong NL, Zongrone AD. The 2019 National School Climate Survey: the experiences of lesbian, gay, bisexual, transgender, and queer youth in our nation’s schools. GLSEN. 2020. Accessed October 3, 2022. 

https://www.glsen.org/sites/default/files/2021-04/NSCS19-FullReport-032421-Web_0.pdf

25. Kulick A, Wernick LJ, Espinoza MAV, et al. 

Three strikes and you’re out: culture, facilities, and participation among LGBTQ youth in sports.

Should I stay or should I go? Employment discrimination and workplace harassment against transgender and other minority employees in Canada’s Federal Public Service.

 Racial/ethnic disparities in history of incarceration, experiences of victimization, and associated health indicators among transgender women in the U.S.

28. Kattari SK, Bakko M, Hecht HK, Kattari L. 

Correlations between healthcare provider interactions and mental health among transgender and nonbinary adults.

29. Russell ST, Pollitt AM, Li G, Grossman AH. 

Chosen name use is linked to reduced depressive symptoms, suicidal ideation, and suicidal behavior among transgender youth.

Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.

31. James SE, Herman JL, Rankin S, et al. The report of the 2015 U.S. transgender survey. National Center for Transgender Equality. 2016. Accessed October 3, 2022. 

https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

32. Puckett JA, Cleary P, Rossman K, et al. 

Barriers to gender-affirming care for transgender and gender nonconforming individuals.

Legislation to criminalize gender-affirming medical care for transgender youth.

Resilience in the study of minority stress and health of sexual and gender minorities.

35. Heise L, Greene MH, Opper N, et al; Gender Equality, Norms, and Health Steering Committee. 

Gender inequality and restrictive gender norms: framing the challenges to health.

36. Streed CG Jr, Beach LB, Caceres BA, et al; American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council.

 Assessing and addressing cardiovascular health in people who are transgender and gender diverse: a scientific statement from the American Heart Association.

37. Flentje A, Heck NC, Brennan JM, Meyer IH. 

The relationship between minority stress and biological outcomes: a systematic review.

Associations between minority stress, depression, and suicidal ideation and attempts in transgender and gender diverse (TGD) individuals: systematic review and meta-analysis.

39. Glick JL, Lopez A, Pollock M, Theall KP. 

Housing insecurity and intersecting social determinants of health among transgender people in the USA: a targeted ethnography.

Differential access to transgender inclusive insurance and healthcare in the United States: challenges to health across the life course.

Prevalence and correlates of substance use among transgender adults: a systematic review.

Psychological interventions promoting resilience among transgender individuals: Transgender Resilience Intervention Model (TRIM).

43. Reisner SL, Bradford J, Hopwood R, et al. 

Comprehensive transgender healthcare: the gender affirming clinical and public health model of Fenway Health.

Psychiatrists are in a unique position to empower their patients by recognizing and addressing key issues surrounding gender and sexuality. 

 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. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

Yesterday, we reported on the courageous 

 who has taken very risky flights in the air to find sustainability alternatives to fossil fuels. Recent news also coveys that physicians in other countries are taking great risk in responding to societal obstacles.

Cheerful and Tearful Over Thanksgiving Weekend

To Address Climate Change, This Psychiatrist Goes Where No One Has Gone Before

First, I heard of the Iranian physicians in the 

 article of November 10, 2022, “Iran’s doctors have jointed the uprising — and are paying the price.”

 Many Iranian doctors early on seemingly questioned the government’s explanation for the death of 22-year-old Masha Amina in mid-September, sparking protests led by other women. Medical personnel were punished for providing care to those injured. On October 26th, hundreds of physicians had gathered outside the Medical Council in Tehran, protesting the misuse of medical equipment and infiltration of hospitals. The riot police reportedly used shotguns with pellets, batons, and tear gas on them.

 had a frontpage story in the Review section titled, “Ukrainian Hospital Stymied Russians With Defiant Doctors and a Fake Covid Outbreak.”

 When the Russians took over Kherson in early March and came to Tropinka Hospital, Leonid Remiga, MD, reportedly refused to cooperate. Two other physicians were detained. Dr Remiga and staff slowed down the takeover by feigning a COVID crisis. On June 11th, he was detained and suffered a stroke, but as he recovered, he advised other physicians while he was on the run. Then, about a month ago, when the Russians were beginning to retreat from the city, the staff hid equipment the Russians wanted to take.

