From the Editor
The story is too familiar: Black women are more likely to have insomnia, and yet less likely to receive the needed care. What can be done? That question speaks to the larger issue of equity.
In the first selection from JAMA Psychiatry, Eric S. Zhou (of Harvard University) and his co-authors offer a culturally tailored form of CBT-insomnia for Black women. They designed an elegant, three-armed RCT, working with several people, including – yes – a Black woman with insomnia. They find: “Participants were more likely to complete the full intervention if they received the tailored program, with intervention completion associated with greater insomnia improvement.” We consider the paper and its implications.
In the second selection, we look at a new paper by Dr. Jack L. Turban (of Stanford University) and his co-authors. In JAMA Psychiatry, they write: “Transgender and gender diverse (TGD) people unfortunately experience high rates of psychiatric morbidity, and their psychopharmacologic needs can be unique when compared with those of cisgender people.” They offer practical suggestions.
Selection 1: “Effect of Culturally Tailored, Internet-Delivered Cognitive Behavioral Therapy for Insomnia in Black Women: A Randomized Clinical Trial”
Eric S. Zhou, Lee M. Ritterband, Traci N. Bethea, et al.
JAMA Psychiatry, 20 April 2022 Online First
Insomnia is associated more frequently with psychiatric disorders than any other medical illness, contributes to an increased risk of cardiovascular disease, obesity, and home, motor vehicle, and workplace unintentional injuries, and results in substantially poorer quality of life. Women are up to 40% more likely to have insomnia disorder during their lifetime than men and are more likely to experience multiple insomnia symptoms…
Poor sleep has also been shown to disproportionately affect Black individuals. For example, Black adults in the US have shorter total sleep duration, experience lighter and more fragmented sleep, and report worse sleep quality compared with other racial groups. Consistent with this literature, we demonstrated that insomnia is a major problem for participants in the Black Women’s Health Study (BWHS), a longitudinal cohort of Black women from across the US. Among 26 139 BWHS participants, approximately 45% had insomnia symptoms, and 15% had symptoms consistent with insomnia disorder…
Cognitive behavioral therapy for insomnia (CBT-I) is a multicomponent intervention that addresses the maladaptive sleep behaviors and beliefs maintaining insomnia disorder, incorporating sleep restriction (limiting time in bed to reflect sleep duration), stimulus control (avoidance of nonsleep activities in bed), sleep hygiene (implementing positive sleep behaviors and improving social/environmental factors), cognitive therapy (reframing negative thoughts surrounding sleep and its daytime impact), and relaxation exercises. Because there are few CBT-I-trained clinicians and state licensure regulations often prohibit cross-border practice, treatment availability is a challenge…
The development of a culturally tailored intervention may be the key to better engaging racial and ethnic minority patients with proven insomnia treatment…
Here’s what they did:
- The authors “conducted a single-blind (participants), parallel randomized clinical trial among Black women with insomnia disorder…”
- Between October 2019 and May 2020, invitation letters were sent to Black Women’s Health Study (BWHS) participants who were randomly selected.
- “Participants were randomized to receive (1) an automated internet-delivered treatment called Sleep Healthy Using the Internet (SHUTi); (2) a stakeholder-informed, tailored version of SHUTi for Black women (SHUTi-BWHS); or (3) patient education (PE) about sleep.”
- In terms of SHUTi: “The SHUTi program is a 6-session program (45 to 60 minutes per session) delivered over 6 to 9 weeks. SHUTi incorporates all core elements of CBT-I, tailoring content based on each participant’s reported baseline sleep function, treatment adherence, and sleep progress.”
- The main outcome: improvement on insomnia severity (as measuring on the Insomnia Severity Index).
Here’s what they found:
- 3 071 women were invited; 1 010 completed an online eligibility questionnaire; 490 were excluded.
- Among those eligible, 333 women enrolled and were randomized.
- Demographics. The mean age was 59.5 years; most had completed at least some college education. Many had medical problems: 46.2% were obese; 42.9% had hypertension; 16.5% had type 2 diabetes.
- Improvement. “Those randomized to receive either SHUTi or SHUTi-BWHS reported significantly greater reductions in ISI score at 6-month follow-up (SHUTi: −10.0 points…; SHUTi-BWHS: −9.3 points…) than those randomized to receive PE (−3.6 points…).”
- Completion. “Significantly more participants randomized to SHUTi-BWHS completed the intervention compared with those randomized to SHUTi (78.2% vs. 64.8%). Participants who completed either intervention showed greater reductions in insomnia severity compared with noncompleters (−10.4 points vs −6.2 points…).
A few thoughts:
1. This is a good paper.
2. The quick summary: the CBT-I interventions worked.
3. The big finding: while little separated the culturally-adapted intervention from the more standard form in terms of symptom reduction, the tailored CBT-I had a better completion rate. The authors note: “At the community level, the scale of public health improvement that is possible with a 13% increase in treatment engagement is immense, especially in a racial group that faces multiple barriers to treatment.”
4. The culturally adapted CBT-I took time to develop. The authors write: “The adapted version of SHUTi (SHUTi-BWHS) was developed over 1 year of collaboration with stakeholders, which included 3 Black women (a BWHS participant, a Black woman with a history of insomnia, and a Black woman with participatory research experience), a sleep physician from a medical center where more than 70% of the patient population are from racial and ethnic minority groups, a sleep researcher serving in a leadership role at a national health organization, and study investigators.”
