Case study

The client is a 31 years old male and stated that he had experienced insomnia for at least six months. During that period, he has had difficulties falling and staying asleep at night. As per his statement, this problem emerged after the sudden demise of his partner. The patient stated that insomnia had worsened to the extent that he could not work efficiently at a nearby chemical company where he worked as a forklift operator. Due to the drowsiness caused by insomnia, the client is at risk of losing his employment. The patient had previously used diphenhydramine, but he discontinued the medication shortly after since it gave him an ill feeling in the morning.

According to his medical history, the patient had previously used hydrocodone as a pain killer due to an injury he had sustained. However, the patient had not used any opiate medication for four years. Presently, the client consumes four beers every night to cope with insomnia. Based on the information given by the patient, a physical examination would not be necessary, and thus, a mental examination WNL was recommended. Based on the mental examination, the patient is alert and fully oriented, makes proper eye contact, and is dressed appropriately. Besides, he does not report experiencing any form of hallucinations and denies harboring any suicidal thoughts. Moreover, his insight and judgment are normal and intact.

Introduction and therapy objective

Based on the case study and the observations made during the interaction, the patient is affected by chronic insomnia. According to Winkleman (2015), insomnia refers to sleeping problems characterized by the inability to fall asleep, difficulties staying asleep, and not getting enough sleep. If not addressed, such sleeping problems have adverse physical and psychological implications. Chronic insomnia occurs when a patient experiences the above sleeping problems for more than three months, and it mostly presents due to underlying physical or psychological problems (Morin & Benca, 2012). In the context of this paper, the client’s bereavement is, to a large extent, the cause of his condition. Considering that the mental examination did not establish any psychological disorder, the client would embark on a six-week therapy to address chronic insomnia. Regardless, before the treatment begins, it would be prudent to examine the patient’s medical history and make proper decisions based on the prevailing life circumstances.

1. Decision 1

As per the outcomes of the mental examination, the patient is in a proper psychological state, and although he stated that insomnia started after his late fiancé’s death, he does not exhibit any symptoms associated with depression or anxiety. In this situation, I recommended that he begin with a daily dosage of Trazodone 50 mg that would be taken orally before bedtime.

• Reasons backing decision 1

Although I would have prescribed Zolpidem 10mg and Hydroxyzine 50mg, there are various reasons why I chose to begin with Trazodone 50mg. Zolpidem is the brand name for Ambien, which is a widely acknowledged first-line medication for chronic insomnia. According to Greenblatt & Roth (2012), Ambien is sedative-hypnotic and initiates sleep by slowing down the brain and the central nervous system. On the other hand, Trazodone is typically an antidepressant and is classified as a serotonin antagonist reuptake inhibitor (SARI). However, Trazodone is recommended as an off-label treatment for insomnia (Jaffer et al., 2017). Lastly, Hydroxyzine is primarily used in treating allergies, and it can also be used to induce sleep. Although both Zolpidem and Trazodone are useful in treating insomnia, Zolpidem is a sedative, and studies show that intoxication is among its most prominent side effects. More importantly, it is more addictive compared to Trazodone. Considering that the patient operates machinery and has an opiate history, it would be more prudent to prescribe Trazodone than Zolpidem. Although Trazodone is linked to suicidal ideation, it would be harmless since the patient does not harbor any suicidal thoughts. Alternatively, recommending Hydroxyzine would not be necessary since the patient does not have experienced any anxiety symptoms, and neither did he report any allergy (Matheson & Hainer, 2017).

•  Achievement

My decision to begin treatment by prescribing Trazodone 50 mg was to achieve specific aspects. Firstly even though I acknowledge that Zolpidem is primarily meant to treat insomnia, I could not recommend it since it would jeopardize the client’s ability to perform his job, and thus, it would increase the risk of him losing employment. More importantly, since the client had recovered from opioids relatively recently, recommending Zolpidem would fling him back to addiction. Generally, my decision was meant to attain recovery while safeguarding the client’s physical and psychological safety and well-being.

•  Ethical considerations

As per the case study, the client reported that he had experienced negative side effects from taking diphenhydramine. In this sense, my decisions would be to protect the client from more adversities while alleviating his condition. In our case, the client had limited knowledge about the most effective medication, and thus, he relied on my decisions. Therefore, in this case, his autonomy in the therapy process was limited. Regardless, I maintained confidentiality and communicated with the patient concerning the possible side effects stemming from the first dosage.

• Decision 2

After two weeks, the patient returned and stated that the sleep problems had relatively subsided. However, due to the medication, he was experiencing a prolonged erection which would last approximately 15 minutes in the morning. As he stated, this new side effect interfered with his work preparation and, more importantly, made it impossible to have breakfast with his family. Otherwise, the client did not report having any hallucinations or any other side effects. Based on the outcomes stated above, I reduced the Trazodone dose to 25mg daily, which would last for two weeks.

• Reasons backing decision 2

According to Greiner et al. (2019), persistent penile erection (priapism) is a normal side effect linked to antidepressants like Trazodone. Extensive studies point out that antidepressant-induced priapism presents rarely. Regardless, since the patient complained that the prolonged erection embarrassed him and interfered with his routine, maintaining the present dose would not be prudent. More importantly, maintaining the present dosage would possibly inflict further physical and psychological harm. Alternatively, switching to Suvorexant would not be appropriate since the first dose attained relatively positive results, and there would be no need to risk drug reactions, more severe side effects, and withdrawal symptoms (Hatano et al., 2018).