As if to punctuate the courage of the health care clinicians in Ukraine, as I was writing this column, I read yesterday’s 

 by the President of the National Psychological Association of Ukraine, Valeriia Palii.

 Surely, any psychologists staying and helping in Ukraine are living up to the highest ethical standards.

Taking into account the limited information, it seems that these physicians and psychologists in Iran and Ukraine made the ethical choice to risk their own well-being for the sake of their patients, public, and country. In the United States, we have not had such societal danger, but 2 issues are causing similar ethical dilemmas: the state laws that are prohibiting abortions and the increasing pressure in some states to forbid medical treatment to trans patients.

Our own well-being is increasingly threatened with our epidemic of burnout due to for-profit business obstacles to healing. So far, there seems to have been increasing resilience, but no collective resistance. In the recent Kaiser Northern California mental health workers strike that seems to have had a successful resolution, psychiatrists did not participate.

It makes me wonder: What would it take for psychiatrists like myself and other physicians in the United States to collectively resist risks to the public’s health and mental health?

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 related to climate instability, burnout, Islamophobia, and anti-Semitism for a better world. He serves on the Editorial Board of

1. Dehghanpisheh B. Iran’s doctors have joined the uprising — and are paying the price. 

. November 10, 2022. Accessed November 29, 2022. 

https://www.washingtonpost.com/world/2022/11/10/iran-protests-mahsa-amini-hijab/

2. Lovett I. Ukrainian hospital stymied Russians with defiant doctors and a fake Covid outbreak. 

. November 25, 2022. Accessed November 29, 2022. 

https://www.wsj.com/articles/ukrainian-hospital-stymied-russians-defiant-doctors-fake-covid-11669243198

3. Palii V. Ukraine now: never so difficult, never so easy. 

https://www.psychiatrictimes.com/view/ukraine-now-never-so-difficult-never-so-easy

What would it take for psychiatrists and other physicians in the United States to collectively resist risks to the public’s health and mental health?

The Health Care Professional Ethical Choice: Ukraine, Iran, and Whether or When to Risk and Resist

 about the attitude of Ukrainians to the Russian invasion and our trust for victory. Globally, nothing has changed during this time, except that we have become even more convinced.

All this time I have been living and working in Ukraine. I left my country only a few times during this period, attending various professional events. I am currently writing this text by candlelight, sharing mobile internet on my computer. No, this is not the creation of a romantic and cozy atmosphere—it is a new necessity. The Russians are methodically destroying our energy system (power plants and heating system) to make us capitulate. Winter frosts in Ukraine sometimes reach -30 degrees Celsius; Russians probably think that without electricity and heating, we will be forced to give up. But they are wrong again.

Not only will we not break down, but we will also become stronger because the enemy shows its true face every time, destroying everything. People die in hospitals without electricity, schools cannot fully function because it is cold, we cannot cook for ourselves because we depend on resources. But we know that by capitulating, we will live even worse than now.

How do Ukrainian psychologists live? Very differently. Some build a temporary new life abroad and help Ukrainian refugees or work with Ukrainians online, privately or within various initiatives. Many stay in Ukraine and adapt to the new situation.

On Friday, the National Psychological Association of Ukraine held a free training session for the members. On Wednesday, Ukraine once again suffered a massive missile attack. All regions of Ukraine were without electricity, internet, and mobile communications. The capital of our country, Kyiv, had no water supply, heating, internet, or mobile connection for 1.5 days. On Friday, everything began to gradually recover, but many colleagues joined our online training from heating points, special tents where you can warm up and where there is satellite internet. What else do you need to know about Ukrainian psychologists?

The National Psychological Association holds 4 to 5 free events for colleagues every month to improve their qualifications and support. Speakers are foreign volunteers who want to support Ukrainian colleagues. We also organize free supervisions, which are conducted for us by volunteers or colleagues, whose work we pay from donations that go to our account. If you want to become a volunteer, you can contact us npa.trainings@gmail.com. If you want to donate, visit our webpage.

In June, the NPA of Ukraine launched a psychological support hotline, which is provided in the format of audio and video calls. The hotline operates on a single number available from Ukraine 0-800-100-102 from 10:00 to 20:00 every day. All calls are free. To receive a video consultation with a psychologist, the client needs to notify the operator, and they will switch the application to video conferencing. Psychologists-consultants on the line are educated specialists trained in providing crisis interventions, trauma-informed approaches, and topics of violence. All consultations are confidential. If necessary, line psychologists can refer individuals to other specialists.

