Antonio Fernando

Prevalence of causes of insomnia in primary care: a cross-sectional study.

BACKGROUND As a result of a research interest in primary insomnia, the prevalence of other causes of insomnia in primary care must be ascertained. No source was found in the literature. It is also essential to know the epidemiology of the common causes of a condition to make an accurate diagnosis in primary care. AIM To determine the prevalence of causes of insomnia in primary care, as part of a method of identifying patients with primary insomnia. DESIGN AND SETTING Cross-sectional study in three general practices in Auckland, New Zealand. METHOD Consecutive patients from the waiting room were asked to complete a nine-page questionnaire on possible causes of insomnia. RESULTS In total, 1517 patients were approached and 955 completed the nine-page questionnaire (63%). Of the 41% (388) who reported difficulty with sleeping, primary insomnia occurred in 12% (45) of the population (95% confidence interval = 9% to 15%); 50% (195) had depression, 48% (185) had anxiety and 43% (165) had general (physical) health problems. Obstructive sleep apnoea occurred in 9% (34) and delayed sleep phase disorder in 2% (7). Only primary insomnia and delayed sleep phase disorder are mutually exclusive; the others can co-exist. CONCLUSION This is the first description of the prevalence of causes of insomnia in primary care. It is hoped that the focus on primary insomnia will result in more behavioural treatments and lower the use of hypnotics in primary care; it should also assist in the appropriate detection and treatment of other causes of insomnia in primary care.

The assessment and management of insomnia in primary care

#### Summary points Insomnia affects about a third of the general population according to a recent longitudinal study in the UK1 and cross sectional studies estimate the prevalence in patients attending primary care to be between 10% and 50%.2 3 According to the American Sleep Disorders Association International Classification of Sleep Disorders coding manual, insomnia refers to “a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment and lasting for at least one month.”4 Although some patients who have this problem may not report it as such, inadequate sleep has been associated with reduced physical health3 4 5 6 and mental health.7 8 9 The continued widespread use of sedative medication to treat insomnia raises concern about the potential for long term tolerance and addiction, particularly where insomnia is the presenting complaint of missed diagnoses such as depression, or when adverse effects might be a problem—for example, falls in older adults.10 11 12 The normal range of sleep is seven to nine hours per night,13 although some individuals claim they can function on as little as four hours, whereas others need up to …

Circadian-Related Sleep Disorders and Sleep Medication Use in the New Zealand Blind Population: An Observational Prevalence Survey

Study Objectives To determine the prevalence of self-reported circadian-related sleep disorders, sleep medication and melatonin use in the New Zealand blind population. Design A telephone survey incorporating 62 questions on sleep habits and medication together with validated questionnaires on sleep quality, chronotype and seasonality. Participants Participants were grouped into: (i) 157 with reduced conscious perception of light (RLP); (ii) 156 visually impaired with no reduction in light perception (LP) matched for age, sex and socioeconomic status, and (iii) 156 matched fully-sighted controls (FS). Sleep Habits and Disturbances The incidence of sleep disorders, daytime somnolence, insomnia and sleep timing problems was significantly higher in RLP and LP compared to the FS controls (p<0.001). The RLP group had the highest incidence (55%) of sleep timing problems, and 26% showed drifting sleep patterns (vs. 4% FS). Odds ratios for unconventional sleep timing were 2.41 (RLP) and 1.63 (LP) compared to FS controls. For drifting sleep patterns, they were 7.3 (RLP) and 6.0 (LP). Medication Use Zopiclone was the most frequently prescribed sleep medication. Melatonin was used by only 4% in the RLP group and 2% in the LP group. Conclusions Extrapolations from the current study suggest that 3,000 blind and visually impaired New Zealanders may suffer from circadian-related sleep problems, and that of these, fewer than 15% have been prescribed melatonin. This may represent a therapeutic gap in the treatment of circadian-related sleep disorders in New Zealand, findings that may generalize to other countries.

EPIDEMIOLOGICAL STUDIES ON MENTAL HEALTH NEEDS OF ASIAN POPULATION IN NEW ZEALAND

Background: New Zealand has recently experienced a massive and rapid influx of Asian migrants. The Asian population has doubled in 10 years and is now the third-largest ethnic group. Materials: Databases reviewed include Medline, NZ government reports and NZ media releases. Discussion: Despite the significant growth in the Asian population, most of whom are in a vulnerable age group for mental morbidity and are exposed to adverse experiences, accurate and systematically obtained information on the mental health of Asians is lacking. Conclusion: This paper argues for a need to conduct a well-designed epidemiological study on the mental health needs of Asians in New Zealand. Recommendations on how to pursue this epidemiological study are provided.

Development and initial psychometric properties of the Barriers to Physician Compassion questionnaire.

Objective Physicians are expected to be compassionate. However, most compassion research focuses on compassion fatigue—an outcome variable—rather than examining the specific factors that may interfere with compassion in a physician’s practice. This report describes the development and early psychometric data for a self-report questionnaire assessing barriers to compassion among physicians. Methods In 2011, a pilot sample of 75 physicians helped to generate an initial list of barriers to compassion. A final 34 item Barriers to Physician Compassion (BPC) questionnaire was administered to 372 convenience-sampled physicians together with measures of demographics, practice-related variables, stress, locus of control and trait compassion. Results The barriers to physician compassion were not one-dimensional. Principal component analysis revealed the presence of four distinct, face-valid and discriminable factors—physician burnout/overload, external distractions, difficult patient/family and complex clinical situation. All barrier components had adequate internal reliabilities (>0.70) and meaningful patterns of convergent and divergent validity. Conclusions Remaining compassionate in medical practice is difficult. With the newly developed BPC questionnaire, specific barriers to compassion can be assessed. These barriers illuminate potential targets for future self- and practice management, interventions and compassion training among physicians.

