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Needs Assessment: Patients with chronic kidney disease represent a substantial and growing segment of the population. CME Accreditation Statement: This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the Mount Sinai School of Medicine and MBL Communications, Inc. Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM.
Faculty Disclosure Policy Statement: It is the policy of the Mount Sinai School of Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine.
To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. In the chronic kidney disease (CKD) population, problems with sleep have been linked to disability days, healthcare utilization, and quality of life (QOL) for dialysis patients.
Self-reported sleep quality is the subjective integration of sleep disturbances and satisfaction with sleep. The hemodialysis population’s sleep quality has been linked to disability days, healthcare utilization, and quality of life (QOL) for dialysis patients. The Figure advocates the approach to this high-risk group’s sleep disorders in which clinicians recognize sleep disorders using patient interviews and screening tests. Insomnia, which involves difficulty falling asleep, maintaining sleep, or waking early in the morning with associated daytime difficulties, is very common among patients with ESRD. Sleep apnea leads to repetitive episodes of hypoxemia, hypercapnia, sleep disruption, and sympathetic nervous system activation. Severe sleep apnea has a higher prevalence among dialysis patients than the general population. Sleep apnea has been associated with decreased HRQOL, mood disturbances, and reduced libido. Sleep apnea has also been shown to increase risk of cardiovascular disease in ESRD patients. A study on when to initiate therapy for sleep apnea in the ESRD population has never been conducted. Since the sleep apnea associated with uremia may be secondary to the effects of uremic toxins, some investigators have examined dialysis’ impact on sleep apnea. While RLS is a syndrome diagnosed using a validated questionnaire based on standard criteria, the periodic limb movements (PLMs) diagnosis requires monitoring of leg movements overnight. The substantial population of patients with CKD and kidney failure will continue to increase with the population’s age.
Further work and refinement should be done on both the screening tools for sleep disorders and on the role of screening in this population with an exceedingly high prevalence of sleep disorders. Why has the eighth edition of The Comprehensive Textbook of Psychiatry (CTP) been so successful? Each edition reflects the latest advances in the field, so the book is fresh and up to date. The goal has always been and remains to foster professional competence and to ensure the highest quality care to all those who suffer from mental illness.
One of the most common aphorisms in gestalt psychology is if one needs to mail a letter, one is always looking for mailboxes.
It is all challenging, but the most enjoyable aspects are both getting to know and working with the contributors. Based on your experiences as both one of CTP’s editors and a practicing psychiatrist, what changes have you seen in psychiatry?
Much has changed since I began practicing in 1963 after I finished my residency at Bellevue; however, much has remained the same. In the 1930s, the psychiatrist Karl Menninger, MD, said that defining new syndromes is an addiction of psychiatrists. In addition, the psychopharmacologic revolution occurred during my career and transformed the practice of psychiatry. Social workers, psychologists, and other mental health professionals often utilize group psychotherapy, which is extraordinarily effective and therapeutic.
The first experience that influenced my career choice was a 3-month elective at King’s Park State Hospital in New York for which I signed up during medical school. The innovators in psychotherapy such as Aaron Beck, MD, and Gerald Klerman, MD, had a profound effect on my career as it progressed. Needs Assessment: This article facilitates knowledge as it relates to the safe and judicious use of psychotropics in individuals with deteriorating kidney function. This article provides a pragmatic and clinically accessible approach to the selection and dosing of psychotropics for individuals with suboptimal renal function (SRF).
Clinical studies indicate that individuals with renal disease are differentially affected by mental disorders.3 The co-occurrence of mental and renal disorders invites the need for familiarity with the safety, pharmacokinetic profile, and efficacy of psychotropics in individuals with SRF.
This article provides a clinically accessible and pragmatic review of the effect of SRF on the handling of psychotropics. Bioavailability denotes the extent to which a dose of drug enters the systemic circulation. Alternatively, SRF (ie, uremia) may be associated with an increase in drug bioavailability. Mechanisms mediating altered volume of distribution in states of SRF are edema, which is related to hypoalbuminemia and consequent fluid retention, and muscle wasting. Alternatively, for SRF patients undergoing renal transplant or hemodialysis, the circulating concentration of α1-acid glycoprotein may increase.
