(GRADED) NURS-6630- Psychopharmalogical Approaches to Treat Psychopathology | Week 8: Assignment 2 | Assessing and Treating Patients with Sleep/Wake Disorders

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Assessing and Treating Patients with Sleep/Wake Disorders Course: NURS-6630- Psychopharmalogical Approaches to Treat Psychopathology Week 8: Assignment 2 Walden University Introduction The ... provided case study is of 31 years old male who presented to the office with a chief complaint of insomnia. Patient reported progressive worsening of his insomnia symptoms. It is difficult for patient to fall asleep and to stay asleep at night. The symptoms started to appear when the patient suffered from an emotional trauma (sudden loss of his fiancé). Patient is a forklift operator at a local chemical company and insomnia is affecting his professional performance. The patient used diphenhydramine but does not like the way it makes him feel the morning after. Past medical history indicated opiate abuse which started when the patient was prescribed hydrocodone/apap for pain management (as he broke his ankle in skiing accident). However, patient has not received prescription for opiate analgesic in 4 years. Currently patient is using alcohol (four beers prior to bed) to fall asleep. Patient is alert and future oriented. Patient denied auditory and visual hallucinations. Reality contact, insight and judgment are all intact. Patient denied suicidal/ homicidal ideation. The pertinent positive information that will impact the decision making when prescribing medication for this patient includes his past medical history (related to opiate abuse), consumption of alcohol, complaining about sleep issues after suffering from emotional trauma (sudden loss of his fiancé) and complaints regarding the after effect of diphenhydramine. It is also important to consider the employment status of patient as insomnia has affected his professional performance, therefore such medications would be recommended that can improve his professional performance by improving his concentration and cognitive abilities. Assessing and Treating Patients with Sleep/Wake Disorders Decision 1 The selected decision one is “Trazodone 50 to 100 mg daily at bedtime”. I selected this decision because Trazodone is an effective drug which is recommended for primary (difficulty in falling asleep or maintaining the sleep cycle) as well as secondary insomnia (insomnia caused by a mental disorder). As the patient reported that he is suffering from sleep issues after the sudden death of his fiancé. This indicates that the patient is suffering from a secondary insomnia. Due to this reason, Trazodone is selected for this patient. According to the study of Jaffer et al. (2017) evidence for the efficacy of trazodone has been repeatedly demonstrated for primary insomnia as well as secondary insomnia including for symptoms that are a result of depression and dementia. The study has also mentioned that Trazodone in low doses (50 to 150 mg/day) possess a good safety profile for the treatment of insomnia. Another study of Wang et al. (2020) has reported that Trazodone is effective in improving concentration and recall abilities. As the patient reported that insomnia is effecting his professional performance as he has fallen asleep on the job due to lack of sleep from the night before. In such cases, it is important to consider the employment status of patient and recommend a drug that can improve his sleep quality along with cognitive skills. Recommending this drug to patient will definitely improve his professional performance because he will be able to concentrate on his work. The patient also reported consumption of alcohol daily, therefore Trazodone is a good decision because Trazodone is recommended in managing sleep disturbances in patients with alcohol use disorder (Kathiresan et al., 2020). Considering- the symptoms presented by the case study-secondary insomnia along with the safety profile of low doses (50 to 150 mg/day), the decision 1 is selected. The option of Zolpidem 10 mg at bedtime was not selected because Zolpidem is associated with sleep related eating disorder and sleep related eating disorder can occur at any dose of Zolpidem. According to the study of Ho et al. (2020) Zolpidem can cause sleep related eating disorder with any dose. This study has also suggested that insomnia is commonly due to underlying disorders (like restless leg syndrome, obstructive sleep apnea and depression). Therefore it is important to control those underlying disorders before initiating Zolpidem. The study reported that discontinuation of Zolpidem has resolved all the cases of sleep related eating disorder. The third option of Hydroxyzine 50 mg daily at bedtime was not considered because Hydroxyzine belongs to the class of anti-histamine as that of diphenhydramine. As the patient reported that he has used diphenhydramine for his sleep issues but does not like the way it makes him feel the morning after. Considering this complaint of patient, the option of Hydroxyzine is not considered. If Hydroxyzine would be recommended then it could have caused the patient to suffer from the similar after- effects of drowsiness, dry mouth and eyes (Silvestro, 2021). Due to the effect of drowsiness and dry mouth and eyes, patient will again stop taking this medication therefore this option is not selected. With the decision of recommending Trazodone, I was