Mindfulness for surgeons

In addition to having the knowledge and technical skills to practice surgery, an ideal surgeon is attentive and focused, relaxed, deals with contingencies calmly, flexible and resilient, unburdened by previous cases or external situations, and is warm and compassionate to patients, families and colleagues. In reality, surgeons, like most humans, are typically not really present. Our minds are commonly described as ‘monkey minds’, restless, confused and easily distracted, with attention easily hijacked by stimuli, little different from a monkey that jumps from branch to branch side-tracked by fruits or anything of fleeting interest. Humans tend to daydream and ruminate about negative events, past failures and future worries. The mind reacts to such events resulting in anger, irritation, frustration, excitement, sadness or disgust. This highly reactive and untamed mind can result in depression, anxiety, addictions and interpersonal conflicts. In short, the untrained mind is prone to being unhappy. Mindfulness is an alternate mind state or way of being to the typical stressed and untrained state that predisposes physicians and surgeons to fatigue and burnout. Mindfulness is distinct from other stress management techniques such as going on holiday or using alcohol, both of which are forms of escaping from the problem. After the holiday or upon sobering up, the problem remains or is worsened. There is no escaping from stress as there will always be stress. However, instead of running away from stress, an alternative approach is to change the way we generate and relate to it. Mindfulness allows practitioners to look at their stress calmly, accepting the situation and then responding appropriately. Mindfulness is not a way out of daily troubles but instead is a ‘way in’.

Barriers to Medical Compassion as a Function of Experience and Specialization: Psychiatry, Pediatrics, Internal Medicine, Surgery, and General Practice

CONTEXT Compassion is an expectation of patients, regulatory bodies, and physicians themselves. Most research has, however, studied compassion fatigue rather than compassion itself and has concentrated on the role of the physician. The Transactional Model of Physician Compassion suggests that physician, patient, external environment, and clinical factors are all relevant. Because these factors vary both across different specialities and among physicians with differing degrees of experience, barriers to compassion are also likely to vary. OBJECTIVES We describe barriers to physician compassion as a function of specialization (psychiatry, general practice, surgery, internal medicine, and pediatrics) and physician experience. METHODS We used a cross-sectional study using demographic data, specialization, practice parameters, and the Barriers to Physician Compassion Questionnaire. Nonrandom convenience sampling was used to recruit 580 doctors, of whom 444 belonged to the targeted speciality groups. The sample was characterized before conducting a factorial Multivariate Analysis of Covariance and further post hoc analyses. RESULTS A 5 (speciality grouping) × 2 (more vs. less physician experience) Multivariate Analysis of Covariance showed that the barriers varied as a function of both speciality and experience. In general, psychiatrists reported lower barriers, whereas general practitioners and internal medicine specialists generally reported greater barriers. Barriers were generally greater among less experienced doctors. CONCLUSION Documenting and investigating barriers to compassion in different speciality groups have the potential to broaden current foci beyond the physician and inform interventions aimed at enhancing medical compassion. In addition, certain aspects of the training or practice of psychiatry that enhance compassion may mitigate barriers to compassion in other specialities.

Enhancing compassion in general practice: it’s not all about the doctor

‘ Patients were left lying in soiled sheets or sitting on commodes for hours. Some patients needing pain relief got it late or not at all. ’1 Such were the findings from the Mid Staffordshire Inquiry with recommendations for recruiting compassionate staff and having clinician compassion training.2 However, this call for compassion is not new. Medical codes of practice require us to practise with compassion. Compassionate care should be routine, a daily motivation and practice not unlike antisepsis and hand washing. The crisis of compassion in medicine is multifaceted in origin and no universal panacea is likely to be found. Many of us cannot define compassion or articulate the differences between compassion and empathy. Others might argue that compassion training is redundant as doctors are either compassionate or not. We remain remarkably ignorant about compassion, unsure of what it is, where it comes from, or what might influence compassion in our practices. Compassion comes from the Latin roots com , which means ‘together with’, and pati , ‘to bear or suffer’.3 Compassion is built on the capacity to empathise — a form of cognitive and emotional perspective taking — but involves the additional step of wanting to alleviate suffering.4 The distinction is important. An after-hours GP may recognise and feel the distress of a crying child having an asthma attack but, because he is now 30 minutes late in picking up his wife at the airport, rushes to the car park and lets colleagues manage the child. The family concerned might feel fobbed off and is unlikely to have experienced compassion as part of the clinical interchange. The doctor was empathetic but, technically, was not compassionate. Empathy without compassion is not only out of step with professional requirements but also is differentially likely to sustain negative …

Sleep disorder (insomnia)

A 53 year old man comes to you complaining of not having slept well for many years. He always feels tired the next day. He has tried sleeping pills, which sometimes help, but he is not keen on taking them continually and has found that the benefits they give him don’t last. He spends about 9-10 hours in bed each night (going to bed about 9 30 pm or 10 pm and getting up at 7 am) and has trouble getting to sleep. His actual hours of sleep are 5.5 to 6 each night. He wakes about three times a night and describes the quality of his sleep as poor. ### Assessment Rule out secondary causes. To assess whether he has depression or anxiety, for example, ask screening questions, take a full history of depression and anxiety, or use a scale such as the Hospital Anxiety and Depression Scale, which gives a score for both conditions. Consider sleep apnoea if he snores a lot at night, has periods of apnoea, falls asleep easily during the day (for instance, …

Outcome of combined melatonin and bright light treatments for delayed sleep phase disorder

Delayed sleep phase disorder (DSPD) is a circadian rhythm disorder characterized by a stable 24 h sleep pattern but with sleep times that are significantly delayed with respect to conventional or d...