Drugs are excreted through the gastrointestinal tract by three exclusive pathways, including inabsorption, active secretion into the gastrointestinal lumen, and excretion via the biliary system.
Several studies indicate that in states of SRF, the overall burden of treatment-emergent adverse events is increased. Patients receiving dialysis treatment require special attention with regard to dosing regimens and the potential need for supplemental dosing following dialysis. Drug dialyzability is determined primarily by several physical and chemical characteristics of the drug. Lithium and Nephrotoxicity: At What Glomerular Filtration Rate Should Lithium Be Discontinued?
The predominant form of chronic renal disease associated with lithium therapy is a chronic tubulointerstitial nephropathy (CTIN). Taken together, studies indicate that a small number of patients treated with lithium develop progressive renal damage (associated with CTIN). Prognosticating which individuals will progress to ESRD has substantial clinical importance. In addition to its predictive value for the irreversible onset of kidney failure, the GFR level is also strongly associated with the risk of complications from SRF. Side by side with prognostication interventions, strategies for minimizing the renal effects of lithium should also be implemented. It should be noted that equations estimating GFR based on serum creatinine (eg, Cockcroft-Gault formula) are more accurate and precise than estimates of GFR from serum creatinine measurements alone.2 Therefore, in a clinical setting, serum creatinine levels should be examined in addition to reporting the estimated GFR. Given concerns over renal safety and excretion, efforts should be made to substitute other drugs for lithium in patients with SRF. In ESRD, the dosage of lithium must be reduced in order to prevent toxicity, so at low levels of renal function the dosage should be 25% to 50% of the usual dose and should be monitored carefully by blood levels (Table 3).4,53 Treatment involves administration of a single dose (usually 600 mg) after each dialysis run. There is some preliminary evidence that SSRIs have a role in the treatment of depression in patients with ESRD.
Squamous cell carcinoma has a high cure rate if found and treated early, but it can be deadly if it is left untreated and spreads.
Squamous cell skin cancer is the second most common form of skin cancer in Canada after basal cell skin cancer. Although actinic keratoses are not true skin cancers, it is important to have these lesions treated as they have the potential to change into squamous cell skin cancers. This group has a high rate of sleep complaints and has recently been shown to have a high prevalence of insomnia, sleep apnea, restless legs, and periodic limb movements.
The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Physicians should only claim credit commensurate with the extent of their participation in the activity. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship.
Hollander and Sussman report no affiliation with or financial interest in any organization that may pose a conflict of interest. Unruh is assistant professor of medicine in the Renal-Electrolyte Division at the University of Pittsburgh School of Medicine in Pennsylvania. Unruh is a consultant to Qualitymetric and receives grant support from the National Institute of Health, the National Kidney Foundation, and the Paul Teschan Research Fund. It is associated with the inability to excrete waste products, control serum electrolytes, handle the daily dietary and metabolic acid load, and maintain fluid balance. Studies of patients on maintenance hemodialysis have found that 50% to 80% of dialysis patients experience some sleep complaint or excessive daytime somnolence.6 The patient perception of sleep quality is important since there is neither a laboratory variable nor a polysomnography (PSG) finding that can serve as a surrogate for telling how patients feel about their sleep. The interventions used to treat sleep disorders are both graded by the severity of the complaint and tailored to this special population.
Up to 75% of dialysis patients experience insomnia,1 but the possible connection between insomnia and RLS in this population has not been investigated. Sleep apnea can be obstructive if respiratory effort persists during upper airway occlusion, central if both respiratory effort and airflow cease, or a combination of the two. The prevalence of severe sleep apnea among a community-based sample of hemodialysis patients was four-fold higher than an age-, sex-, race-, and body mass index (BMI)-matched comparison group.17 Sleep apnea in ESRD is likely due to factors related to uremia and volume overload. It leads to the poor daytime experiences of those on dialysis19 by causing excessive daytime sleepiness and diminished QOL.3 Among patients with ESRD, sleep apnea may contribute to fatigue, tiredness, and lack of energy. The high rate of sleep apnea among patients undergoing hemodialysis has been proposed to negatively impact HRQOL and cognitive function performance measures of cognitive function. Sleep apnea in those with ESRD disrupts the normal non-rapid eye movement (REM) sleep, and vagal heart rate modulation is attenuated while sympathetic modulation predominates.