In the paper, they go into detail on the process, which included stakeholders working through the modules and semi-structured interviews to collect their feedback. They were particularly focused on two areas: to change the visual and to recognize the “cultural and social contexts in which insomnia occurs for Black women” (so, for example, “how to successfully implement stimulus control in a crowded living environment and ways to address neighborhood noise levels…”).
6. Like all paper there are limitations. The authors note several, including that the participants “were of a higher socioeconomic background than US Black women as a whole. This can limit the generalizability of our findings to Black women for whom health disparities are most salient.”
7. There is great potential here. After all, the intervention is highly scalable and low cost. And there is the ability to design future versions to help other groups, bridging cultural and language barriers in access to care.
8. A note of caution: the majority of people offered help for insomnia in this way didn’t respond to the letter. Digital interventions are appealing to some, but not all.
The full JAMA Psychiatry paper can be found here:
Selection 2: “Psychopharmacologic Considerations for Transgender and Gender Diverse People”
Jack L. Turban, Marija Kamceva, Alex S. Keuroghlian
JAMA Psychiatry, 20 April 2022 Online First
Transgender and gender diverse (TGD) people have a gender identity beyond societal expectations based on their sex assigned at birth. TGD communities encompass not only identities within a binary gender paradigm but also gender diversity that includes nonbinary, genderfluid, agender, and bigender identities…
TGD people experience high prevalence of psychiatric morbidity, owing to minority stress (ie, stress resulting from societal stigma toward TGD people) and to physical gender dysphoria. TGD people can also develop psychiatric conditions in a manner comparable with cisgender people, including bipolar spectrum and primary psychotic disorders, which may necessitate psychopharmacologic interventions.
So begins a paper by Turban et al.
They focus on four areas:
Spironolactone and Hypotension
“Some TGD patients pursue gender-affirming medical care, which may include gender-affirming hormones (GAHs; eg, estradiol or testosterone). GAHs have consistently been linked to improved mental health outcomes. Nevertheless, we often hear reports of clinicians discontinuing GAHs owing to concern for worsening mental health. Some reports suggest an association between exogenous testosterone administration and mania; these reports, however, focused on cisgender men with supraphysiologic levels of anabolic steroids. In contrast, standard of care for TGD patients involves physiologic serum testosterone levels, and there is little evidence of psychiatric decompensation with this approach. Similarly, there is no evidence suggesting that standard doses of estradiol worsen mental health for TGD people. GAHs have overall been shown to improve mental health symptoms for TGD people.”
“For trans masculine people, the potential adverse effect of hyperprolactinemia and subsequent gynecomastia may be of particular concern owing to chest dysphoria. This risk is highest with risperidone. Intermittent prolactin level monitoring may be helpful for reassuring patients and improving adherence, whereas aripiprazole can be effective in treating hyperprolactinemia.
“Studies have indicated that patients taking estrogen and spironolactone do not exhibit increased prolactin levels. As such, the likely cause of hyperprolactinemia in patients taking an antipsychotic with GAHs or spironolactone, either alone or in combination, is most likely the antipsychotic.”
“Lamotrigine is an antiepileptic that is often used for mood stabilization. Estrogen has been shown to decrease the concentration of lamotrigine, and it is possible that lamotrigine itself interferes with estrogen levels. For patients who reach an effective lamotrigine dose before initiating estrogen, we recommend aiming to maintain that serum lamotrigine level after starting estrogen. This is often done for patients who become pregnant while taking lamotrigine. For patients who are already taking estrogen when starting lamotrigine, monitoring serum estradiol and lamotrigine levels may reassure TGD patients hesitant to start a medication that could interfere with GAH effectiveness and thus bolster lamotrigine adherence.”
Serotonergic Agents and Spontaneous Erections
“Many TGD people have substantial dysphoria related to erections. Trans feminine people may become concerned about priapism, or prolonged erections, from treatment with trazodone. It is important to provide evidence-driven counseling conversations that involve describing priapism as an uncommon medical emergency distinct from a spontaneous erection.”
They also note that SSRIs “have consistently been linked to sexual adverse effects and difficulty maintaining erections. Future research may benefit from evaluating the use of SSRIs as an off-label treatment for dysphoria that results from spontaneous erections, particularly given the high prevalence in TGD communities of anxiety and depression, which may respond well to SSRIs.”
A few thoughts:
1. This paper is concise and highly practical.
2. The authors make mention of psychiatric crises, noting that clinicians may mull stopping gender-affirming hormones in such situations. They recommend against that; “It is key for clinicians to keep in mind that TGD patients typically experience discontinuation of GAHs as deeply invalidating, and GAH cessation is likely to worsen mood, both acutely and chronically. The risks of discontinuing GAHs include increasing minority stress, gender dysphoria, and medical trauma that could exacerbate an existing psychiatric crisis.”
3. Looking for more on care for transgender individuals? In a past Reading, we reviewed a podcast on the topic, featuring Drs. June Lam and Alex Abramovich (both of the University of Toronto).
The conversation offers practical suggestions for clinical encounters. For example, Dr. Lam comments: “A first tip: introduce your own pronouns. I try to that with everyone and start by saying my name is June Lam or Dr. Lam, I’m a psychiatrist, and I use he/him pronouns. Just to signal that you can’t assume someone’s pronouns or gender just by looking at someone and to normalize that it’s OK to have conversations around pronouns…”
The Reading can be found here:
The full JAMA Psychiatry can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.