Scenario
Subjective
The patient is a 31-year-old male reporting worsening insomnia over the past six months. He has always struggled with sleep, but now has trouble both falling and staying asleep, which began after his fiancée’s sudden death. The sleep loss is affecting his work as a forklift operator, and he has even fallen asleep on the job. He previously tried diphenhydramine but disliked the next-day effects. His chart notes a past opioid misuse following an ankle injury, with no prescriptions in the last four years. He now drinks about four beers at night to help himself sleep.
Mental Status Exam
The patient is alert, oriented, and appropriately dressed with good eye contact. He denies hallucinations, shows intact judgment and insight, and reports no suicidal or homicidal ideation. He remains future-oriented.
Case Summary
Insomnia is one of the most common sleep disorders, characterized by difficulty falling and staying asleep and poor sleep quality. It can range from mild to severe and is usually linked to various medical, psychiatric, and lifestyle factors (Morin et al., 2019). In this case, the patient has reported insomnia that has progressively worsened over the past six months, a history of opiate abuse, and has been using alcohol to help him fall asleep, consuming approximately four beers before bed. These factors must be considered when determining this patient’s best course of treatment. For example, Zolpidem and Hydroxyzine were not chosen in the first place due to the patient’s use of alcohol. Therefore, it is integral to consider patient factors when prescribing medication for insomnia.
Decision 1
Trazodone 50 mg po at bedtime.
The Reasons for Making This Decision
Trazodone 50 mg PO at bedtime is an effective treatment for insomnia due to its sedative and anxiolytic effects. According to Mathews et al. (2022), clinical trials have demonstrated that the dose efficiently enhances sleep quality in adults with insomnia. For example, a placebo-controlled trial found that trazodone 50 mg significantly improved sleep efficiency, latency, and wake time after sleep onset after four weeks of treatment (Krystal et al., 2019). Additionally, Trazodone is recommended for the short-term treatment of insomnia. Therefore, Trazodone 50 mg PO at bedtime can effectively treat insomnia in adults.
The Reasons for Not Using Other Medications
Zolpidem and Hydroxyzine were not chosen for treating insomnia because these medications can result in unwanted side effects such as drowsiness, confusion, and headache. In addition, they are not recommended for this patient due to his history of opiate abuse and his current use of alcohol (Kosten & Baxter, 2019). Zolpidem can cause physical and psychological dependence, and alcohol can increase the effects of zolpidem, potentially leading to an overdose. Hydroxyzine can result in respiratory depression when taken in high doses, which becomes more dangerous when combined with alcohol or opioids. Thus, using these medications on this patient could be potentially fatal.
The Achievement of The Decision
The decision to use Trazodone 50 mg PO at bedtime was meant to give the patient a more restful night’s sleep and improve their overall quality of life. Trazodone is an antidepressant with a chemical structure similar to serotonin, which aids in increasing serotonin levels in the brain (Krystal et al., 2019). This can help to reduce anxiety, improve mood, and make it easier to sleep. Additionally, this drug has fewer side effects than many sleep medications, and its sedative effects usually wear off quickly after waking.
Ethical Consideration
Ethical considerations should always be taken into account when treating patients. As far as the treatment plan of taking 50 mg of Trazodone orally at bedtime to manage insomnia is concerned, it is essential to ensure that the patient is made aware of the potential side effects and risks associated with this medication (Krystal et al., 2019). In addition, it is essential to ensure that the patient is provided with resources to help them cope with any potential issues arising from taking the medication. Ensuring the patient has all the necessary information to make an informed decision.
Decision 2
Decrease Trazodone to 25 mg daily at bedtime.
The Reasons for Choosing the Decision
Decreasing the dose of Trazodone from the standard 50mg to 25mg daily at bedtime is a viable option for treating insomnia. Gonçalo & Vieira-Coelho (2021) have shown that lower doses of Trazodone, such as 25 mg, provide similar efficacy to the standard 50mg dose, with fewer adverse effects and a better safety profile. Furthermore, the treatment guidelines for insomnia suggest that Trazodone should be used at doses lower than 50mg and that at least four weeks of treatment be given. Thus, the decision to reduce the trazodone dose to 25mg daily at bedtime during insomnia is supported by both clinical evidence and treatment guidelines.
The Reasons for Not Choosing Other Decisions
The other decisions were not chosen because they were not viable for the patient. Firstly, priapism is a prolonged erection lasting more than 4 hours, and one lasting 15 minutes is not considered priapism (Gonçalo & Vieira-Coelho, 2021). Continuing with the current dose is the best action to allow the erection to subside. Secondly, Trazodone has been proven to be an effective treatment for insomnia and can provide relief quickly; it would be best to continue this medication while adding suvorexant (Gonçalo & Vieira-Coelho, 2021). This combination can offer more efficient and long-term relief while reducing the risk of side effects.
