Psychopharmacologic Approaches To Treatment Of Psychopathology

Case study
Insomnia 31-year-old Male

 
BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
 
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a great sleeper but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fianc. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
 
MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.
Decision Point One
Select what you should do:
 
Zolpidem: 10 mg daily at bedtime
 
Trazodone: 50100 mg daily at bedtime
 
Hydroxyzine: 50 mg daily at bedtime
Decision Point One
 
TrTrazodone: 50100 mg daily at bedtimeazodone: 50100 mg daily at bedtime
RESULTS OF DECISION POINT ONE
Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of a prolonged erection of the penis, approximately 15 minutes after waking
Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two
 
Decrease trazodone to 25 mg daily at bedtime
 
RESULTS OF DECISION POINT TWO
Patient returns to clinic in 2 weeks
Patient states trazodone is very effective for sleep
Patient states sometimes the 25 mg dosage isnt quite enough to help him sleep through the night
Patient denies auditory/visual hallucinations and is future oriented
 
Decision Point Three
 
Continue dose. Encourage sleep hygiene. Follow up in 4 weeks
 
Guidance to Student
Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.