Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
**For this Discussion, review the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
- Metformin 500mg BID
- Januvia 100mg daily
- Losartan 100mg daily
- HCTZ 25mg daily
- Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
BY DAY 3 OF WEEK 7
Post a response to each of the following:
- List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
- Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
- List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
- List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
- For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
- Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
references are to be no older than five years
Expert Solution Preview
Introduction:
Insomnia is a common medical condition that is often indicative of an underlying mental illness. The bidirectional relationship between insomnia and mental illness underscores the importance of considering both psychopharmacologic treatments and proper sleep practices for optimal health and well-being. In this discussion, we will review a case study and consider various therapy approaches for assessing, diagnosing, and treating a patient’s health needs.
1. List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
a. How often do you experience difficulty falling asleep or staying asleep?
– This question helps assess the severity and frequency of the patient’s insomnia symptoms.
b. Since the passing of your spouse, have you noticed changes in your appetite or daily routine?
– This question explores the patient’s depressive symptoms and how they relate to her insomnia.
c. Are you currently using any sleep aids or over-the-counter medications to help with sleep?
– This question helps to further identify the patient’s current sleep habits and any potential treatment interventions that may have been attempted.
2. Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
a. Family members or caregivers
– Questions might include how the patient has been behaving at home, changes in appetite or energy levels, and whether or not the patient has expressed thoughts of self-harm.
b. Primary care physician
– Questions might include any previous history of depression or mental illness, current medication regimen, and past treatment approaches for insomnia and depression.
c. Mental health specialist
– Questions might address specific interventions or therapies that have been attempted and any potential underlying mental health conditions or stressors that may be contributing to the patient’s emotional state.
3. Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
A physical exam would be appropriate to assess for any potential physical conditions or changes that may be contributing to the patient’s insomnia. Basic blood work, including a complete blood count and comprehensive metabolic panel, can help identify any underlying conditions such as poorly managed diabetes or thyroid dysfunction, which could be exacerbating the patient’s symptoms. Additional diagnostic tests, such as a sleep study, may also be needed to better evaluate the patient’s sleep habits and identify any underlying sleep disorders contributing to the insomnia.
4. List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
Differential diagnoses may include insomnia due to depression, insomnia due to medication use, or primary insomnia. Given the patient’s history of depression and recent loss of her spouse, it is likely that her insomnia is related to her underlying mental health condition.
5. List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
Two pharmacologic agents that may be appropriate for antidepressant therapy in this patient include sertraline and escitalopram. Sertraline is an SSRI that increases the levels of serotonin in the brain, while escitalopram is a selective serotonin reuptake inhibitor (SSRI) that increases the levels of serotonin in the brain. From a mechanism of action perspective, both agents work similarly to increase the levels of serotonin in the brain, making them appropriate options for treating the patient’s depression.
6. For the drug therapy you select, identify any contraindications to use, or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
Potential contraindications for these medications include known hypersensitivity, concomitant use of monoamine oxidase inhibitors (MAOIs), and unstable seizures. Additionally, there may be ethical concerns with the use of antidepressant medications in elderly patients, particularly in cases where there is a risk for falls or other adverse events. For this reason, it may be necessary to start with a lower dose of medication and closely monitor the patient’s response to treatment.
7. Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.) and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Follow-up data at regular intervals, such as Week 4, 8, and 12, will allow for assessment of the patient’s response to treatment and any potential side effects. Based on the patient’s response, therapeutic changes may include adjusting the medication dosage, changing medication, or adding nonpharmacologic treatment modalities, such as cognitive-behavioral therapy (CBT) or sleep hygiene education.