Similar to the general population, one should consider the severity of sleep apnea, hypoxemia, hypertension, and daytime symptoms. The use of intravenous iron in RLS treatment among ESRD patients has been studied in a small randomized study examining both short-term changes in symptoms and adverse effects of intravenous iron.43 Hemodialysis patients who were determined to have RLS by IRLSSG criteria were administered either 1,000 mg of iron dextran or normal saline intravenous (IV) in a blind fashion. This patient population has a remarkable rate of sleep complaints and has been shown to have a much higher prevalence of sleep disorders than the general population.
In addition to screening, the management of patients with ESRD and comorbid sleep disorder needs further study. Sleepiness, sleeplessness, and pain in end-stage renal disease: distressing symptoms for patients. Prevalence, severity, and importance of physical and emotional symptoms in chronic hemodialysis patients. Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6,800 persons over three years.
Hemodialysis timing, survival, and cardiovascular outcomes in the Hemodialysis (HEMO) Study.
Randomized placebo-controlled trial of continuous positive airway pressure on blood pressure in the sleep apnea-hypopnea syndrome.
Sleep apnea in patients on conventional thrice-weekly hemodialysis: comparison with matched controls from the sleep heart health study.



Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study. Sleep disordered breathing in ESRD: acute beneficial effects of treatment with nasal continuous positive airway pressure. Improvement of sleep apnea in patients with chronic renal failure who undergo nocturnal hemodialysis.
Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. Reliability of a questionnaire screening restless legs syndrome in patients on chronic dialysis. Clinical and biochemical findings in uremic patients with and without restless legs syndrome. Restless legs symptoms among incident dialysis patients: association with lower quality of life and shorter survival. Periodic leg movements are not more prevalent in insomnia or hypersomnia but are specifically associated with sleep disorders involving a dopaminergic impairment.
Potential novel predictors of mortality in end-stage renal disease patients with sleep disorders.
A preliminary study of the effects of correction of anemia with recombinant human erythropoietin therapy on sleep, sleep disorders, and daytime sleepiness in hemodialysis patients (The SLEEPO study).
A double-blind, placebo-controlled trial of intravenous iron dextran therapy in patients with ESRD and restless legs syndrome. Sadock reports no affiliation with or financial interest in any organization that may pose a conflict of interest. Our contributors are carefully chosen for expertise in their various areas and the material is edited to create a readable and coherent whole. It is geared to provide clinicians with both the broadest and the most thorough base of knowledge so they can offer the best care for their patients. Any young psychiatrist who has to take the American Board’s written exam will describe months of studying and memorization to accumulate that hard data. The editors must flesh out an outline that covers the past, present, and future of psychiatry. For example, I began my career using the 1st edition of the Diagnostic and Statistical Manual of Mental Disorders3 (DSM), which had under 100 diagnostic categories. We can now provide almost immediate relief to patients with intractable anxiety, depression, and psychosis. Criteria can be used to determine how well therapy is working, but they are not tangibly verifiable. I lived on the hospital grounds and spent each day seeing and talking to severely mentally ill patients.
Also provided are tactics and strategies to the selection, sequencing, and dosing of psychotropics across disparate patient populations which share in common kidney failure. McIntyre is associate professor of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit at the University Health Network at the University of Toronto in Ontario, Canada.
The authors conducted a PubMed search of all English-language articles published between 1977 and 2007. Hitherto, the evidentiary base which informs the selection, dosing, monitoring, and sequencing of psychotropics in SRF is woefully inadequate. An oral dose is first absorbed from the gastrointestinal tract subsequently passing through the liver wherein metabolism and biliary excretion may occur.4,7 In SRF, a decrease in bioavailability for some agents occurs at the level of drug absorption from the gastrointestinal tract. The two overarching factors influencing distribution are the volume of distribution and protein binding.
Edema alters the apparent volume of distribution of drugs, particularly those of high hydrophilicity, by expanding the extracellular fluid volume. Moreover, in states of SRF, albumin undergoes conformational changes with hypothesized changes in binding properties.5 Taken together, SRF results in diminished protein binding and an increase in the bioactive free fraction of acidic drugs in plasma. In most jurisdictions, laboratory evaluation does not parse out and separately evaluate the unbound and biologically active fraction.
