 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 -40 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. She has a private psychological practice and heads the Ukrainian Publishing Company UA-TEST.

Articles

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?

I would think so. Some of these measures [such as] the latency to persistent sleep, LPS, and wake after sleep onset, or WASO, they’re polysomnography measures. It may be difficult to wrap our heads around it. I do pay a lot of attention to subjective measures because that’s what I would expect patients to report to me in treatment. So subjective total sleep time is really important. We saw that improvement after 1 week in the clinical trials, and it continues to improve over time, so I pay special attention to that. With the idea of the IDSIQ sleepiness domain score showing a statistically significant degree of improvement over placebo at the 50-mg dose, but not statistically significant at the 25-mg dose, it tells me I probably will be better off with 50 mg. But although it was not statistically significantly different for the 25-mg dose, it was still numerically better, so I wouldn’t completely dismiss the 25 mg dose. There may be instances where a patient may be skittish about trying a new medicine and worried about dosing. They may tell you, “I’m very sensitive to medicine, doctor, and I really don’t want to take too much of it.” The last thing you want is for them to have a complaint when you force a dose they’re not comfortable with. So in those circumstances I would think about a 25-mg dose, but I would also say that the clinical studies tell us that 50 mg is a better dose.

You’ve already said that some of these data that came out were at month 1 and month 3, but I’m aware that the clinical studies showed also weekly increments about how things went with patients over a 3-month period. It seemed like when you looked at the total sleep time and at the IDSIQ that it seemed to build over time. That means that as the patient took the medication, it seemed to do better. Maybe you’re reaching maximum effect at around 5, 6, or 7 weeks. Does this translate into telling our patients that when they take this medication, “Start taking the medicine, but don’t judge it let’s say after the first week or two. Give it longer than that because it seems from the clinical trials that the benefits of it seem to improve over time,” at least when we look at the total sleep time and at the IDSIQ. Is that fair to say?

I’d be a little cautious there because you would expect something like this to start to work right away. A phase 2 clinical trial was done, and it demonstrates that daridorexant does work right away. But the first time point that was measured in the phase 3 clinical trial program for the polysomnography measures was at the end of the first month. And the first time point where subjective total sleep time was assessed was at the end of the first week. But I would expect something like a DORA [dual orexin receptor antagonist] to work right away. I’m glad to see that there is continued improvement over time as someone persists in taking it. That’s good. That’ll be self-reinforcing for the patient to continue that medicine.

I tell patients it should work, it should work pretty quickly, but you do have to give it about a week or so before making any judgment here. I say this particularly for patients who are used to taking other medicines like Z-drugs or benzodiazepine, when they’re used to being knocked out with a sledgehammer. This does not do that, but it does help patients fall asleep faster and stay asleep longer, and that’s definitely true. That’s seen in polysomnography as well as in subjective measures. Patients need to be told it works differently and it will feel different to them. They won’t get that same kind of sensation that they may have gotten with a benzodiazepine, but it’ll still work with their sleep.

This medication as you said earlier has the shortest half-life of all the DORAs; I think you said it was 8 hours or so. Does that translate into next morning residual effects?

If you look at the rate of adverse events, of somnolence or sedation, they are low, and they are comparable to what was observed with placebo, so I wouldn’t expect it to be an obstacle to its use.

Are there any safety data and maybe even dose discontinuation data with daridorexant?

I tell patients that with the DORAs including daridorexant, you can stop it at any time, and there is no rebound insomnia as they may have experienced in the past when they tried to stop their zolpidem abruptly, for example, and it was a disaster for them. They may be very leery about a new sleeping medicine. They may be worried about being physically dependent on it, hooked on it. They don’t want to experience that again. So I have encountered that from time to time in patients who are no longer on a sleeping medicine, and somehow they did manage to wean off it, and they’re very hesitant to start again with something that they worry may be difficult to stop. I can tell them it can be stopped abruptly. There were no withdrawal symptoms, there was no rebound insomnia, and the effects don’t wear off as you continue taking this medicine like it did the last time they were on a hypnotic.