We also have free numbers in 14 European countries. It means that people who do not know the local language can seek help from Ukrainian psychologists over the borders. Psychological help for Ukrainians abroad is available by toll-free numbers in Poland, Czech Republic, Romania, Slovakia, Hungary, France, Italy, Austria Portugal, Sweden, Ireland, United Kingdom, Bulgaria, and Spain. Our psychologists work on the hotline remotely. They are located in different parts of the country and beyond, and they can also insure each other in case of loss of communication or lighting.

Despite the difficulties we face, many of our members work in field teams and help civilians and military personnel who have experienced various problems. Topics that our colleagues have worked with are psychological (and neurological) consequences of terrorist attacks, genocide, rapes and other sexual crimes, property losses, bereavement, separation, health problems, and economic crises, etc.

Our association also actively cooperates with various ministries, such as the Ministry of Health or the Ministry of Veterans Affairs. This is important because we can more effectively help and develop different important initiatives for now and the future.

In conclusion, I want to say that living and working in Ukraine today has never been so difficult, but it has never been so easy either, because we make a significant contribution to our victory.

 is president of the National Psychological Association of Ukraine. 

Ukraine Now: Never so Difficult, Never so Easy 

The tele-geropsychiatry new patient consultation appointment started. The patient and his wife were on camera. The patient was able to answer most of the interview questions himself, with his wife chiming in intermittently. The patient was a very pleasant man living with Parkinson disease. We talked about where the patient and his wife live, their children, the patient’s time in the military, and the state of his mood. Then I asked about eating and sleeping and started the review of medications.

The consult was a referral from the patient’s primary care physician noting anxiety and that “wife requests refill for patient’s clonazepam 1.0 mg qhs.” The consult mentioned that clonazepam was the only medication to assist with the patient’s mood and sleep. It also mentioned that the primary care physician had recommended trazodone but that the prescription was never filled. 

Naturally, I thought about clonazepam and the fall risk for the patient—an older gentleman with Parkinson disease—and about how clonazepam is the “only medication that assists the patient,” according to the consult. I was eager to talk with the patient and his wife and curious about whether there might be pushback when discussing the adverse effects of such a medication, especially in a patient with Parkinson disease.

I was prepared to discuss the risks and benefits of using clonazepam at this dose in an individual with dizziness and falls, compounded by a neurodegenerative disease. Then came a natural pause—one of the moments in the psychiatric interview that can often be just a moment to hold space with the patient.

“He used to thrash in his sleep,” the patient’s wife said.

“Could you tell me a little bit more?” I asked.

The patient’s wife then described years in which the patient would become agitated during the night, moving his legs and arms and sometimes striking his wife during these episodes. The only medication that the patient had used over the last 12 years was clonazepam. When he trialed quetiapine, the thrashing got worse.

Thrashing…in someone with Parkinson disease…got worse with quetiapine…Could this in fact be rapid eye movement sleep behavior disorder (RBD)?

 I quickly went to UpToDate and searched for “treatment” and “first line: clonazepam 0.5 to 1.0 mg qhs.” Then came the “ah-ha” moment.

The patient and his family were never told the actual medical name for “thrashing.” They were never told that the clonazepam was to lessen these episodes. There was no documentation of this diagnosis anywhere in the patient’s direct access chart. It was through digging back 11 years in a remote medical chart and finding one neurology note that said—albeit in 3 letters—“RBD,” with no subsequent explanation, that I realized this was what the patient was experiencing. Could it be true?

This was not about benzodiazepines. It was not about overuse or misuse of the drug. It was about the first-line FDA-approved drug for RBD

—and the only one that worked for this patient. RBD is a disorder in which patients act out their dreams, which is commonly seen with comorbid Parkinson disease.

 This diagnosis was never discussed with the patient and his family, who were also never given a diagnosis to explain the years of sleep disruption. It never made it into the patient’s formal diagnosis list, so it never got carried forward on his problem list.

I immediately wondered how many times this patient must not have been listened to because his wife was asking only for clonazepam. What would have happened if his wife had never mentioned thrashing during sleep in this patient encounter? This certainly could have gone very differently.

Today, when doctors are targeted for irresponsible prescribing practices, how many physicians are hesitant to prescribe what turns out to be the first-line treatment for a legitimate medical condition? Ultimately, that is where the buck stops. 