The need for supplemental dosing is determined by the extent to which a drug is removed by dialysis (ie, drug dialyzability). These include molecular size, protein binding, water solubility, volume of distribution, and plasma clearance (ie, the sum of renal and non-renal clearance). This condition is often heralded by the insidious development of renal insufficiency, with little or no proteinuria, often in the setting of chronic nephrogenic diabetes insipidus. Despite withdrawal of lithium, several patients have been reported to develop ESRD after long-term lithium exposure (ie, >20 years) requiring dialysis therapy. A single report documented that serum creatinine levels could serve as a useful biomarker in categorizing individuals at risk for progression.
Examples include diabetes, hypertension, family history of kidney failure, and ethnicity (ie, African Americans, American Indians, Hispanic Americans). However, discontinuation of lithium in long-term lithium responders often exposes individuals to the risk of severe recurrences of bipolar disorder or even an uncontrollable worsening in the course of the illness, and so the psychiatric risk also has to be taken into account despite availability of other mood stabilizers (ie, antipsychotics or anticonvulsants).58 Moreover, some bipolar patients with ESRD do not respond to the anticonvulsants or antipsychotics that are often used as alternatives to lithium. A single dose will result in a steady serum level and, as a result, no supplemental lithium is required.
Only one small study was identified in a recent comprehensive Cochrane review63 of randomized clinical trials. This type of skin cancer fortunately is the least dangerous but must be treated since it will continue to grow, invading and destroying surrounding skin tissue, eventually causing disfigurement. This form of skin cancer must be treated because the lesion may continue to grow in size, damaging surrounding tissue, and may spread to other areas of the body. When found at an early stage, melanoma has one of the highest cure rates of all cancers at more than 90 per cent.
Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices.
Early submission of this posttest is encouraged: please submit this posttest by January 1, 2010 to be eligible for credit. Studies in the general population have linked these problems to greater use of health services, increased use of hypnotics, and reduced functional capabilities. In addition, kidney failure causes inadequate production of erythropoietin, deranged calcium and phosphorous metabolism, difficulties with high blood pressure, and accelerated progression of cardiovascular disease. Neuroimaging studies have suggested that patient self reports may reflect neurophysiologic findings a PSG does not measure.7 Furthermore, those with insomnia complaints can have PSG findings comparable to normal sleepers. The most common metric for sleep apnea is the apnea-hypopnea index (AHI), which is the number of apneas and hypopneas in 1 hour of sleep.
In a community-based study of the general population, the risk factors for sleep apnea were obesity, male sex, and neck circumference.18 These risk factors have not been associated with sleep apnea among patients with ESRD,19 perhaps due in part to the small number of patients studied. Daytine functioning aspects have shown to be diminished in ESRD patients.23 Furthermore, these aspects are thought to be intimately linked to sleep and are negatively impacted by sleep apnea. While the estimates of RLS among the hemodialysis population range up to 10 times more frequent than the general population,30 the etiology and risk factors for RLS in those with ESRD remain unclear.
However, the use of a single time point has been shown to be subject to bias from marked day-to-day variability in PLMs.
Eleven patients were randomly assigned to the iron dextran administration, and 14 patients were randomly assigned to the saline IV administration. For example, patients undergoing hemodialysis in the evening with severe symptoms of RLS may benefit from a change to the morning shift during which symptoms of RLS may be less intense. It may be that poor sleep and sleep disorders contribute to the substantial morbidity and mortality found in patients with kidney failure.
If a patient has severe sleep apnea, does CPAP or changing the dialysis prescription best serve the patient?
Gregory professor of psychiatry and vice chairman at the New York University (NYU) School of Medicine.
Like the first edition of CTP, the eighth edition abundantly uses illustrations, photographs, and charts, making the content easier to follow, especially in a book if this size.
Psychiatry, like all medical fields, is an art, but it has continuously been burdened with the myth that it is all art and no science.