I do run into some patients, and this is quite common in clinical practice, who are continuing to take something like zolpidem every night, and they’ve been taking it for 10 years, and every time they tried to stop it they’d run into problems. They’re not sleeping well. The medicine no longer works for them. I want to offer them a DORA, and I’ll give them the DORA, and then I’ll proceed to wean them off the other hypnotic very slowly, over many weeks. That way I ensure a better experience. If I too abruptly discontinue their prior medicine that they have been taking every night for years, they might experience rebound insomnia. Then they tell me, “This new medicine you gave me doesn’t work at all.” In fact, it’s not the new medicine; it’s the withdrawal effects from their old medicine.

So, one way of going from a present sleeping medication to another is to have an overlap period with a discontinuation gradually of the first medication.

Videos

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

Daridorexant Trials for Insomnia Treatment

Let’s talk about the dual orexin receptor antagonists, or DORAs. How do they impact sleep and wakefulness cycles?

Just a quick recap of these orexin neurons; their cell bodies are in the hypothalamus, we only have about 50,000 of them, they project to various parts in the brain, and they keep us awake. Now, people with insomnia, they’re working overtime. The dual orexin receptor antagonists block those receptors in the brain and help someone fall asleep and remain asleep. It’s very different than knocking someone over the head with a sledgehammer with a Z-drug or a benzodiazepine.

: What advantage, if any, would a DORA offer compared to other treatments that you said are like using a hammer to put them out? What advantage would a DORA necessarily offer?

In addition to not deleteriously affecting sleep architecture, long-term use of DORAs is not associated with tolerance. That’s huge. It’s not associated with withdrawal or rebound insomnia when abruptly stopped, so that’s huge too. It continues to work, in fact they are tested. There are 3 of them in the marketplace here in the United States, and they’ve been tested as daily, once a night treatment for insomnia disorder. They’re not PRNs taken as needed, they weren’t studied like that, and they’re not middle of the night drugs. They were all designed to be taken 30 minutes or so before falling asleep when you have about 7 hours ahead of you to be asleep, and taken every night. This is a very different approach than in the past where you’d take something to knock yourself out, and maybe at 2 in the morning repeat again. A very different approach. This is much more thoughtful in terms of saying you have insomnia disorder, here’s how to treat it, here’s a medicine, you take it every night, and your sleep is better regulated.

So you’re targeting the hypervigilance and hyperactivity that’s keeping somebody awake as opposed to doing what you’ve been doing with the benzodiazepines. Now many DORAs have been studied in insomnia, and 3 are FDA approved. The first one that came out was suvorexant, the second lemborexant, and the third daridorexant. Can you tell us how these are different in their pharmacologic and pharmacodynamic properties?

The 3 drugs—suvorexant, lemborexant, and daridorexant—share in common affinity toward the 2 orexin receptors. They’re called No. 1 and No. 2; I guess there was a lack of imagination among those who called them those names. Basically they are dual orexin receptor antagonists, and they have somewhat different affinities to 1 or 2. I don’t think that’s the major difference between these 3. The drugs are very different in terms of their pharmacokinetic profiles, some have longer half-lives, for example. The most recently approved DORA, daridorexant, has a half-life of about 8 hours or so. It’s the shortest, and when you look at the pharmacokinetic curve, the concentration curve over time, you reach a maximum concentration in about an hour or two, and then the concentration drops off. The exposure is primarily when someone is in bed, when they’re supposed to be sleeping, and there are no carry over effects the next day, and there’s no accumulation. That in itself is very attractive, the pharmacokinetic profile itself.

As far as suvorexant and lemborexant go, they have longer half-lives, which may spill over into the next day, so that may have some bearing on some of the adverse effects. Is that possible?

It is possible. I’m not sure how relevant clinically that would be for most people, but the rates of somnolence the next day are somewhat higher for lemborexant than they are for daridorexant.