expecting that the patient will revisit and will report that his sleep quality has improved as the medication helped him in falling asleep and maintaining that sleep cycle for whole night. I was also expecting that the patient will not report about drowsiness during day time and will report that he was able to work efficiently (Jaffer et al., 2017). Decision 2 The selected decision 2 is “decrease Trazodone to 25 mg daily at bedtime”. I selected this decision on the basis of results of decision 1. As the patient returns to clinic in two weeks and reported that Trazodone is working well but is causing unpleasant side effect of prolonged erection of penis, approximately 15 minutes after waking. Due to this issue, it is difficult for patient to get ready for work or have a coffee with his girlfriend and daughter in the morning. Priapism is a rare side effect of Trazodone and it gets diminished after few weeks of therapy along with the dosage adjustment. According to the stuidy of Kuśnierz, Meisner & Sarecka- Hujar (2021) priapism is a rare side effect of Trazodone. The study suggested that to avoid such side effects, it is important to adjust the dosage and the treatment should be initiated with the dose which is ¼-1/3 of the target daily dose. It means that the dose of 50 mg of Trazodone is the cause of priapism, therefore it is prudent to reduce the dose of Trazodone. The other option of dose continuation along with the explanation (that priapism diminish over time) is not selected because untreated priapism can cause men to suffer from anatomical deformation of penis. According to the study of Cuomo et al. (2019) Trazodone should be used with caution in men because Trazodone is associated with rare occurrences of priapism. Untreated priapism can cause anatomical deformation of penis. Therefore, patients taking Trazodone should be advised to refer to an emergency room in case of priapism. The third option of discontinue Trazodone and initiate therapy with Suvorexant was not selected because patient has not complained about the inefficacy of Trazodone. Instead, patient reported that the medication is working well. This indicates that Trazodone is improving his sleep cycle. In such condition, it would not be prudent to change the drug as such practices will be against the treatment algorithm of insomnia. According to the study of Riemann et al. (2017) if a drug improves sleep cycle without causing addiction and side effects, then the drug should not be changed until the patient reports any serious complications. Moreover, Suvorexant possess an adverse effect of daytime somnolence and also has moderate potential for causing addiction. According to the study of Matheson & Hainer (2017) Suvorexant-due to its addictive properties and adverse effect of daytime somnolence- is not recommended as a first-line treatment for insomnia. The study also reported that Suvorexant is a cost effective medication. As the patient reported that he do not want to use diphenhydramine due to its side effect of daytime somnolence, therefore recommending such drugs like Suvorexant would not be a prudent decision because it will produce the same effect (of daytime somnolence) and will cause a patient to withdraw from the treatment plan. In addition to this, the patient’s past medical history has indicated opiate abuse which means that patient possess the tendency of developing addiction to drugs, in such cases recommendation of drugs having potential addiction profile is risky. With decision 2, I was expecting that the patient will come and will report that Trazodone is still effective and has improved his sleep cycle without causing the unpleasant side effect of priapism (Kuśnierz, Meisner & Sarecka-Hujar, 2021). Decision 3 For decision 3, I selected “continue dose and encourage sleep hygiene, follow up in four weeks”. I selected this decision on the basis of results of decision 2. As the patient came after two weeks and stated that Trazodone is very effective for sleep. Patient did not complained about the unpleasant effect of priapism. However, patient complained that sometimes 25mg dosage is not quite enough to help him sleep through the night. Analysis of sleep hygiene is important because sometimes a good sleep hygiene along with pharmacotherapy can improve the sleep quality. According to the study of Rios et al. (2019) non-pharmacological interventions are considered as the effective first line therapies for adults with insomnia. When these interventions are recommended along with pharmacological therapies then the duration of treatment gets reduced and a patient produces the desired treatment outcomes within short span of time. Short span of time of treatment reduces the risks associated with pharmacological therapies and improves treatment outcomes. It means that pharmacological therapies along with non- pharmacological approaches can improve the risk-benefit ratio, safety profiles and treatment outcomes. On the basis of such evidences, the dose of Trazodone was not increased instead an advise of adopting a good sleep hygiene was made. The other two options of discontinuing Trazodone and initiating therapy with Ramelteon or Hydroxyzine was not selected because the patient has not reported about the inefficacy of Trazodone. Instead the patient reported that Trazodone is very effective for sleep. Moreover, patient has not reported about any side effects caused by Trazodone. In such cases, discontinuation