In addition, the stigma associated with mental illness exists in so many aspects of our society, including the insurance industry, government, the public, and even the medical profession. I am in the former group, constantly aware of what is happening in the field of psychiatry. Although it has been an amazing advance, there may have been too many editions of and changes in the manual without any real evidence-based data. The advances in psychotherapy also have been tremendous; ie, cognitive, interpersonal, and dialectical behavior therapy.
It remains a very important modality, but unfortunately, psychiatrists are not being trained as much as they should be in the practice.
Overly medicated with chlorpromazine, barefoot and dressed in drab hospital pajamas, patients shuffled around, oblivious to their movement disorders. Changes in these factors would be predicted to alter distribution of any drug administered. This effect is predicted to result in dilution of the drug and hypothetically requiring an increase in dose. A marked lowering of blood levels will occur upon dialysis in patients receiving medication that is dialyzable (of the psychotropics, namely, lithium, gabapentin, and pregabalin). In addition, technical aspects of the dialysis procedure (eg, dialysis membrane and flow rates) may also determine drug dialyzability. With further progression of renal insufficiency, there is the appearance of renal fibrosis which may progress, despite elimination of the offending agent (ie, lithium), to ESRD.54 A consensus does not exist as to when lithium treatment should be discontinued in the context of diminishing kidney function. Complications include hypertension, malnutrition, anemia, bone disease, neuropathy, and reduced functioning and well being (eg, depression).
Additionally, some patients whose illness is well controlled by lithium therapy refuse to consider interruption and substitution (ie, psychological dependence). At the next dialysis, which removes the lithium from the body, the same single dosing should be repeated.4,61 Serum lithium levels obtained before and after dialysis sessions are used to establish the proper dose. The need to address sleep quality in the CKD population is highlighted by the 15% to 31% prevalence of hypnotic use. In addition, physicians should consider the removal of aggravating medications when possible since ESRD patients take a median of eight to 10 prescription drugs daily. However, several approaches could optimize sleep hygiene, screen for other sleep disorders, use a brief trial of cognitive-behavioral therapy and hypnotics, or consider a sleep study in patients that remain symptomatic. Sleep apnea causes gas exchange abnormalities, sleep fragmentation, and autonomic activation, all implicated causes of substantial adverse health effects.15 This disease commonly produces daytime sleepiness, decreased QOL, and impaired cognitive ability. In 49 ESRD patients, those with sleep apnea had a higher apneic threshold and a higher sensitivity to hypercapnia.20 These results suggest that central and peripheral chemoreceptor sensitivity is increased in patients with sleep apnea and ESRD, leading to destabilization of respiratory control during sleep. Investigators have demonstrated that sleep apnea causes restless sleep and daytime somnolence as well as complaints of memory difficulties and inability to concentrate. Can patients with sleep disorders tolerate nocturnal dialysis, the seemingly best treatment for uremic sleep apnea? He is attending psychiatrist at the Bellevue and Tisch Hospitals and is consulting psychiatrist at Lenox Hill Hospital. Whether I am reading The New York Times, The Wall Street Journal, The Green Journal, or any other piece of literature, ideas for the book are constantly being generated.
For example, John Nemiah, MD, Editor Emeritus of the American Journal of Psychiatry, has contributed to every edition of the book since its beginning. Finding a contributor with writing skills is not easy, but the editing process is heavy and improves the writing.


These are just a few that did not exist when I started practicing, and we have to make sure this trend continues. For example, the patient’s well-being is key in terms of determining psychotherapeutic benefit.
Despite their condition, they were eager to talk, and I spent hours listening to  their intriguing stories. He gave me Silvano Arieti, MD’s book, Interpretation of Schizophrenia,5 in which the author describes schizophrenia in extraordinary detail. Alternatively, muscle wasting, dehydration, and cachexia, all of which are commonly encountered in SRF, are predicted to decrease the apparent volume of distribution, possibly inviting the need for dose reduction. Furthermore, the risk of progression to ESRD is considerably increased below this GFR level. When it reaches the blood stream or the lymphatic system, it has a chance to spread to other parts of the body and often causes death. Among incident dialysis patients, patients with poor sleep quality were more likely to report poor physical and mental well being, decreased vitality, and more bodily pain.