Drs Paul Doghramji and Leslie Citrome provide an overview of dual orexin receptor antagonists (DORAs), suvorexant, lemborexant, and daridorexant, in treatment of insomnia disorder.

Dual Orexin Receptor Antagonists (DORAs) in Treatment of Insomnia

 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

” I bemoaned the slowness of society and psychiatry to help reduce climate change and instability. I asked for creative ways to obtain climate attention. I found one by serendipity.

The Benefits and Limitations of Resilience

Cheerful and Tearful Over Thanksgiving Weekend

,” I had CNN on in the background. I was catching a bit about someone who was flying balloons around the earth to save fossil fuel. Then he was being interviewed and I stopped writing to listen. To my great surprise, he was also identified as a Swedish psychiatrist: Bertrand Piccard, MD. I had never heard of him.

The last name of Piccard may remind some of the 1980s TV series of “Star Trek—The Next Generation,” where Patrick Stewart played Captain Picard (with 1 c), with the slightly revised introductory phrase: “where no one has gone before.” The “Star Trek” use of the last name was in honor of the 3 generations of Piccards who have been renowned adventurers. In 1999, Bertrand made history with the first nonstop balloon flight around the world, topping that in 2016 when he did the same with a solar-powered airplane.

Dr Piccard’s conclusion was that renewable energy can be harnessed to achieve seemingly impossible goals. To help that occur, he founded the Solar Impulse Foundation to jumpstart numerous alternative energy projects.

Intermittently, among all these adventures, he not only continued to practice psychiatry, but realized that applying psychiatric principles about inner space was essential to his success in outer space.

He turned some of these psychiatric principles into what he felt were universal aphorisms:

“You must overcome the past by doing something in the present that helps you in the future.”

In his clinical work, he encouraged patients to build confidence through novel experiences. The ensuing aphorism, applicable to both patients and the public, is:

“Routine is more dangerous than adventure.”

In his outer space explorations, he came to realize how fragile our planet is to be able to maintain human life. Because his personal revelation came in such a unique situation, he felt that to attract a large audience, he needed to be inspiring. Once again, the psychiatric perspective was a key:

“My experience as a psychiatrist is that you have to speak the language of the people you want to convince. . . I had to tell them something that would wake them up.”

 and his Ted Talks strikingly convey, Piccard can be a model for what we in psychiatry can contribute uniquely to our climate and environmental challenges. As he maintains, outer and inner space can be usefully explored using the same principles!

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. Taub B. Bertrand Picard’s Laps Around the World. 

. October 3, 2022. Accessed November 28, 2022. 

https://www.newyorker.com/magazine/2022/10/10/bertrand-piccards-laps-around-the-world

Psychiatry and inner space—closer than you think. 

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

Do you have any specific traditions that you enjoy with your loved ones during the holidays? If so, 

Contact us now to be part of our Holiday Traditions series, a special content series where mental health clinicians will share their favorite holiday traditions. If you would like to contribute a brief article, poem, or video about your holiday traditions, write us at 

Tell us about your holiday traditions for a chance to be featured in our Holiday Traditions series.

What’s Your Favorite Holiday Activity?

 covered a wide variety of psychiatric issues and industry updates, from the unique challenges of treating physician-patients to updates on MDMA and psilocybin research and access. Here are some highlights from the week.

Concurrent Treatment With SRIs and Anticoagulants: Minimizing the Hemorrhagic Hazard

Serotonergic antidepressants (SRIs) are among the most commonly prescribed medications and play important roles in treating depression, anxiety, agitation, and other behavioral syndromes. Data from 2015 to 2018 published by the National Center for Health Statistics show that during those years, 13.2% of adults aged 18 years and over reported using an antidepressant medication within the preceding 30 days. Women aged 60 years and older reported a rate of 24.3%.

