Insomnia

Insomnia can cause many disruptions with daily life activities such as not being able to

stay awake while at work and causing issues with mood disruption. Prior to diagnosing a patient

with insomnia, the patient must meet certain criteria. The patient must have one of the following

symptoms according to DSM 5; Difficulty initiating sleep, difficulty maintaining sleep (frequent

awakenings or problems returning to sleep), and early-morning awakening with inability to

return to sleep, sleep disturbance caused by distress or impairment in social, occupational,

educational, academic, behavioral, and other areas of functions. These are just a few of the

diagnostic criteria for insomnia.

The patient this week is a 31-year-old male that presents with complaints of insomnia. He

states his insomnia has gotten worse over the past six months right after the loss of his fiancé. He

is currently a forklift operator at a local chemical company and has been using diphenhydramine

to help with sleep. He does state that it causes him to be drowsy the next day after taking it. He

has been falling asleep on the job due to lack of sleep from the previous night. He has a history

of opiate abuse but has not taken hydrocodone/apap in four years and is now utilizing alcohol to

help him fall asleep and drinks about four beers prior to bed. He is alert and oriented and denies

any suicidal/homicidal ideation. This patient has primary insomnia which is defined as an

organic illness in which sleep disturbances last longer than one month and no identifiable

etiology (Jaffer et al., 2017).

Decision one- Start Trazodone 50mg PO at bedtime

It is appropriate to start the patient on Trazodone 50mg by mouth at bedtime. Trazadone

belongs to the class S-MM and SARI. It is FDA approved for the use of depression, insomnia

(primary and secondary), and anxiety. The onset of therapeutic actions in insomnia are

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immediate if the dosing is correct. For insomnia the use can be long term due to there not being

any reliable evidence of tolerance, dependence, or withdrawal. This is a good choice since the

patient has a history of drug dependence and is currently using alcohol to help with sleep.

Trazadone is not usually used as a monotherapy to treat insomnia but works to improve patients

sleep that are having withdrawal from alcohol or other psychiatric disorders (Stahl).

Initial dosing for insomnia is 25-50mg by mouth at bedtime and would need to be

increased as tolerated. Patients can have carryover sedation, ataxia, and intoxicated-like feeling if

dosed too aggressively (Stahl). Trazodone should not be used if a patient is taking an MAOI.

Jaffer et al. (2017), states that one limitation of the current review was the lack of systematic

analysis of measuring insomnia. However, they did conclude that trazodone is the most common

off-label choices for treatment of insomnia.

Zolpidem 10mg by mouth at bedtime would not be appropriate for this patient. Zolpidem

is in class GABA-PAM and non-benzodiazepine hypnotic; alpha 1 isoform selective agonist of

GABA-A/ benzodiazepine receptors. It is used for short term treatment of insomnia and is

controlled release indication is not restricted to short term (Stahl). Side effects include sedation,

dizziness ataxia, dose-dependent amnesia, hyperexcitability, nervousness, rare hallucinations,

diarrhea, nausea, and headache. It can cause respiratory depression and increases when taken

with other CNS depressants in overdose. Since the patient drinks four beers per night this would

not be a good choice because it can increase his risk of respiratory depression. The patient as

stated before has a history of drug dependence. Zolpidem is a schedule IV and may cause

dependence. This is increased in this patient due to prior drug addiction.

Hydroxyzine 50mg by mouth at bedtime would not be appropriate either because it can

cause drowsiness the day after taking. It is a histamine receptor antagonist (H-RAn) is normally

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prescribed for anxiety, pruritus, and can be used for insomnia (Stahl). It is usually used for short

term symptoms of anxiety. It too can cause CNS depression. The patient is using alcohol, so this

also makes this drug not a good choice. The hydroxyzine will cause him to be drowsy the next

day and it can be dangerous especially with his line of work.

Outcome-

The outcome is that the Trazodone will help the patient with insomnia. After he returns in

two weeks, he states that the medication is working well for him, but he has an unpleasant side

effect of an erection lasting approximately fifteen minutes after waking. He complains that it

causes difficulty getting ready for work and that it is hard for him to enjoy family time in the

mornings. He denies any visual/auditory hallucinations.

Ethical Considerations-

Ethical considerations would include on educating the patient on the side effects of the

trazodone such as the morning erection and explain to him that it is not considered a priapism

(persistent and painful erection of the penis). However, he states that the medication is causing

issues with his family life in the mornings, so it is important to find a medication that is working

and not interfering with his daily activities. Patient safety is very important, and the zolpidem

and hydroxyzine is dangerous due to CNS depression and daytime drowsiness.

