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The scenario for this paper presents ST, a 25-year-old male who comes to the clinic with a severe case of insomnia. His medication includes diazepam and alprazolam, and he says that they are helping him to go to sleep. His medical history shows that he was diagnosed with asthma at the age of ten. ST says that he has been using an inhaler, as needed, although he cannot remember the name of it. At this time, he is a part-time worker employed through a temp agency, and he had no luck in finding a full-time position. His insomnia could be caused by various conditions; therefore, more information is required to provide an accurate diagnosis and treatment.
Additional Information
To find the exact cause of his affliction, a few questions would need to be answered. First, it would be important to ask if his job prevents him from having a normal sleeping schedule. Does he work a day or night shift? This information would be useful to realize if his circadian rhythm was affected by the sudden change to his sleeping schedule (Sateia & Buysse, 2016). Then it would be good to ask if he experiences night awakenings from his asthma (Lack & Sweetman, 2016). Some more information about his insomnia would be needed. How does he sleep without medication? Does he have trouble going to sleep at the end of the day, or does he wake up too early and cannot get back to sleep despite the desire for it (Shanahan, Copeland, Angold, Bondy, & Costello, 2014)? Also, it would be important to ask if any of his family members are suffering from insomnia (Srinivasan et al., 2013).
Possible Reasons
A multitude of possible causes for his insomnia could be interpreted from the given information. The first one could be depression triggered by his lack of full-time employment. Both of the drugs he is taking are prescribed in cases of anxiety and depression (Shanahan, Copeland, Angold, Bondy, & Costello, 2014). If he wakes up early and cannot go to sleep after, it might also be a sign that his insomnia is caused by depression (Shanahan, Copeland, Angold, Bondy, & Costello, 2014). ST has been diagnosed with asthma, and it could be related to his insomnia. If he experiences night awakenings, this could be a sign of sleep apnea caused by asthma (Lack & Sweetman, 2016). If he has trouble going to sleep at night, his work affects his sleeping schedule, and his family has a history of insomnia it could be caused by a melatonin deficiency (Srinivasan et al., 2013).
Treatment
First of all, no matter the reason he should stop taking diazepam because his asthma condition could lead to serious side effects and even death (Nakafero, Sanders, Nguyen-Van-Tam, & Myles, 2015). Also, in any scenario, the patient should first go through cognitive behavioral therapy for insomnia, also known as CBT-I (Sateia, Buysse, Krystal, Neubauer, & Heald, 2017). Asleep journal and repeated evaluations should help monitor the condition of STs sleep during and after treatment (Sateia, Buysse, Krystal, Neubauer, & Heald, 2017). If the provided information shows that the insomnia is caused by depression, a sedating anti-depressant like trazodone could be prescribed to be taken 150 mg per day in divided doses with a possible increase of the dose by 50 mg every 3 to 4 days with a maximum of 400 mg per day (Generali & Cada, 2015). The patient should be educated about different treatment options to find the best choice of medication for him as well as make sure he understands his condition and treatment (Sateia, Buysse, Krystal, Neubauer, & Heald, 2017). If his insomnia is comorbid and is caused by sleep apnea, no additional medication should be prescribed, and the treatment should focus on CBT-I (Lack & Sweetman, 2016). If the lack of melatonin is the cause of his insomnia, then ramelteon could be prescribed. It should be taken in doses of 8 mg orally 30 minutes before going to sleep (Srinivasan et al., 2013).
References
Generali, J., & Cada, D. (2015). Trazodone: Insomnia (adults). Hospital Pharmacy, 50(5), 367-369.Â
Lack, L., & Sweetman, A. (2016). Diagnosis and treatment of insomnia comorbid with obstructive sleep apnea. Sleep medicine clinics, 11(3), 379-388. Web.
Nakafero, G., Sanders, R., Nguyen-Van-Tam, J., & Myles, P. (2015). Association between benzodiazepine use and exacerbations and mortality in patients with asthma: a matched case-control and survival analysis using the United Kingdom Clinical Practice Research Datalink. Pharmacoepidemiology and drug safety, 24(8), 793-802.Â
Sateia, M., & Buysse, D. (2016). Insomnia: Diagnosis and treatment. New York, NY: CRC Press.
Sateia, M., Buysse, D., Krystal, A., Neubauer, D., & Heald, J. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of clinical sleep medicine, 13(02), 307-349. Web.
Shanahan, L., Copeland, W., Angold, A., Bondy, C., & Costello, E. (2014). Sleep problems predict and are predicted by generalized anxiety/depression and oppositional defiant disorder. Journal of the American Academy of Child & adolescent psychiatry, 53(5), 550-558. Web.
Srinivasan, V., Zakaria, R., Partonen, T., Lauterbach, E., Kuppuswamy, P., & Brzezinski, A. et al. (2013). Melatonergic drug: Ramelteon and its therapeutic applications in insomnia. Melatonin and melatonergic drugs in clinical practice, 1(1), 343-352.Â
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