The SRIs include selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs). Although the SRIs’ adverse effect profiles are milder than those of the earlier tricyclic antidepressants and monoamine oxidase inhibitors, SRI treatment is nonetheless associated with several potentially problematic adverse reactions including effects on sexual function, sleep, appetite, and sodium regulation. Another important adverse effect of SRIs is their association with increased bleeding. Their serotonin reuptake blocking effect not only improves depression through its activity in the brain, but also interferes with normal hemostasis by diminishing platelets’ accumulation of serotonin, which cannot be synthesized by a platelet. 

Senators Introduce New Bill to Promote Research and Access to MDMA, Psilocybin

Senators Cory Booker (D-NJ) and Rand Paul (R-KY) introduced a new bill, the Breakthrough Therapies Act, that would allow the Drug Enforcement Administration to make findings to reclassify MDMA and psilocybin as schedule II drugs. MDMA and psilocybin are currently schedule I substances and have “no currently accepted medical use and a high potential for abuse,” according to the Controlled Substances Act.

“Recent studies suggest that some schedule I substances such as MDMA and psilocybin could represent an enormous advancement for the treatment of severe post-traumatic stress disorder, depression and addiction,” Booker said. “Unfortunately, regulatory red tape and a series of bureaucratic hurdles involved in studying schedule I substances impedes critical research on these and other promising schedule I compounds.” 

“Oh No, My Patient is a Physician!” Hurdles When Treating Physician-Patients

Control is a powerful tool and can affect every aspect of daily life. Within the medical field the term control has its own implications, especially when treating patients. There is an unspoken bond that control is relinquished by the patient and given to the physician in hopes of recovering from the illness. What happens when the physician is the one in need of treatment? What happens when the physician perceives themself as ill and weak?

Physician-patients can be very reluctant to give control of their medical health to another person. The general public is taught from a young age that “the illness belongs to the patient” and that physicians are supposed to be invulnerable. When they are sick, they can be in a world of denial and feel forced to bear the torment of their illness alone. Therefore, physicians may delay seeking medical help; when they do, they may also project their own feelings onto the treating physician, or transference. On the other hand, it is very easy for the treating physicians to project their own feelings onto the physician-patient, or countertransference. 

After the tragic mass shooting in a LGBTQ+ club in Colorado Springs over the weekend, Nietzsche’s well-known statement takes on tragic proportions. Five were killed, and many more wounded. There will be inevitable traumatic ripples into the wider LGBTQ+ communities, and those who love them.

The goal of trauma recovery will include resilience. Resilience is the ability to bounce back stronger after trauma with the supportive help of community and a vision for the future. That vision, which we have discussed in the last 2 columns, must include less violence and hate toward LGBTQ+ individuals. Generally, resilience is thought to be a positive characteristic, even a panacea for getting through trauma stronger. Yet, like most good things in life, too much resilience may be problematic at times. Why? How could increased psychological strength be a problem? 

. And 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 

From the unique challenges of treating physician-patients to updates on MDMA and psilocybin research and access, here are highlights from the week in Psychiatric Times.

The Week in Review: November 21-25

Research increasingly is finding a heavy mental health burden among 

+. Now, new data indicates gender-affirming therapy may help address an increased risk of sleep disturbances among this patient population.

Ronald R. Gavidia Romero, MD, MS, clinical assistant professor of neurology at the University of Michigan Medical School, and colleagues conducted a retrospective cross-sectional study utilizing a large US-based administrative claims database. Participants included 1,216,044 youth aged 12 to 25 years, of which 2603 (0.2%) identified as 

(TGNC). About half (1387) pursued gender affirming therapy (GAT); 868 and 519 were identified as transmasculine and transfeminine, respectively.

In comparison with cisgender youth, TGNC youth had higher odds ratios (OR) of insomnia (OR = 5.4, 95% confidence interval 4.7, 6.2), sleep apnea (OR = 3.0, 95% confidence interval 2.3, 4.0), and other sleep disorders (OR = 3.1, 95% confidence interval 2.5, 3.9). However, data indicated that GAT had a positive impact on reported sleep disorders. Romero and colleagues found a decreased risk of 

 for TGNC youth who were receiving GAT as opposed to those who were not receiving GAT (OR = 0.5, 95% confidence interval 0.4, 0.7).