Chronic kidney disease (CKD), the term used to describe a chronic decrease in GFR, has different levels. The response to treatment should be monitored with sensitive instruments, medical follow-ups, and assessments of the patient’s overall well being. For those undergoing hemodialysis, it may be reasonable to move the shift to earlier in the day, consider thermoneutral hemodialysis, and ask the patient to avoid napping during treatments.
While alteration in chemosensitivity during sleep may explain the development of sleep apnea in ESRD patients, other factors such as extracellular fluid volume overload leading to upper airway edema21 and reduced upper airway muscle tone due to uremia compromising upper airway patency in ESRD22 likely contribute to the severity of sleep apnea in uremic patients. As a result of sleepiness, the cognitive disturbances may lead to increased use of sick days at work. The vitality, social functioning, and mental health domains in the 36-item short-form health survey (SF-36) and the emotional reactions from the Nottingham Health Profile (NHP) were significantly higher in those without sleep apnea. While 10 patients with sleep complaints were on recombinant human erythropoietin (rHuEPO) therapy, they were studied by PSG while moderately anemic (mean hematocrit=32.3%). The treatment of insomnia, sleep apnea, short sleep, and RLS may improve this population’s QOL, functional status, and mood.
Does the treatment of sleep apnea improve the poor sleep quality, mood, and fatigue in patients with medical comorbidity?
The second, clinical area includes examination and diagnosis, classification, and the clinical disorders. In the first edition, for example, there were only 40 pages on subjects like neurochemistry and neurophysiology. We dedicated many editions of the book to those who work and care for the mentally ill because doing so is an exceedingly difficult job. Although contributors are contacted both through e-mail and by telephone, meeting with them directly is not necessarily common.
For example, diagnosis of compulsive buying disorder is being considered, and I once reviewed a book in which the author suggested a diagnosis of compulsive credit card usage disorder. He describes how sometimes one may have to spend hours with a schizophrenic patient in order to get him or her to relate to the psychiatrist. Due to heterogeneity in manuscript quality and scientific methodology as well as a dearth of available adequately powered controlled studies, an inclusive approach was taken. While there are many causes for poor sleep in patients with kidney disease, such as depression, insomnia, restless legs, and periodic limb movements, sleep apnea may be the most common.
Its prevalence is rapidly increasing worldwide, and the projections are that the number of patients with kidney failure will double in the next 10–15 years.
Those using overnight peritoneal dialysis may need to adapt their regimen to avoid both frequent alarms and abdominal discomfort.
The contribution of uremia and volume overload to sleep apnea pathogenesis in ESRD patients has been supported by the improvement in sleep apnea following changes from hemodialysis to nocturnal hemodialysis, use of automated peritoneal dialysis, and KTx. Both poor social functioning from the SF-36 and emotional reactions from the NHP were independently associated with the AHI after adjusting for BMI. The patients were studied again when hematocrit was normalized (mean hematocrit=42.3%) through increased rHuEPO dosing. The recommendations for sleep disorder treatment in this high risk population reflect an evolving understanding of sleep disorders, particularly in populations with medical comorbidities.
Sadock is diplomate of the American Board of Psychiatry and Neurology and Distinguished Life Fellow of the American Psychiatric Association. We cannot rely solely on medication with its brief follow-up visits and sacrifice the doctor-patient relationship, which is built on an in-depth knowledge of our patients. Patients, some in catatonic poses, were either actively hallucinating or enveloped in strange delusional beliefs. I remember having to spend 4 hours with this withdrawn girl who would neither look at nor respond to me in any way. Swartz report no affiliation with or financial interest in any organization that may pose a conflict of interest. SRF is associated with clinically significant alterations in all dimensions of pharmacokinetics. A significant percentage of end-stage renal disease  patients report hypersomnolence, snoring, and even witnessed apneas.
Both sleep disorders and poor sleep quality have a negative impact on daytime symptoms of sleepiness and fatigue. However, this report was limited by a small sample size and a minimal adjustment for age, gender, and comorbidity in relating the QOL results to sleep apnea.
All 10 subjects experienced highly statistically significant reductions in the total number of arousing PLMs (P=.002).
An approach to the treatment of RLS among patients with kidney failure has been recently outlined and adapted for the Table.44 RLS patients should have both a history and a physical examination that exclude causes of pain in the extremities such as peripheral vascular disease and neuropathy.