• Achievement

To arrive at the above decision, I made several critical considerations. Firstly, if the previous dosage caused priapism, maintaining it would harm the patient in the long run. Studies suggest that if the patient continued having prolonged erections, there would be a risk of penile fibrosis and erectile dysfunction (Song & Moon, 2013).  Secondly, I decreased the dose so that the client could proceed with treatment whereas adhering to his work and family routine. Lastly, the drug reactions, withdrawal symptoms, and severe side effects that would stem from switching suvorexant would erode all the positive progress we have made so far.

• Ethical considerations

As a medical practitioner, I am always bound by my professional ethics to safeguard the client from any harm during treatment. Even with such knowledge, the client experienced priapism due to the decision I made in the treatment. Since the client had to recover while avoiding oversedation, I reduced the dose. More importantly, I infringed upon the patient’s right to participate in the therapy in making such a decision.

• Decision 3

After reducing the Trazodone dose to 25mg, the patient returned after two weeks and reported that the present dose was working well even though it could not get him to sleep throughout the night. Notwithstanding, he had not experienced any hallucinations or adverse side effects.  Based on the patient’s report, I maintained the present dose (Trazodone 25mg) for four weeks and encouraged the patient to practice sleep hygiene.

• Reasons for making decision 3

Considering the outcomes attained by making the second decision, it was only suitable to maintain the current dosage and advise the patient to develop sleep hygiene. Firstly, as per the patient’s report, the present dose was working well, and he could sleep well at night. Such results signify that the patient was responding well to treatment and was recovering from insomnia (Smith et al., 2016). Therefore switching to ramelteon would decrease the efficacy and consistency of treatment. On the other hand, since the previous side effects had waned, any further dosage increase would cause problems. Moreover, since the patient had not practiced sleep hygiene previously, it would be a better time to develop and adhere to a proper sleeping program while taking the present dose (Irish et al., 2015). If the patient would not report any positive change within four weeks, exploring other options like Hydroxyzine would be necessary.

• Achievement

By maintaining the present dose and advising the client to practice sleeping hygiene. Firstly, since the client gave positive feedback about the present dosage, maintaining it would give it more time to attain full recovery while avoiding the risks of switching new medications like ramelteon. Secondly, since the patient started Trazodone and it worked, I aimed to increase dosage efficacy and consistency. Lastly, since CBT is more effective in treating insomnia, it would be better for the patient to practice sleeping hygiene than to rely on medication (Irish et al., 2015).

• Ethical considerations

As a health provider, I was glad that the patient had almost recovered within the time allocated for treatment. Regardless, I was worried that even though the sleeping problems would soon end with the therapy, the ultimate cause of the problem was never highlighted or addressed. In our initial examination, the patient reported that the sudden demise of his fiancé triggered insomnia. From this perspective, treating sleeping disorders would only be eluding the real problem.

Conclusion

This paper discusses an 8-week treatment plan for a 31yrar old male diagnosed with chronic insomnia. The main objective of the therapy was to get the patient to sleep normally within four weeks while maintaining his daily routine. The therapy period lasted for eight weeks, with appropriate patient monitoring and follow-up on progress. As discussed, the patient began treatment with a daily dosage of Trazodone 50mg, the recommended dose for adults. After two weeks, the client reported positive progress, although he was experiencing priapism mainly due to Trazodone intake. As per the second decision, the dose was reduced to 25mg, upon which the side effects declined, and the patient expressed positive changes in his sleeping. Based on such an outcome, the dose was maintained for four weeks, and the client was advised to practice sleep hygiene. Based on the outcomes of the last recommendation, the client would switch to another medication while maintaining sleep hygiene. Throughout the therapy, I recommended Trazodone rather than Zolpidem, Hydroxyzine to reduce sedation so as the client to remain active at work. On the other hand, switching to particular medications like ramelteon would exacerbate side effects and produce unwanted drug reactions. More importantly, advising the client to practice sleep hygiene was the best decision since he would learn to sleep well without depending on alcohol or medication.

Reference

Greenblatt, D. J., & Roth, T. (2012). Zolpidem for insomnia. Expert opinion on pharmacotherapy, 13(6), 879-893.

Greiner, T., Schneider, M., Regente, J., Toto, S., Bleich, S., Grohmann, R., & Heinze, M. (2019). Priapism induced by various psychotropics: A case series. The World Journal of Biological Psychiatry, 20(6), 505-512.

Hatano, M., Kamei, H., Inagaki, R., Matsuzaki, H., Hanya, M., Yamada, S., & Iwata, N. (2018). Assessment of Switching to Suvorexant versus the Use of Add-on Suvorexant in Combination with Benzodiazepine Receptor Agonists in Insomnia Patients: A Retrospective Study. Clinical psychopharmacology and neuroscience : the official scientific journal of the Korean College of Neuropsychopharmacology, 16(2), 184–189. https://doi.org/10.9758/cpn.2018.16.2.184

Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23-36.

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34.

Morin, C. M., & Benca, R. (2012). Chronic insomnia. The Lancet, 379(9821), 1129-1141.

Smith, E., Narang, P., Enja, M., & Lippmann, S. (2016). Pharmacotherapy for Insomnia in Primary Care. The primary care companion for CNS disorders, 18(2), 10.4088/PCC.16br01930. https://doi.org/10.4088/PCC.16br01930

Song, P. H., & Moon, K. H. (2013). Priapism: current updates in clinical management. Korean journal of urology, 54(12), 816-823.

Winkelman, J. W. (2015). Insomnia disorder. New England Journal of Medicine, 373(15), 1437-1444.