“This study demonstrated a high burden of sleep disorders in TGNC youth in comparison to cisgender,” Romero and colleagues concluded. “However, GAT may confer a protective effect on sleep disorders among TGNC youth. Longitudinal assessments of sleep disorders prior to and post-GAT are needed to uncover their temporal relationships.”

1. Gavidia R, Whitney DG, Hershner S, Selkie EM, Tauman R, Dunietz GL. 

Gender identity and transition: relationships with sleep disorders in US youth

New research explores the impact of GAT on TGNC youth. 

 Leveraging GAT to Address Sleep Burden in Youth

Richard Berlin, MD, shares his poem "On Transience," which is featured in the December issue of 

and decay, Freud responding empathically,

of loss. And to explain the poet’s sadness,

which are thus in a sense taken into our ego

when I struggle to unpack Freud’s terms

for psych residents, they only give me grief.

Young men with slide shows and loosened ties

and compete with psychoanalysts for leadership,

their theories of “chemical imbalance”

and neurotransmitters raising hope for cures

of schizophrenia, depression, and anxiety.

by a photo of a smiling young psychiatrist

early career colleagues with senior mentors

management with psychotherapy, an approach

Behind his couch, Freud senses summer’s

return, draws a puff, flicks the ash, smiles

has been writing a poem about his experience of being a doctor every month for the past 24 years in the

“Poetry of the Times” column. He is instructor in psychiatry, University of Massachusetts Medical School, Worcester, Massachusetts. His latest book is

"For no particular reason I lift my dusty volume of Freud’s Standard Edition from a shelf..."


"On Transience"

As I presented at a Thanksgiving presentation and discussion this past Sunday, I viewed this Thanksgiving as extra special because the lessening of the COVID pandemic allows more live get-togethers. I called it COVID Relief Thanksgiving. Yet, because of the mortality and morbidity of COVID, there will also be sadness. Although it is usually considered a happy and inclusive holiday in the media, Thanksgiving is much more complex than that.

Add 30 Exclamation Points to “Remember Transgender Individuals This Weekend”!

The gratefulness we are supposed to feel on Thanksgiving Day is often laced with anxiety over the quality of the food, the family dynamics, missing members, and political divisiveness. To address that, I devised an acronym that can also be applied to other holidays that bring family and friends together. It is called CHEERFUL, which stands for:

Many already told me they are using it, including a man who was grieving the recent death of his wife:

“Trying to be cheerful, as you suggested in your talk.”

In addition, the day after Thanksgiving, when many are also off from a formal workday, is also full of complexity and contradictions. This Friday is known as Black Friday, when people pursue sales of merchandise, a celebration of capitalism for those who have enough money and opportunity. But that Friday was federally designated as Native American Heritage Day in 2008. However, many Indigenous designate it as a National Day of Mourning because Thanksgiving has historically been associated with the decimation and displacement of Native Americans.

As I discussed on Sunday, one example goes back to 1863-1864. In October of 1863, while still in the midst of the Civil War and all the anxiety about it, President Lincoln made Thanksgiving an annual national holiday. Yet, no thanks to the Indian Removal act of 1830, the Navajo Long Walk began in early 1864, where thousands were marched over 400 miles from their homelands in desirable Arizona territory to New Mexico. Much morbidity and mortality occurred along the way.

These associations left me coming up with a different acronym for today, the other side of the Thanksgiving coin. It is TEARFUL, which stands for:

Given the continuing divisiveness and xenophobia in the United States, our challenge is to provide equity and understanding across our cultures, including the social disparities in psychiatric care. Thanking Native Americans for using their land—as is done at many events—that was taken away from them will not cut it. At most, it may be heard as value postering without real corrective action. Profits from their gambling casinos help, but only getting back some of the better lands, appreciation of their cultural values, and reduction of their higher prevalence of mental disorders, will provide a Thanksgiving of adequate thankfulness.

The two sides of the Thanksgiving coin… what are they and what do they mean? 