Sometimes this is due to preconceived notions or scenarios we often play out in our head prior to engaging with patients. Sometimes it is because we do not dig deep enough into medical charts and then make assumptions. And then, there is a staunch reminder that the patient’s story is the center of the encounter. We need to keep an open mind about the patient’s narrative and ensure that it is what remains front and center.

 come into play at times whether we like it or not, especially when it comes to frequently controversial medications. If we do not ask, if we do not explore, and if we do not engage in those moments of holding space with patients, our biases can cloud our judgment and divert patient care in very different directions than intended. 

 to patients, asking them questions, and maintaining an open mind throughout the conversation can be key not only to preventing our implicit biases from taking over, but also to providing more effective patient care.

is a PGY2 psychiatry resident at Nova Southeastern University College of Medicine/Bay Pines VA Healthcare System.

is a medical student at Nova Southeastern University College of Medicine. 

is associate training director of the general adult psychiatry residency program and geriatric psychiatry site director at Nova Southeastern University College of Medicine.

Drug treatment of REM sleep behavior disorder: the use of drug therapies other than clonazepam

2. Howell M, Schenck CH. Rapid eye movement sleep behavior disorder. UpToDate. Updated August 18, 2022. Accessed September 25, 2022. 

https://www.uptodate.com/contents/rapid-eye-movement-sleep-behavior-disorder/print#:~:text=INTRODUCTION%20Rapid%20eye%20movement%20(REM,thrashing%2C%20punching%2C%20and%20kicking

"Our own implicit biases come into play at times whether we like it or not, especially when it comes to frequently controversial medications."

The Importance of Avoiding Implicit Bias in Advocating for Patients

Let’s go into daridorexant a little more deeply, and let’s take in the data from the phase 3 trials. Can you get into some of those? Starting with the randomized, double-blind, placebo-controlled international trials of patients 18 and older, can you start there?

Sure, there were 2 studies. One is called Study 1 on the product label, and it looked at doses of daridorexant at 50 or 25 mg vs placebo, and that included close to 1000 people. That is supported by Study 2, which looked at a lower dose of 25 mg and included a 10 mg dose arm as well compared to placebo, also in close to 1000 people. The bottom line is that 50 mg appears to be the best dose in terms of the effect in helping patients fall asleep faster and stay asleep longer, as well as scores on the IDSIQ [Insomnia Daytime Symptoms and Impacts Questionnaire] sleepiness domain. The 25 mg a night dose still works, numerically it also shows improvements over placebo, but did not separate from placebo statistically on the IDSIQ sleepiness domain score the next day. So putting all the data into perspective here, and if I had to choose a starting dose, I would select 50 mg. However, 25 mg is available, and there may be instances where that may be preferred by the patient under certain circumstances.

So there’s a 25 and 50 mg dose, but there’s no mandate to start with the 25 mg and titrate upward, is that correct?

That’s correct. You can start at 50 mg, you can start at 25 mg, you can give 25 mg and then 50 mg, you can give 50 mg and then give 25 mg. You can do whatever you like with those 2 doses. I look at the clinical trial data, and I ask myself where is the effect size the most robust, and where would I increase my chances of success? It would be with the 50-mg dose.

Now you’ve already said that the 25 and 50 mg both increase the latency to persistent sleep, how long it took patients to get to sleep. It also improved wake after sleep onset, they both did. They both also increased the total sleep time, and you’ve also said that with the IDSIQ score, the next day effects were only improved by the 50 mg. Does that make us want to consider the 50 mg more, and to prescribe that more often because it was the one compared to 25 mg that improved the daytime sleepiness?

Experts discuss daridorexant efficacy and safety data, and dosing considerations and what to communicate with patients when using daridorexant for insomnia.

Covering the Basics: LGBTQ+ Terminology

Affirming Evidence-Based Care for Young Patients Who Are Transgender or Gender Diverse

The Health Care Professional Ethical Choice: Ukraine, Iran, and Whether or When to Risk and Resist

Ukraine Now: Never so Difficult, Never so Easy

The Importance of Avoiding Implicit Bias in Advocating for Patients

Daridorexant Trials for Insomnia Treatment

Dual Orexin Receptor Antagonists (DORAs) in Treatment of Insomnia

To Address Climate Change, This Psychiatrist Goes Where No One Has Gone Before

What’s Your Favorite Holiday Activity?

The Week in Review: November 21-25