Introduction
This case study will assess and treat a 31-year-old male with insomnia. Since his fiancé’s unexpected death roughly six months ago, he has been experiencing worsening sleeplessness. He works as a forklift operator and claims that his sleepiness interferes with his ability to do his job properly and that he occasionally sleeps over the course of the day. To help him fall asleep, he has tried over-the-counter (OTC) drugs like diphenhydramine, but he does not like how they make him feel when he wakes up the next morning. He has a history of abusing opiates, that is, hydrocodone/acetaminophen, but he has not had a prescription for that in four years. The patient acknowledges that he has recently been drinking four beers a night to help him sleep.
According to the evaluation of his mental state, he is well-oriented to person, time, and place. He also maintains proper grooming, maintains eye contact, and exhibits sound judgment and understanding. According to him, he had no auditory or visual hallucinations nor any suicidal or homicidal thoughts. Nothing further was checked or tested for as a diagnosis of insomnia was made. It is crucial to bear in mind the patient’s history of substance abuse and present everyday drinking while prescribing them. There will be a step-by-step process for psychopharmacological treatments and the justification for each. The expected outcome for his therapy is for him to fall asleep and stay asleep the entire night, get a better night’s sleep, wake up feeling rested, and not need to drink to fall asleep. It is critical to consider the prescription therapy that will be most beneficial to him and have the fewest negative effects.
Decision One
As the mental health nurse, I would choose from my three options of drugs to start: Zolpidem 10 mg once daily at bedtime, Trazodone 50-100 mg once daily at bedtime, and Hydroxyzine 50 mg once daily at bedtime. The objective is to find a treatment that the patient tolerates and at least slightly improves his sleep cycle. I would decide to start the patient on 50–100 mg of trazodone. If he tolerates it, I would initiate him with a lesser dosage of 50 mg and suggest he increase it to 100 mg after two weeks. To reduce side effects like drowsiness, I would also instruct him to take it with or after meals. Trazodone is classified as a selective serotonin reuptake inhibitor (SSRI) and has a low side effect profile. Trazodone is originally prescribed for the treatment of depression; however, its use for treating sleeplessness has since surpassed that of depression (Yi et al., 2018). Still, there should be educated regarding combining alcohol and antidepressants.
I did not choose Zolpidem 10 mg for this reason—prolonged drug usage may result in physical and psychological dependence. The patient already has a history of drug dependency, making it more likely that he may also develop an addiction to this substance. Furthermore, Zolpidem is also available in a 5 mg dosage; a lower dose is advised when introducing a new medicine to a patient. Similar to benzodiazepines, Zolpidem acts on GABA receptor cells to produce its desired effects. Since GABA affects neurological functions and sleep, Zolpidem may have signs of central nervous system (CNS) depression (Edinoff et al., 2021). Alcohol is a known CNS depressant; combining it with alcohol can be extremely harmful.
Since Hydroxyzine 50 mg is an antihistamine, I decided against selecting it as the final choice. Antihistamines are often accompanied by anticholinergic adverse effects such as dry mouth, drowsiness, and blurred vision (Leung & Hon, 2019). Since it is a potent sedative, hydroxyzine might be harmful when used with alcohol. Additionally, the detrimental effects of hydroxyzine on anticholinergic systems have been documented. Trazodone 50–100 mg is the option from the list that can help this patient’s insomnia with the least number of side effects.
Decision Two
I currently have two options: I may either maintain the same course of treatment or inform him that sleepiness is a temporary adverse effect of trazodone. I may maintain the dosage the same and advise him on how to deal with daytime sleepiness and how long it might continue. On the other side, I could opt to decrease trazodone and only take 25 mg at night. The key objective at this point is to keep getting results from his sleep while also putting an end to his daytime sleepiness. Trazodone’s most frequent adverse effects are sleepiness, nausea, drowsiness, and dry mouth (Khouzam, 2017). Trazodone is typically well tolerated and may have a lower risk of sleeplessness, sexual adverse effects, and anxiety than certain other antidepressants. In terms of ethics, one should keep the patient on the drug that is helping rather than switching to one that could have more harmful side effects.
