Discussion: Treatment for a Patient With a Common Condition
Discussion: Treatment for a Patient With a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
Post a response to each of the following:
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. CORE SKILL: this discussion is about prescribing DECISIONS in the face of comorbidity and patient-specific factors — not about naming a hypnotic.
THE FIRST MOVE, ALWAYS: insomnia is usually SECONDARY. Before selecting an agent, ask what is causing it — depression (early morning awakening is classic), anxiety (initial insomnia), OSA (screen with STOP-BANG; sedating a patient with untreated OSA is dangerous), restless legs, chronic pain, nocturia, substances (caffeine, alcohol — which fragments the second half of the night — nicotine, stimulants), medications (SSRIs, steroids, beta-agonists), and circadian/shift-work factors. Treating the insomnia while ignoring the driver is the error the discussion is designed to surface.
THE EVIDENCE-BASED HEADLINE: CBT-I is FIRST-LINE for chronic insomnia (American College of Physicians guideline) and its effects OUTLAST medication. Components: STIMULUS CONTROL (bed is for sleep only; leave the bed if awake >20 min), SLEEP RESTRICTION (counterintuitive but the most powerful component — restrict time in bed to actual sleep time to build sleep drive, then titrate up), sleep hygiene, cognitive restructuring, relaxation training. A post that recommends a Z-drug without mentioning CBT-I is missing the central point.
THE AGENTS AND THEIR TRADE-OFFS:
— Z-DRUGS (zolpidem, eszopiclone, zaleplon): FDA BOXED WARNING for complex sleep behaviors (sleep-driving, sleep-eating, with amnesia). Next-day impairment. Zolpidem requires LOWER DOSING IN WOMEN due to slower clearance — a specific, citable, high-value detail. Falls and fractures in the elderly.
— OREXIN ANTAGONISTS (suvorexant, lemborexant, daridorexant): a newer mechanism, lower dependence liability; consider in patients where BZD-receptor agents are contraindicated.
— RAMELTEON (melatonin agonist): no abuse liability — a strong choice in a patient with substance-use history.
— TRAZODONE: extremely common off-label choice; sedating via H1 and alpha-1 antagonism; watch orthostasis and (rarely) priapism.
— LOW-DOSE DOXEPIN: FDA-approved specifically for sleep MAINTENANCE.
— BENZODIAZEPINES: generally avoid for chronic insomnia — dependence, tolerance, withdrawal, cognitive effects; Beers Criteria in older adults.
— AVOID diphenhydramine and other anticholinergics in older adults (confusion, falls, urinary retention, anticholinergic burden).
THE POPULATION-SPECIFIC REASONING the rubric wants (this is where the marks are): pediatric — behavioral interventions first, most agents off-label; PREGNANCY — non-pharmacologic strongly preferred, and any agent requires an explicit risk-benefit discussion; ELDERLY — reduced clearance, polypharmacy, fall risk, START LOW; HEPATIC or RENAL impairment — dose adjustment; SUBSTANCE USE HISTORY — avoid controlled substances entirely; and consider cost, formulary, and access, which are real determinants of whether the plan actually happens.
Then: what would you change and why, and what would you monitor at follow-up?
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