Assessing and Treating Patients with Sleep/Wake Disorders
Sleep/wake disorders are the various conditions associated with the ability to fall asleep, maintain sleep and get back to sleep after waking up. Sleep disorders can be symptoms of other psychiatric conditions or result from the disorder. In addition, sleep disorders such as insomnia can be a side effect caused by psychiatric and other treatments.
Care providers are responsible for administering different treatment therapies to sleep disorders patients, managing the symptoms over time, and deciding whether to change the current medication or therapy to ensure the desired health outcome. They should also consider the medications’ various side effects, thus making decisions to address or reduce them.
Insomnia is characterized by difficulty falling asleep, persistent awakening and finding it challenging to go back to sleep, and a complete lack of sleep. Insomnia can negatively affect an individual’s physical and mental aspects and quality of life, especially when it is long-term. Therefore, avoiding other related effects such as diabetes, weight gain, and hypertension requires immediate attention.
This paper analyzes a patient with insomnia, the treatment options available, the most appropriate decisions, and the changes made after interacting with the patient at different points, considering the patient’s pharmacokinetic and pharmacodynamics processes.
The case involves a 31-year-old male who has been diagnosed with insomnia. He reports that the condition has been progressively worsening in the last six months. He states that it began after he suddenly lost his fiancé. He also mentions that the condition is affecting his productivity at the workplace. He has used diphenhydramine in the past but does not like how it makes him feel in the morning.
Also, his medical record has a history of opiate abuse.in addition, he mentions using alcohol to help him sleep, approximately four beers before bedtime. The patient maintains eye contact and is alert and oriented to place, time, and person. He has dressed appropriately and denies suicidal ideations and hallucinations. His judgment, reality, and insight are intact.
Decision point One
The first decision is to begin Trazodone 50mg PO daily before bedtime. Trazodone is an antidepressant medication that belongs to the medication class of Serotonin-Antagonist and Reuptake Inhibitors. It works by inhibiting both serotonin transporter and serotonin type 2 receptors. Trazodone is FDA-approved and is one of the most effective medications used to treat sleep disorders, specifically helping maintain sleep and addressing the issue of difficulty in falling asleep. The decision was selected due to its effectiveness.
Despite being used for treating depressive disorders, Trazodone can be used in low doses to effectively treat primary and secondary insomnia (Shin & Saabadadi,2022). Shin and Saabadadi note that Trazodone has been found effective in reducing nightmare episodes and improving sleep habits.
Zolpidem 10mg daily at bedtime was not selected due to its adverse side effects and the sleep-related eating disorder. Zolpidem is an FDA-approved drug used to treat short-term insomnia in patients with difficulty falling asleep and improve sleep quality for patients with chronic insomnia. It is a non-benzodiazepine receptor modulator. It works by increasing GABA inhibitory effects, leading to sedation.
However, it has adverse side effects, such as changes in behavior and abnormal thinking, memory loss, central nervous system depression, and withdrawal. Given the patient’s current quality of life, the medications were avoided to prevent these side effects. In addition, the patient initially reports alcohol use to help him sleep, whereby he uses at least four beers before bedtime.
According to Bouchette, Akhondi & Quick (2022), administering Zolpidem to patients with alcohol or drug toxicity may experience visual and auditory hallucinations associated with strange behavior changes and agitation. Therefore, Zolpidem is not the best medication for the patient since he is more likely to experience these side effects.
Beginning Hydroxyzine 50mg daily at bedtime was the other option. It was not selected since it is an antihistamine used to treat allergic reactions. The medication has a sedative effect that usually takes 4-6 hours. Therefore, it cannot be the best treatment option for insomnia. The patient reports using diphenhydramine in the past. Hydroxyzine is in the same class as diphenhydramine. Thus, administering it would mean changing therapy with medications from the same class, placing the patient at a higher risk for severe side effects.
In addition, the patient reports developing counter-reactions from the intake of antihistamines. Thus, Hydroxyzine is not the best treatment therapy for him due to the possibility of severe side effects. More so, the medication is not approved for treating insomnia.
The important ethical considerations, in this case, include non-maleficence and beneficence. The selected treatment therapy ensured minimal harm to the patient and maximum benefit. The side effects of each medication were also considered to avoid adverse side effects. Also, the most appropriate medication was selected, which is Trazodone. It was expected to produce a desirable health outcome with minimal side effects.
Decision point two
After some time, the care provider evaluates the previous medication/ treatment therapy based on the side effects present and the effectiveness of the medication in treating the symptoms. Thus, a decision on whether to make changes is made. The second decision is to reduce the Trazodone dose to 25mg daily.