The patient’s concerns about feeling tired and drowsy were specific to this problem. Ethics dictate that the patient should not be given a prescription for a medication that may result in adverse effects. Trazodone dose reduction would be ineffective since there is no connection between drowsiness episodes and the quantity or length of the medicine that produces this side effect. In addition, the dose increased his sleep, which was our objective. The customer returns after two weeks and says his tiredness has lessened, especially during the day. Even though 50 mg of trazodone is the recommended dosage, he occasionally wakes up in the mornings still feeling sleepy—no other reported psychological symptoms. The signs of sleep disturbances include daytime sleepiness and difficulty falling asleep during the night (Mayo Clinic, 2020). Additionally, some people have a tendency to sleep when driving. Thus, the patient must receive health education and appropriate medications.
Decision Three
The psychiatry nurse should now choose whether to stop taking trazodone and start taking Sonata 10 mg at night with a four-week follow-up or stop taking trazodone and start taking Hydroxyzine 50 mg at bedtime with a four-week follow-up. The psychiatry nurse should determine whether to keep him on the present dosage and advise him he can divide the 50mg dose in half to aid with the next day’s drowsiness. The main goal is to reduce his morning drowsiness while preserving his sleep schedule through the night. My choice would be to lower the dosage in half and reevaluate him in four weeks. We want our patients to sleep better while still avoiding being exhausted the next day, which is why I settled on this option.
Sonata is a sedative for insomnia; however, I decided against its use. Sonata is categorized as a scheduled intravenous medication, which indicates that it has both medicinal use and the risk of abuse and dependency (Milhorn, 2017). There is no significant danger of overdose while using Sonata alone. Sonata and alcohol both increase the risk of overdose and severe respiratory depression. Since both drugs have a depressant effect on the CNS, they can reduce respiration and heart rate. Therefore, giving this drug to this patient would be unethical.
Hydroxyzine is an antihistamine and might have similar effects to diphenhydramine; hence, I decided against stopping trazodone and starting it. Since trazodone is helping, it is recommended to keep taking it, albeit at a lesser dosage. By the end of four weeks, it will be determined if the patient’s dosage was of benefit. If not, a decision would be made whether to put him on a different medicine that would be a better fit and put him on a drug that will not make him better would be unethical.
Conclusion
Conditions that are considered sleep disorders cause changes in how people sleep. Insomnia and other sleep disorders can impact general health, safety, and quality of life (Mayo Clinic, 2019). Lack of sleep can make it more difficult for one to drive safely and raise one’s chance of developing other health issues. Stress, an irregular sleep routine, eating late, drugs, caffeine, nicotine, medical illnesses, or mental health issues are just a few of the issues that can cause insomnia. To find the underlying reason, more research would be required.
The drug most frequently recommended to aid with sleep is trazodone, especially among those in alcohol addiction treatment. Trazodone is prescribed for depression but is often used off-label for insomnia. In the case study, after the death of his fiancé, the patient began to have sleeplessness. He also reports drinking daily and may still be experiencing some depression. He found that trazodone functioned best for him since it is safe to use with alcohol and has a serotonin-related impact that can aid his mood and sleep.
Educating this patient extensively about the medicine and its negative effects would still be necessary. If he does not cease alcohol consumption, it should be moderated. His primary concerns upon entering the facility were his daytime fatigue and sleeplessness. The therapy is ineffective if he can sleep at night but cannot function during the day, affecting his ability to work. It is only fair to focus on both of his issues.
References
Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and Side Effects for Insomnia. Health Psychology Research, 9(1). Web.
Khouzam, H. R. (2017). A review of trazodone use in psychiatric and medical conditions. Postgraduate Medicine, 129(1), 140-148.
Leung, A. K., & Hon, K. L. (2019). Motion sickness: An overview. Drugs in Context, 8, 1–11.
Mayo Clinic. (2019). Sleep disorders – Symptoms and causes.
Milhorn, H. T. (2017). Sedative-Hypnotic Dependence. Substance Use Disorders, 59–76.
Yi, X., Ni, S., Ghadami, M. R., Meng, H., Chen, M., Kuang, L., Zhang, Y., Zhang, L., & Zhou, X. (2018). Trazodone for the treatment of insomnia: A meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25–32.