It is also important for the psychiatric field to recognize both the role of medications as potential aggravators of RLS and PLMs and the role of behavioral and non-pharmacologic interventions in the management of sleep disorders.
Many other sections of interest such as addiction, geriatric and forensic psychiatry, and a thorough coverage of child psychiatry are included. With respect to the clinical syndromes, for example, each one is discussed starting with the definition.
Some studies have shown that psychotherapy in combination with medication is better therapy for many disorders.
If a compulsive gambler stops gambling or if a compulsive drinker stops drinking, those changes are clear endpoints. Manic patients dressed up as clowns while schizophrenic patients wore aluminum foil on their heads to prevent themselves from being disintegrated by atomic rays. I spoke about anything that came to mind, essentially mundane topics such as the weather, baseball, and food. Taken together, SRF predictably affects renal excretion of psychotropic agents with more variable effects on absorption, distribution, and metabolism.
Those undergoing thrice-weekly hemodialysis have been shown to have a high rate of sleep apnea, insomnia, restless legs syndrome, and excessive daytime sleepiness. Daytime sleepiness and fatigue are frequent and bothersome problems for the chronic dialysis population.4 One-hundred hemodialysis patients were surveyed regarding their willingness to perform hemodialysis more frequently. Overnight dialysis may change daytime experience with respect to sleep, uremia, and free time for rest and activity. Most importantly, the eight-channel ambulatory PSG recording unit utilized in this study does not document actual sleep time; therefore, the AHI used was only an estimate. RLS severity should be clinically assessed and the clinicians should consider using a validated instrument to document RLS severity. Over the years, approximately 2,000 psychiatrists and behavioral scientists have contributed to the book.
We have to foster psychotherapy; it is something psychiatrists must be continually trained in so they do not lose those skills. The adjudication of the safe and effective dose for any psychotropic needs to be individualized for each such agent. In the general population, sleep disorders such as sleep apnea have been associated with premature death, cardiovascular disease, depression, and poor QOL.
A increase in energy level (94%) and improvement in sleep (57%) were the most commonly cited potential benefits that would justify more frequent hemodialysis.5 This finding highlights the importance of sleepiness and fatigue in patients undergoing RRT.
Nonetheless, these findings support the position that sleep disorders impact this population’s daytime functioning. If the patient has mild-to-moderate RLS, the team should focus on non-pharmacologic interventions, ie, using a bicycle or distracting activities.
Approximately 50% of contributors are replaced in every edition, and new authors are invited to keep CTP vital and current. I was on that rotation for 1 month, and I saw her every day for hour-long, supervised sessions. Strong pronouncements regarding contraindication of use for any psychotropic extends beyond available data. Emerging evidence suggests that sleep disorders may contribute to the high rates of medical and psychological comorbidity in CKD patients.
This article examines the association between kidney failure and sleep disorders, highlighting the impact of sleep disorders on health-related quality of life (HRQOL) and mood.
In chronic illnesses such as kidney failure, self-reported HRQOL may be the most important treatment outcome. If RLS is severe, it would be important to both use a pharmacologic intervention for the improved quality of life and encourage adherence with dialysis. Sadock is author and editor of over 100 publications and book reviewer for psychiatric journals, including the American Journal of Psychiatry.
Approximately 60% of contributors have been professors, 30% associate professors, and 10% assistant professors and instructors. Nevertheless, psychotropics that depend on normal kidney function for disposal require dosing alteration and in many cases should be avoided.
The diagnosis and treatment of sleep disorders among this high-risk population remains understudied.
In the manuscript of the 8th edition, a book of 4,000 printed pages contained 16,000 typed pages; this is a lot to process. We always try to get young people to contribute to the book to get a sense of future leaders in the field.
The comfort level of a good doctor-patient relationship is associated with positive results over all, regardless of the school of thought to which the psychiatrist adheres.
Unfortunately, few psychiatrists are available to do that kind of psychotherapy nowadays, and even if it were available, it would be rather expensive. Specific tactics and strategies regarding the use of psychotropics in this patient population are provided.
The recommendations for therapy have been largely based on findings in the general population since studies of the CKD population have been limited in scope.
Last, when the editors are finally satisfied, the manuscript is promptly delivered to the publisher.



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