Dr. Kaplan correctly identified tolerance and tachyphylaxis as significant problems when prescribing traditional hypnotics, and proposed a solution of using 2 sleep medications, each having a different mechanism of action, on an alternating schedule.However, with the availability of the dual orexin receptor antagonists (DORAs) daridorexant, lemborexant, and suvorexant, this approach is unnecessary.Moreover, the mechanism of action of orexin receptor antagonism directly addresses extant hyperarousal by decreasing wake signaling, without any deleterious effect on sleep architecture. 1Additionally, the DORAs are not associated with physiological dependence, withdrawal, or rebound.Their efficacy profile is as good as or better than other FDA-approved agents for insomnia disorder.
In the United States, opioid use by patients who are pregnant more than quadrupled from 1999 to 2014. 1 Opioid use disorder (OUD) in the perinatal period is associated with a higher risk for depression, suicide, malnutrition, domestic violence, and obstetric complications such as spontaneous abortion, preeclampsia, and premature delivery. 2Buprenorphine and methadone are the standard of care for treating OUD in pregnancy. 3,4While a literature review found that maternal treatment with buprenorphine has comparable efficacy to treatment with methadone, 5 a small randomized, double-blind study found that compared to buprenorphine, methadone was associated with significantly lower use of additional opioids (P = .047). 6This suggests methadone has therapeutic value for patients who are pregnant.Despite the benefits of methadone for treating perinatal OUD, the physiological changes that occur in patients who are pregnant-coupled with methadone's unique pharmacologic properties-may complicate its use.Patients typically take methadone once a day, and the dose is titrated every 3 to 5 days to allow serum levels to reach steady state. 7uring pregnancy, there are increases in both the volume of distribution and medication metabolism secondary to increased expression of the cytochrome P450 3A4 enzyme by the liver, intestine, and placenta. 8Additionally, as the pregnancy progresses, the rate of methadone metabolism increases. 9Methadone's half-life (20 to 35 hours) leads to its accumulation in tissue and slow release into the blood. 10As a Divided doses can help address the unique needs of patients who are pregnant Opioid use disorder in pregnancy:A strategy for using methadone EMIN KULIYEV/SHUTTERSTOCK
Pearls Childbirth-related posttraumatic stress disorder (CB-PTSD) is a form of PTSD that can develop related to trauma surrounding the events of giving birth.It affects approximately 5% of women after any birth, which is similar to the rate of PTSD after experiencing a natural disaster. 1Up to 17% of women may have posttraumatic symptoms in the postpartum period. 1 Despite the high prevalence of CB-PTSD, many psychiatric clinicians have not incorporated screening for and management of CB-PTSD into their practice.This is partly because childbirth has been conceptualized as a "stressful but positive life event." 2 Historically, childbirth was not recognized as a traumatic event; for example, in DSM-III-R, the criteria for trauma in PTSD required an event outside the range of usual human experience, and childbirth was implicitly excluded as being too common to be traumatic.In the past decade, this clinical phenomenon has been more formally recognized and studied. 2 CB-PTSD presents with symptoms similar to those of other forms of PTSD, with some nuances, as outlined in Table 1. 3 Avoidance can be the predominant symptom; this can affect mothers' engagement in postnatal care and is a major risk factor for postpartum depression. 3any risk factors in the peripartum period can impact the development of CB-PTSD (Table 2,3 page 56).The most significant risk factor is whether the patient views the delivery of their baby as a subjectively negative experience, regardless of the presence or lack of peripartum complications. 1 However, parents of infants who require treatment in a neonatal intensive care unit and women who require emergency medical treatment following delivery are at higher risk.