Decision two- Decrease Trazodone to 25mg PO at bedtime

I chose to decrease the trazodone to 25mg by mouth at bedtime because the patient stated

that it worked for him. Decreasing the medication dosage can help decrease the side effects. The

other choice was to continue the same dosage and educate that the erection should diminish over

time or to discontinue trazodone and initiate therapy with suvorexant 10mg by mouth at bedtime.

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It is important to decrease the medication due to the unwanted side effects of the erection.

Suvorexant is a dual orexin receptor antagonist; hypnotic. In the case of this drug the dosage

would need to be started at 5mg by mouth at bedtime and not 10mg. This is also a schedule IV

drug and can cause sleep paralysis and hallucinations. Patients would also need to be guaranteed

to have a full night’s sleep at least seven hours.

Outcome-

After choosing to lower the dosage of trazodone to 25mg by mouth at bedtime the patient

returns in two weeks and states that the trazodone is effective for sleep. He does complain that it

isn’t quite enough to help him sleep through the night. However, it is important that the

medication does not cause daytime drowsiness. Also, the patient is no longer having the morning

erections that he had on the 50mg dosage.

Ethical Considerations-

Education is key for this patient. He needs to be educated that the suvorexant is not a safe

medication for him due to drinking four beers a night and that it can cause hallucinations. It can

be safe to say that he could have some depression due to the death of his fiancé and this

medication can cause an increased risk of suicidal ideations.

Decision three- Continue Trazodone at 25mg PO at bedtime. Encourage sleep hygiene.

Follow up in 4 weeks

I chose to continue trazodone at 25mg by mouth at bedtime and encourage sleep hygiene.

One option was to discontinue the trazodone and initiate therapy with ramelteon 8mg by mouth

nightly and the other was to discontinue the trazodone and initiate therapy with hydroxyzine

50mg by mouth at bedtime and follow up in four weeks. The hydroxyzine as previously

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discussed is not safe for the patient due to daytime drowsiness especially in his line of work. As

stated, before it can cause CNS depression. The ramelteon 8mg is a Melatonin 1 and 2 receptor

agonist and is used to treat insomnia. This medication can lead to next day drowsiness and can

also cause issues with memory.

Outcome-

The outcome would be for the patient to have improvement with his sleep. Encouraging

good sleep patterns would be beneficial. The patient may also need other testing such as a sleep

study to make sure he does not have sleep apnea. Encouraging him to discontinue the alcohol in

the evening would also be beneficial and could be the cause of him waking up in the middle of

the night.

Ethical Considerations-

I would consider talking to the patient about starting AA meetings to help with the

alcohol abuse. It seems that he is using it for coping mechanisms and could possibly be the

reason he is having issues with sleep.

Conclusion

According to (Plescia et al., 2021), the sleep wake cycle plays a key role in the genesis of

several mental disorders such as post-traumatic stress disorder, straining, depression, anxiety, and

is also associated with sleep disorders and substance abuse.

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References

Greenblatt, D., Harmatz, J., Singh, N., Steinberg, F., Roth, T., Harris, S., & Kapil, R. (2014).

Pharmacokinetics of Zolpidem from Sublingual Zolpidem Tartrate Tablets In Healthy

Elderly Versus Non-Elderly Subjects. Drugs & Aging, 31(10), 731–736.

https://doi.org/10.1007/s40266-014-0211-3

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.

Plescia, F., Cirrincione, L., Martorana, D., Ledda, C., Rapisarda, V., Castelli, V., Martines, F.,

Vinnikov, D., & Cannizzaro, E. (2021). Alcohol Abuse and Insomnia Disorder: Focus on

a Group of Night and Day Workers. International Journal of Environmental Research

and Public Health, 18(24). https://doi.org/10.3390/ijerph182413196

Salmani, B., & Hasani, J. (2021). Comparing the Effects of Cognitive-behavioral Therapy and

Zolpidem 10 mg on Illness Perception and Sleep Efficiency in Individuals With Chronic

Insomnia. Arak Medical University Journal, 24(2), 292–305.

https://doi.org/10.32598/JAMS.24.2.6260.1

Unruh, M., Cukor, D., Rue, T., Abad, K., Roumelioti, M.-E., McCurry, S. M., Heagerty, P., &

Mehrotra, R. (2020). Sleep-HD trial: short and long-term effectiveness of existing

insomnia therapies for patients undergoing hemodialysis. BMC Nephrology, 21(1), 1–12.

https://doi.org/10.1186/s12882-020-02107-x

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