therapy and adoption of a new therapy would be against the treatment algorithm of insomnia. Moreover, both Ramelteon and hydroxyzine causes daytime drowsiness like that of diphenhydramine. Therefore, if any of these drugs are recommended then it will make the patient drowsy at day time and will affect his professional performance. Due to the drowsiness side effect, the patient will not take this medicine and will withdraw from the treatment plan. Therefore these drugs are not recommended (Check, 2021). With decision 3, I was hoping that encouragement about sleep hygiene will definitely improve his sleep cycle and as the dose of Trazodone is already reduced therefore the patient will not report any side effects. A follow up visit is recommended and in this visit analysis of the sleep hygiene will be conducted. If the patient is following a proper sleep hygiene and still Trazodone sometimes fail to help him sleep through the night, then the medication will be change. If the analysis indicated that the patient is not following a good sleep hygiene, then the patient will be educated about the adoption of good sleep hygiene and its effects on the sleep quality (Rios et al., 2019). Ethical Considerations Patient has reported that he is taking alcohol daily in order to fall asleep. Therefore it is mandatory to inform him that now he is on pharmacotherapy and therefore he needs to avoid alcohol consumption. Patient needs to be educated that alcohol consumption is not a solution of his insomnia issue rather, such lifestyle will further worsen his life quality. It is important to make patient satisfied that the recommended treatment plan is sufficient to improve his sleep cycle and therefore he needs to stop taking alcohol. Moreover, patient should be educated that alcohol consumption with this treatment plan can reduce the efficacy of drug, therefore alcohol should be avoided. Patient should be educated about sleep- hygiene in order to further improve the response of treatment. An informed consent will be obtained from patient and patient will be educated about her treatment options and relevant side effects. It is also important to help and guide patient towards the selection of most effective treatment option with fewer side effects (Gaxatte et al., 2017). Conclusion As the patient reported that the symptoms of insomnia started after the sudden death of his fiancé. This indicates that the patient is suffering from secondary insomnia. In such cases, it is important to initiate the treatment plan with non-pharmacological approaches. For example, cognitive behavioral therapies are considered as the first line treatment recommendation for patients suffering from secondary insomnia. So the recommendation in decision one is related to cognitive behavioral therapies. If that option was provided then I would have selected the option of cognitive behavioral therapy. If the patient reported that such therapies are not improving his sleep cycle then the pharmacological approaches would have been selected. The second recommendation is the analysis of sleep hygiene before and after the initiation of treatment plan with Trazodone. Such analysis would have indicated that whether the patient is following a good sleep hygiene or not and the dose of the Trazodone would have been selected accordingly. For example, if the option of Trazodone 25mg was available along with the analysis of sleep hygiene then I would have selected that option instead of recommending 50mg of Trazodone as a starting dose (Matheson & Hainer, 2017). References Check, Q. (2021). 1.09 Approach to insomnia and sleep disturbance in. Management of Complex Treatment-resistant Psychotic Disorders, 56. Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A. & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria, 54(4), 137-149. Gaxatte, C., Faraj, E., Lathuillerie, O., Salleron, J., Deramecourt, V., Pardessus, V. & Puisieux, F. (2017). Alcohol and psychotropic drugs: Risk factors for orthostatic hypotension in elderly fallers. Journal of Human Hypertension, 31(4), 299-304. Ho, T., Jimenez, A., Sanchez, I., Seeger, C., & Joseph, M. (2020). Sleep-related eating disorder associated with zolpidem: Cases compiled from a literature review. Sleep Medicine: X, 100019. Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N. & Ishak, W. W. (2017). Trazodone for insomnia: A systematic review. Innovations in Clinical Neuroscience, 14(7-8), 24. Kathiresan, P., Rao, R., Narnoli, S., Hans, G., & Sharan, P. (2020). Adjuvant trazodone for management of protracted delirium tremens. Indian Journal of Psychological Medicine, 42(4), 391-393. Kuśnierz, P., Meisner, M., & Sarecka-Hujar, B. (2021). Depression and its treatment with trazodone. EJMT, 1, 30. Matheson, E. M., & Hainer, B. L. (2017). Insomnia: Pharmacologic therapy. American Family Physician, 96(1), 29-35. Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G. & Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26(6), 675-700. Rios, P., Cardoso, R., Morra, D., Nincic, V., Goodarzi, Z., Farah, B. & Tricco, A. C. (2019). Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: An overview of reviews. Systematic Reviews, 8(1), 1-16. Silvestro, S. (2021). Hydroxyzine (Vistaril): Dosage, uses, side effects. Drugs. Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in Arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11, 620. [Show More]

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