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Sleep is fundamental to good health and sense of well-being. When either of these is affected, sleep quality needs to be a key consideration.

With that premise, sleep expert Carmel Harrington, PhD, researcher and author about sleep on behalf of 

 discusses 6 things for you to look for-and ask about-when your female patients tell you they can’t sleep.

The Complete Guide to a Good Night's Sleep

Throughout their lives, women require more sleep than men-but they experience more trouble getting it. Some of the problems and the times women encounter sleep difficulties include:

 During the second half of the cycle, a woman may experience difficulty in getting to sleep or getting the amount of sleep she needs. Many women become sleep-deprived at this time and suffer all the ill effects, including depression, moodiness, tiredness, and lack of energy, all of which are recognized characteristics of the premenstrual syndrome. Rather than immediately prescribing an antidepressant at this time, it is important to investigate the woman’s sleep. The first step is to get her to complete a sleep diary and if sleep is the problem, a sleep health program should be implemented.

 About 1 of 2 women with this disorder have sleep apnea. For this reason, it is critical to investigate sleep in a woman with PCOS.

This can be severely debilitating not only for the young woman experiencing it, but also for her family and friends. Little is known about what causes postnatal depression, but women with the most disturbed sleep are at significantly greater risk. Rather than prescribing an antidepressant, women presenting with postnatal depression should be queried about their sleep: if sleep deprivation is occurring, a sleep program should be implemented with some urgency.

Many women at and beyond menopause have difficulty in sleeping, and either a sleeping pill or an antidepressant is prescribed without any investigation of their sleep health. About 10% of postmenopausal women have sleep apnea, which is associated with significant sleep deprivation and all of its symptoms-including restless sleep, fatigue, waking up unrefreshed, and depression. These are often perceived as traditional menopausal symptoms, but rather than immediately treating with medication, investigating sleep quality is a good first step.

 Any woman of any age who has a chronic disorder, such as depression, obesity, type 2 diabetes mellitus, hypertension (especially resistant hypertension), heart disease, or a hormonal cancer (such as breast cancer), should have her sleep investigated. Poor quality and/or insufficient sleep is highly associated with these chronic disorders. Improving sleep health may improve their parameters. 

It is not normal for a woman to feel fatigued every day or to lack the energy to enjoy life. When a woman presents with these symptoms, her sleep health is a relevant consideration. Keep in mind that a woman’s language around sleep may be different than that of a man-for starters, women don’t like talking about snoring and many won’t admit to it. Women are more inclined to focus on sleeplessness and lack of energy.

Podcasts

6 Things to Look for When Your Female Patient Can’t Sleep

70-Year-old Mrs Smith has a 7-year history of type 2 diabetes. Her medications include glipizide, 2.5 mg a day, and lisinopril, 10 mg a day. She weighs 175 pounds and her BMI is 30. Her HbA1c is 7.5 and her blood pressure 130/80. Recently she has experienced 2 episodes of dizziness and her blood sugars were 50 and 55. 

 I was surprised that her blood sugars were so low with an HbA1c of 7.5. Does that surprise you?

  I also have had similar patients. Remember that HbA1c reflects the average blood sugar for the last 2 to 3 months. So an HbA1c of 7.5 probably means a mean plasma glucose of about 170; but this number doesn’t tell us the about the variability or swings in daily glucose levels. This patient probably has daily drops below 70 and post meal increases to 200 plus to give her a mean blood sugar of roughly 170.

  What do you suggest for this patient? 

  We usually think of hypoglycemia in patients taking insulin or a sulfonylurea but it can occur for reasons other than medication. For example, as patients  age, their eating habits change. This patient may be eating erratically. Excessive alcohol ingestion, chronic renal disease, and poor sleep habits are other factors. About 42% of type 2 diabetes patients experience hypoglycemia, but it is usually mild (>50). 

For this patient’s management, I would stop the glipizide and obtain a creatinine and GFR. If her GFR is > 60, I would start metformin. If her GFR is lower, I would consider using a DPP4 inhibitor or GLP-1 receptor agonist that has limited renal clearance. Linagliptin, a DPP4 inhibitor, and liraglutide, a GLP-1 receptor agonist, are good options in patients with lower GFRs and higher creatinine.