The Achievement of The Decision
The expected achievement of decreasing Trazodone to 25 mg daily at bedtime was to lower the risk of side effects and mitigate the risk of overdosage. Thomas (2022) has demonstrated that lower doses of Trazodone are associated with fewer side effects, including drowsiness, dizziness, nausea, and hypotension. Furthermore, reducing Trazodone to 25 mg daily at bedtime can help prevent accidental overdose, leading to serious medical complications.
Ethical Considerations
Ethical considerations play an essential role in the decision-making process when considering a treatment plan for the patient. For example, when decreasing the dosage of Trazodone to 25 mg daily at bedtime, it is integral to ensure the patient understands the potential risks linked with the reduction and is comfortable with the plan (Thomas, 2022). In addition, it is crucial to consider the patient’s individual goals and preferences, as well as their medical history, to ensure the best possible outcome. Open and honest communication with patients is key to ensuring they are adequately informed and understand the treatment plan.
Decision 3
Discontinue Trazodone. Initiate therapy with Hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks.
Reasons For Selecting the Decision
Hydroxyzine has been proven efficient in treating insomnia symptoms such as difficulty falling asleep and staying asleep. DeMartini et al. (2019) have found that Hydroxyzine has fewer side effects than Trazodone, including less risk of dizziness, headaches, and fatigue. In addition, Hydroxyzine has been linked with enhanced sleep quality, fewer awakenings during the night, and more restorative sleep. These considerations make it a better option for treating insomnia than Trazodone. Following up in four weeks is crucial to ensure that the patient is improving with Hydroxyzine and to make any necessary changes to treatment.
The Reasons for Not Choosing Other Decisions
The two decisions are ineffective because the patient has shown signs of practicing good sleep hygiene. Firstly, continuing with the 25mg dose of Trazodone daily to encourage sleep hygiene can cause serious side effects, such as dizziness, drowsiness, and confusion (Cohen et al., 2022). It is best to try other safer methods of sleep hygiene first before resorting to medication. Secondly, prolonged use of Trazodone means that the patient would continue to suffer from side effects such as drowsiness, confusion, dizziness, and blurred vision. It is essential to monitor patient safety and comfort when introducing any medication.
Ethical Considerations
Ethical considerations involve ensuring the patient knows all the risks and benefits of changing their treatment plan. This includes communicating the differences between Trazodone and Hydroxyzine to the patient and how the new medication will affect their symptoms. It is integral to be honest about potential side effects and ensure the patient knows all the risks associated with the new medication (DeMartini et al., 2019). Additionally, follow-up care ensures the patient responds well to the new treatment. This can include periodic check-ins with the patient, such as calls or video conferencing, to ensure that the treatment plan meets the patient’s needs.
Final Recommendation
The recommendation is to start Trazodone 50 mg PO at bedtime for treating insomnia. Clinical trials have shown that it should be used for short-term relief of symptoms, as long-term use can lead to tolerance and dependence. It is considered to be safe and effective, with minimal side effects. After two weeks of using Trazodone, there is a need to decrease the dosage to reduce the side effects and enhance safety. Studies have found that Trazodone at 25 mg daily is as effective as higher doses for treating insomnia. When the patient has shown good sleep hygiene practices, it is recommended that Trazodone be discontinued because it is not effective for long-term use. Therapy should be initiated with Hydroxyzine 50 mg nightly at bedtime. Hydroxyzine is a sedative-hypnotic medication that has been proven effective in reducing anxiety and insomnia symptoms.
References
Cohen, Z. L., Eigenberger, P. M., Sharkey, K. M., Conroy, M. L., & Wilkins, K. M. (2022). Insomnia and other sleep disorders in older adults. Psychiatric Clinics, 45(4), 717-734. Web.
DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. Web.
Gonçalo, A. M. G., & Vieira-Coelho, M. A. (2021). The effects of trazodone on human cognition: A systematic review. European Journal of Clinical Pharmacology, 77(11), 1623-1637. Web.
Kosten, T. R., & Baxter, L. E. (2019). Effective management of opioid withdrawal symptoms: a gateway to opioid dependence treatment. The American Journal on Addictions, 28(2), 55-62. Web.
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: An update. World Psychiatry, 18(3), 337-352. Web.
Mathews, A., Halsey, S., & Bell, K. (2022). Sleep disturbances following traumatic brain injury. Current Physical Medicine and Rehabilitation Reports, 1-13. Web.
Morin, C. M., Beaulieu-Bonneau, S., & Cheung, J. M. (2019). Handbook of sleep disorders in medical conditions. Academic Press.
Thomas, S. (2022). Trazodone side effects & withdrawal symptoms. Greenhouse Treatment Center. Web.