Treatment for a Patient with Depression and Insomnia
Poor sleep has detrimental effects on physical and mental health (Abbott, 2016). Sleep disturbances are both a symptom of and a cause of mental illnesses like depression and anxiety (Abbott, 2016). While treating the underlying mental illness is associated with mild improvement in sleep difficulties, insomnia tends to be chronic unless it is the direct target of treatment (Abbott, 2016). This post will focus on treating insomnia in a depressed 75-year-old woman who lost her husband to death in the past year. Specific questions to ask, key stakeholders to involve, and diagnostic tests to perform will be highlighted. Also, a differential diagnosis will be given with recommendations for psychopharmacology and check points to ensure adequate resolution of symptoms.
Questions to Ask
- How long have you been taking the sertraline? One of the main side effects of sertraline is insomnia (Muijsers et al., 2002), so a further understanding of the timeframe of insomnia onset compared to starting sertraline would be helpful information.
- What are the patient’s bedtimes and rise times? Do they vary throughout the week? What does the nighttime routine look like? Poor sleep hygiene is associated with insomnia (American Family Physician, 1999).
- Does the patient have frequent jerking movements of the arms or legs when trying to sleep? Medical conditions like restless legs syndrome can significantly and adversely affect sleep (American Family Physician, 1999).
Family members and friends with frequent contact with the patient can be invaluable sources of information to further assess the patient’s depression and insomnia. The patient may identify vague complaints of not feeling rested, but the family or caregiver may be able to further specify patient symptoms. Questions to ask include: 1) Is your family member having any increased mood disturbances or irritability?, 2) Have they been more prone to mistakes or accidents lately?, 3) How are they functioning in social and family situations? (Suzuki et al., 2017).
Physical Exams and Diagnostic Tests
The most helpful tool to detect insomnia is a thorough sleep history that can be included in the review of systems (American Family Physician, 1999). If the patient is having trouble identifying sleep patterns, then a sleep journal may be used for tracking (American Family Physician, 1999). Since the patient is a diabetic and has HTN, a thorough medical exam should be done to see how well these conditions are being managed. States of hyperarousal can be studied through EEG testing (Levenson et al., 2015), although it is unclear how helpful this information is in treating insomnia beyond the information that can be gathered through subjective exams. Additionally, cortisol, melatonin, calcium, and noradrenaline are compounds associated with increased insomnia depending on levels (Levenson et al., 2015).
- Insomnia Disorder – The primary feature of insomnia disorder is difficulty falling asleep, staying asleep, or being generally dissatisfied with sleep quantity or quality (American Psychiatric Association [APA], 2013). While a thorough sleep questionnaire will reveal further information about the patient’s insomnia, the diagnosis of insomnia disorder is the most likely differential diagnosis. This condition is closely associated with patients having comorbid depression (APA, 2013).
- Situational/acute insomnia – As opposed to insomnia disorder, acute insomnia’s time course is few days to several weeks. Symptoms of acute insomnia are significant distress and social, personal, and occupational functional decline (APA, 2013).
- Restless legs syndrome – RLS causes problems falling asleep and maintaining sleep due to urges to move the legs (APA, 2013). This condition, as well as any other physical causes of insomnia, would be teased out through a thorough sleep evaluation questionnaire.
Because of the risks of polypharmacy, nonpharmacologic methods of promoting restful sleep should always be considered. These include regular exercise, keeping the bedroom dark and quiet, eating at regular times and not too closely to bedtime, and avoiding caffeine intake (Suzuki et al., 2017). However, if left untreated, insomnia has a significant and negative impact on quality of life and mental health, and it should be addressed accordingly (Suzuki et al., 2017). Pharmacotherapy will differ depending on the patient’s responses on the questionnaire. For example, if the patient has difficulty initiating sleep but does not have difficulty staying asleep, then a short-acting hypnotic like zolpidem is indicated. Zolpidem has a lower risk of falls and residual tiredness than other benzodiazapine hypnotics, and its starting dose in the elderly population is 5mg (Suzuki et al., 2017).
A second drug that would be useful in this case study is trazodone. Trazodone is effective in the treatment of depression and insomnia (Mayor et al., 2015), and it could be used as an adjunct to the sertraline for treatment-resistant depression. Concerns in this elderly patient include the risk of serotonin syndrome when combining an SSRI with trazodone and the need to monitor sodium levels (Mayor et al., 2015). The usual daily dose of trazodone is 200-400mg (Stern et al., 2016), but the patient’s age and concomitant use of sertraline makes a starting dose of 50mg oral nightly preferable. Starting elderly patients at half the usual adult dose is indicated due to slower processing and excreting of medications by the elderly (Fisher & Valente, 2009). The patient should follow up at two and four weeks to see resolution or continuation of sleep difficulties. After sleep has been restored, followup every three to six months seems appropriate.
In conclusion, managing depression more effectively may promote resolution of insomnia, but the cyclical nature of insomnia and depression means that both will likely require treatment at least for the short term. Elderly patients are at increased risk of polypharmacy and problems metabolizing and excreting medications, so followup should be frequent at first and then taper off once symptoms have resolved and no intolerable adverse effects are reported. Finally, several possible solutions were provided in this post, but this list is by no means exhaustive and completion of a sleep questionnaire is essential to fully understanding the patient’s insomnia and appropriate treatment options.
Abbott, J. (2016). What’s the link between insomnia and mental illness? https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
American Family Physician. (1999). Insomnia: Assessment and management in primary care. American Family Physician, 59(11), 3029–3038.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596
Fisher, D., & Valente, S. (2009). Evaluating and managing insomnia. The Nurse Practitioner, 34(8), 20–26. https://doi.org/10.1097/01.NPR.0000358658.43101.d0
Levenson, J. C., kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Mayor, J. S., Pacheco, A. P., Esperanca, S., & Silva, A. O. (2015). Trazodone in the elderly: Risk of extrapyramidal acute events. BMJ Case Reports. https://doi.org/10.1136/bcr-2015-210726
Muijsers, R. B., Plosker, G. L., & Noble, S. (2002). Sertraline: a review of its use in the management of major depressive disorder in elderly patients. Drugs & Aging, 19(5), 377–392. https://doi.org/10.2165/00002512-200219050-00006
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics (1st ed.). Elsevier.
Suzuki, K., Miyamoto, M., & Hirata, K. (2017). Sleep disorders in the elderly: Diagnosis and management. Journal of General and Family Medicine, 18(2), 61–71. https://doi.org/10.1002/jgf2.27