SSRIs and TCAs for Insomnia Treatment Paper

One of the common symptoms of depression is lack of sleep or an inability to fall and stay asleep. in the discussion, the patient is diagnosed with major depressive disorder (MDD) and one of the presenting symptoms is insomnia. In the management of the patient, I recommend that SSRIs or TCAs can be used in treatment. evidence has shown that both SSRIs and TCAs are equivocally efficient in the treatment of depression. SSRIs are however the most preferred because of their fewer side effects and they are more tolerable by the patients. in the discussion. SSRIs and TCAs discussed in the paper are for the management of MDD and not for the treatment of insomnia. However, the expected outcome is that by treating MDD, the insomnia should resolve are a result since it is a consequence of the MDD.

SSRIs and TCAs for Insomnia Treatment Paper

SSRIs and TCAs can still be used for the management of insomnia. Everitt et al. (2018) conducted randomized controlled trials on adult aged 18 years or older and noted that there was a small improvement in sleep quality with short term use of low dose SSRIs and TCAs when compared to placebos. The tolerability and safety of antidepressants for the treatment of insomnia was however uncertain due to limited reporting of adverse effects. TCAs improved sleep efficiency but increased the likelihood of somnolence and had sedating effects even during the day.  According to Everitt et al. (2018), the use of antidepressants to treat insomnia is widespread.  Low‐doses (sub‐therapeutic of depression) of TCAs, particularly amitriptyline, have been used to treat insomnia for decades. Low-dose amitriptyline works by antagonizing histamine H1 receptor.

These drugs are however associated with toxicity in overdose such as in amitriptyline and other TCAs. monitoring for tolerability and adverse effect issues such as increased restless leg syndrome is therefore essential. SSRIs are associated with periodic limb movements in sleep and sleep bruxism (Everitt et al., 2018)

SSRIs and TCAs for Insomnia Treatment Paper Reference

  • Everitt, H., Baldwin, D. S., Stuart, B., Lipinska, G., Mayers, A., Malizia, A. L., Manson, C. C., & Wilson, S. (2018). Antidepressants for insomnia in adults. The Cochrane database of systematic reviews5(5), CD010753. https://doi.org/10.1002/14651858.CD010753.pub2

Major Depressive Disorder Sample 2

The patient is a 75-year-old patient who lost her husband 10 months ago and presents with complaints of insomnia. The questions I might ask the patient are:

  • Can you tell me how I may be of assistance today? This is an open-ended question that can serve to create rapport and encourage the patient to give me a lot of information about herself with the knowledge that the doctor is ready to listen and help her.
  • Do you live with someone at home? By asking this question, I will understand the type of support system the patient has at home and know which support to prescribe for the patient.
  • Are you following your regimen correctly? This will help me know if the patient is compliant to her medication and whether the support at home is helping the patient follow her regimen correctly.
  • How would you describe a well-rested sleep? This open-ended question would give me information regarding the patient’s expectations of enough sleep and this would be useful in designing an effective goal for her personal treatment plan.

The people in the patient’s life that I would need to speak to are her children, her close friends and neighbors. I could also speak to her aide if she has one.  these people will help me know the severity of the patient’s problem. Some of the questions I will ask them are;

  • Based on your personal experience with her, can you describe her as a mother or friend or neighbor? This question will help me understand how the patient usually is so as to easily identify any anomalies from the subsequent history taken.
  • Has the patient been behaving more differently recently or experiencing worse symptoms of depression since her husband’s death? This question will help me understand the changes that the people close to her have noticed and whether they have noticed if she is depressed or not.
  • Does the patient complain about her medication or treatment regimen? This question will allow me to assess whether the patient is compliant or know the side effects the patient experiences, if any.
  • Has the sleeping patterns changes recently? This question will help me understand the severity of insomnia.

The physical exams appropriate for this patient include heart rhythm, respiratory rate, pulse rate, and oxyhemoglobin saturation. This is done because anxiety disorders can affect the findings of these parameters.

Tests such as Complete Blood count and Blood chemistry. Thyroid function tests assess possible contributing factors to her depression. Thyroid dysfunction can play a role in the pathogenesis of depression. Kidney function tests which test the ability of the kidney to eliminate waste from the body. These tests will include the urea, electrolytes and creatinine, and the GFR tests. Liver function tests which assess the liver enzymes. LFTs and KFTs test how well the body can metabolize and eliminate medications to be prescribed.

The diagnostic tests for this patient include polysomnography and actigraphy tests that are used to measure the patient’s sleep patterns. The actigraphy alone measures sleep efficiency, sleep latency, and total sleep time. The polysomnography will diagnose sleep disorders (Niel et al., 2020). Depression screening tests can also be done using different questionnaires to assess the level of her depression.