This medication was retained, being the best decision for the patient because the patient reported an improvement in the resolution of the symptoms. However, he complained of severe side effects, including an unpleasant erection lasting up to about 15 minutes, thus affecting his daily activities, such as making it difficult for him to get ready for work. It was, therefore, important to reduce the dosage to 25mg daily and see how the patient responded to it within the next two weeks.
Continuing with the trazodone 50mg daily was not selected despite the patient responding well to it since he also presented with unpleasant side effects. The side effects could, however, be managed by reducing the dosage. Research shows that lower doses of Trazodone are effective in less presentation of side effects and improving the quality of sleep and the sleep cycle (Wichniak, Wierzbicka, & Jarema, 2021). Due to the present side effects, the current dosage could not be maintained.
Changing the medication and introducing Hydroxyzine or Suvorexant was not selected since the patient was already positively responding to the current medication. These two are also used for insomnia treatment but are usually associated with severe side effects such as addiction, compromising physical and mental capabilities, and Priapism (Olson et al., 2021). The patient is already experiencing priapism, which mines a medication such as Hydroxyzine would make it worse.
The ethical principles considered in making the second decision were informed consent and beneficence. The patient was informed on why the change in dose reduction was made and the implications of the change. The decision also intended to benefit the patient by reducing the side effects and addressing the symptoms.
Decision Point Three
The third decision after a two-week follow-up clinic was to continue the dose of Trazodone 25mg daily before bedtime for four weeks and to encourage sleep hygiene. The decision was selected because the patient is already positively responding to the medication. The symptoms are partially resolved, and the patient denies presenting adverse side effects such as auditory/visual hallucinations.
However, the patient reported that the 25mg daily dose was insufficient to help him sleep through the night. Therefore, the decision included advice on sleep hygiene to ensure that even with the small dose, he can sleep through the night.
The discontinuation of Trazodone was not selected since the patient had not experienced complete symptom resolution. More so, no severe side effects were reported during the second clinic. It is safe to use Trazodone long-term to ensure that the patient heals completely (Vgontzas et al., 2020).
Changing the medication to either Ramelteon or Hydroxyzine was also not selected since, at this point, the patient was already showing a positive response to the current medication. In addition, the current dose of Trazodone has demonstrated efficacy in improving the patient’s sleep quality and sleep cycle. It also reduced the patient’s symptoms considerably, as well as the manifestation of the side effects such as priapism.
The beneficence ethical principle was considered to ensure patient safety and protect the patient from more harm. Continuing the dose and initiating sleep hygiene advice aims to improve the patient’s condition further, reduce side effects, and provide the desired health outcome.
Insomnia is a sleep disorder that can affect the patient’s physical and mental abilities, reducing their quality of life. Long-term insomnia requires immediate medical attention. In this case, the most appropriate decisions for the patient were beginning Trazodone 50mg PO daily, reducing the dose to 25mg, and continuing with the dosage for at least four weeks on the first, second, and third points, respectively.
Despite the patient presenting with undesirable side effects during the second clinic, the dosage reduction enhanced a regression and helped improve sleep quality and sleep patterns. In addition, given that the patient had used antihistamines in the past and presented with adverse side effects, Hydroxyzine could not be used.
An analysis and evaluation of medications from different points of interaction with the patient enable the care provider to make changes where necessary to ensure the best outcomes are achieved. It is vital to consider ethical principles while making medication decisions and involve the patient actively in every change.
- Bouchette D, Akhondi H, Quick J. Zolpidem. [Updated 2022 Oct 1]. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK442008/
- Olson, C., Jhawar, A., Elfessi, Z., & Doyle, R. (2021). Hydroxyzine-induced priapism. The American Journal of Emergency Medicine, 48, 375-e5. https://doi.org/10.1016/j.ajem.2021.03.066
- Shin J.J, & Saadabadi A. Trazodone. [Updated 2022 Jul 10]. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470560/
- Vgontzas, A. N., Puzino, K., Fernandez-Mendoza, J., Krishnamurthy, V. B., Basta, M., & Bixler, E. O. (2020). Effects of Trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: a preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009-2019. https://doi.org/10.5664/jcsm.8740
- Wichniak, A., Wierzbicka, A. E., & Jarema, M. (2021). Treatment of insomnia – effect of Trazodone and hypnotics on sleep. Psychiatria Polska, 55(4), 743–755. https://doi.org/10.12740/PP/125650