Don’t forget to discuss the other possible causes of hypoglycemia like skipped meals and excessive alcohol ingestion. A tip to overnight hypoglycemia would be nightmares and night sweats. If the patient wakes up in the middle of the night, ask her to check her blood sugar.

  Are future episodes of hypoglycemia a concern?

Yes-prior hypoglycemia is a predictor of future hypoglycemia. More frequent self-monitoring of blood sugar should help.

Hypoglycemia in type 2 diabetes patients can be the result of insulin or sulfonylureas.

Challenging Case: A Patient With Hypoglycemia and High HbA1c

A Therapeutic Primer for Primary Care Physicians: Part 3: Anxiety, Major Depression, Bipolar Disorder

In this podcast, Dr Lieberman discusses the associated features of three specific mental disorders: anxiety, major depressive disorder, and bipolar disorder. He offers practical techniques that can be used in diagnosing each of these disorders and provides suggestions for treatment.

Undiagnosed depression is associated with increased symptomatology, decreased quality of life, and suicide. Using the BATHE technique will elicit the patient’s affect, and the 2-question screener discussed in the first podcast can confirm a diagnosis of depression.

1. In the past month have you been  feeling down, blue, depressed, or hopeless?
 2. In the past month have you lost  interest in doing things that you formerly found pleasurable?

• See the patient regularly but keep  sessions brief
 • Set realistic expectations for both  patient and practitioner
 • Set small tasks for the patient to  reverse feeling of worthlessness
 • Give the patient permission to feel  depressed: stop trying to cheer the patient up
 • Provide behavioral suggestions and  cognitive therapy along with pharmacotherapy
 • Focus on the fact that although the  patient has an illness, the illness will resolve
 • Remember the power of “yet”
 • Be supportive
 • Set limits on the patient’s worrying  and wallowing time

Podcast: A Therapeutic Primer for Primary Care Physicians: The Value of Talk - Part 3: Anxiety, Major Depression, Bipolar Disorder

Primary care physicians are often the first to see patients with mental health problems and they provide 70% of mental health care to patients. They also write a majority of the prescriptions for antidepressant and antianxiety medications in the United States. This is understandable in light of the fact that physical and mental ailments are often comorbid. But, there may be more to treating a patient who presents with depression than prescribing a pill.

We’ve invited Dr Joseph A. Lieberman to record a series of informational podcasts based on a book he has coauthored, 

The Fifteen Minute Hour: Therapeutic Talk in Primary Care.

 Part 1 is an introduction familiarizing physicians with why talking to patients is important and the concepts and tools that can be used to facilitate discussion.

 Dr Lieberman will discuss how physicians can manage difficult patients, whether they are a chronic complainer, substance abuser, or hypochondriac. He explains how you can see these patients as a learning experience rather than a challenge to be rid of as quickly as possible.

Anxiety, major depression, and bipolar disorder will be discussed in 

. In this section, Dr Lieberman presents some simple tools that can be used to help diagnose a disorder. The focus of the last podcast is 2-pronged: how to talk to your patients, and how to take care of yourself (

To read a Book Review of Dr Lieberman's book 

The Fifteen Minute Hour: Therapeutic Talk in Primary Care

In this first podcast, Dr Lieberman reviews the essentials used in teaching primary care clinicians the art of therapeutic talk. Listening to Dr Lieberman’s podcast will help you recognize and treat mental health problems that you may encounter in your patients. He provides several techniques that you will probably find valuable in your daily practice.

 An early technique developed by Dr Larry Weed in the 1970s.


: A technique to elicit information from patients.


  Background: what is going on in your life?


Two-question screener to determine whether patient is depressed:
1. In the past month, have you been feeling down, blue, depressed, or hopeless?
2. In the past month, have you lost interest in doing things that you formerly found pleasurable?

   Sleep or sexual desire increased or decreased


   Interest or pleasure in activities decreased



• Patient Health Questionnaire (PHQ9)
• Generalized Anxiety Questionnaire (GAD7)
• Mood Disorder Questionnaire (MDQ)
• Fatigue Severity Scale (FSS)
• Epworth Sleepiness Scale (ESS)

Primary care physicians are often the first to see patients with mental health problems and they provide 70% of metal health care to patients. They also write a majority of the prescriptions for antidepressant and antianxiety medications in the United States. This is understandable in light of the fact that physical and mental ailments are often comorbid. But, there may be more to treating a patient who presents with depression than prescribing a pill.

Sleep Disorders

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