The patient’s differential diagnoses include:

  • Generalized Anxiety Disorder (GAD),
  • Major Depressive Disorder (MDD),
  • Restless Leg Syndrome.

Major depressive disorder (MDD) is the most likely disease that could explain why the patient is experiencing insomnia. MDD usually presents clinically as insomnia, difficulty concentrating, loss of appetite, and hopelessness. The patient lost her husband of 41 years and it is possible that this contributed to her depression, which has also affected her sleeping pattern. Bennabi et al. (2019) states that patients with MDD are at risk of experiencing sleeping disorders.  Since the patient is responding to grief, her chances of developing MDD are high.

The pharmacologic agents that would be appropriate for the patient’s therapy are:

  • Selective serotonin uptake inhibitor (SSRIs). An example is Prozac. The required dose is 10 mg given PO qDay. The mechanism of action of SSRIs is by inhibiting the serotonin transporter (SERT) at the presynaptic axon terminal to prevent serotonin re-uptake. Inhibition of SERT results in an increased amount of serotonin in the synaptic cleft which then increase the serotonin levels, activity and effect in the brain.
  • Tricyclic antidepressants (TCAs) are used to treat MDD. An example is Amitriptyline. The required dosage is 10-25 mg given PO qHS. The mechanism of action of TCAs is blocking the reuptake of both serotonin and norepinephrine neurotransmitters consequently increasing the levels of norepinephrine and serotonin levels in the brain.

In terms of treating MDD, both TCAs and SSRIs show equivocal efficacy. However, SSRIs are the preferred drug for treatment of MDD because of fewer and milder side effects associated with this type of antidepressant drug. TCAs cause more adverse effects because of their anticholinergic effect. Also, when considering the patient’s age, SSRIs are the preferred drug (Bauer et al., 2017). TCAs on an elderly client might result in adverse cardiovascular effects such as dysrhythmias or orthostatic hypotension that may lead to dizziness, falls, and fractures.

Various research has shown that other races such as Asians and African Americans resort to using other alternative medication to treat their depression and these medications require lesser drug dosages to achieve the desired effect. SSRI use for the white race is always on standard prescription values with regards to its dosage and schedule. Administering these drugs to elderly patients however warrant that a modification is done. This is done through dose adjustment to minimize the side effects and polypharmacy considerations for drug-drug interactions (Salehi, 2019). The drug contraindicates in the patients taking selective serotonin reuptake inhibitors are mirtazapine, and other vasoconstrictors and analgesics.

After administering these drugs, the patient will be assessed after a four-week interval to determine if the symptoms have improved. If the symptoms have not improved after four weeks, Prozac will be increased by 10-20 mg for four weeks until a maximum of 80 mg, which is the maximum recommended dose per day. If the symptoms improve within the first four weeks, the regimen will be maintained until the patient completes the dose. After completing the dose, the patient will sleep well and the symptoms of depression will be well managed. Once the desired outcome has been achieved the patient Prozac daily should be discontinued and started on Prozac weekly after one week. The patient should be closely monitored for any changes in behavior and suicidal tendencies within the first 4- 8 weeks. Prozac may also interfere with glycemic control as it may cause hypoglycemia especially in diabetic patients (DiVall & Woolley, 2019)

I have learnt that depression is a major illness that affects many patients and details in the history of a patient should be carefully examined to make the appropriate diagnosis and commence the proper treatment modalities.

References

  • Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J. B., Destouches, S., Lancrenon, S., & Haffen, E. (2019). Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC Psychiatry, 19(), 262. https://doi.org/10.1186/s12888-019-2237-x
  • Bauer, M., Severus, E., Möller, H. J., Young, A. H., & WFSBP Task Force on Unipolar Depressive Disorders. (2017). Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. International Journal Of Psychiatry In Clinical Practice21(3), 166-176. https://doi.org/10.1080/13651501.2017.1306082
  • DiVall, M. V., & Woolley, A. B. (2019). CHAPTER Pharmacologic Agents. Acute Care Handbook for Physical Therapists E-Book, 431.
  • Niel, K., LaRosa, K. N., Klages, K. L., Merchant, T. E., Wise, M. S., Witcraft, S. M., Hancock, D., Caples, M., Mandrell, B. N., & Crabtree, V. M. (2020). Actigraphy versus polysomnography to measure sleep in youth treated for craniopharyngioma. Behavioral sleep medicine18(5), 589-597. https://doi.org/10.1080/15402002.2019.1635133
  • Salehi, M., Hadizadeh, H., Chang, A., & Grados, M. A. (2019). Recommendations for prescribing SSRIs. Contemporary Pediatrics36(11), 24-27.