The Treatment of Insomnia in a Younger Adult

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Treatment of Insomnia in a Younger Adult Background Sufficient sleep is a crucial element of a person’s life. It helps empower the body to recover from stress and stay refreshed. Unfortunately, people go through various events that disrupt their sleep patterns. Inability to sleep properly is associated with multiple factors, including underlying medical conditions, medication use, and mental issues. Traumatic incidences may also cause insomnia, which is the inability to initiate and sustain sleep for sufficient hours. This condition is rarely isolated but rather a symptom of an underlying physiological or psychological disorder.

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Insomnia is mostly associated with stressful conditions and mental illnesses such as PTSD, depression, anxiety and panic attacks. It affects the health of a person and the quality of life. Literature shows that over 40% of people with insomnia have comorbid psychiatric conditions. Other poor outcomes associated with insomnia are long-term disability, low economic productivity, more sick leave, and chronic fatigue. Statistics highlighted by the CDC (2021) show that over 30% of adults in the United States have insomnia. Over 10% of the adult U.S populace suffers from chronic insomnia. This data shows that insomnia is the most prevalent sleep disorder. Insomnia increases the risk of other health conditions such as pain disorders and hypoxemia (Olfson et al. 2018). Treatment of insomnia is challenging since the clinician has to identify and treat the underlying causes. The treatment plan involves both pharmacologic agents and psychotherapeutic interventions. This discussion highlights the treatment of progressive insomnia in a middle-aged man.

Case summary The client is a 31-year-old man vising the facility due to insomnia. He noted that his condition has progressively worsened over six months. The client noted that although he has never been a “great sleeper,” his inability to initiate and sustain sleep for sufficient periods is worrying. He started experiencing sleep problems six months ago following the abrupt death of his fiancée. Insomnia has affected the client’s occupational performance. He has used various medications including diphenhydramine to improve his sleep patterns but he stopped taking them after developing some side effects. Medical history indicates that he abuses opiate substances following prolonged use of prescribed hydrocodone for ankle pain. The patient pointed out that

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he uses alcohol to help him sleep at night. The mental exam of the client indicates that he is alert and oriented and maintains eye contact during the interview. The client does not experience hallucinations and suicidal ideations.

Decision #1 Choice: Hydroxyzine 50 mg daily at bedtime Justification: hydroxyzine is an antihistamine used in treating allergic conditions. This medication blocks the natural substances involved in producing allergic reactions. Evidence shows that hydroxyzine is a potent agent against anxiety. This medication has strong sedative properties, as demonstrated in studies investigating its efficacy in inducing sleep among surgery patients (Bushnell et al. 2018). The therapist prescribed a low dose of hydroxyzine to obviate adverse effects.

Rejected results: The therapist did not select zolpidem 10mg and trazodone 50mg daily at bedtime for the client. Zolpidem is a strong sedative-hypnotic drug. This drug slows brain activity improving sleep (Avers & Wong, 2019). However, it is associated with adverse effects such as fatigue, daytime drowsiness, and loss of coordination. This drug can also cause memory loss and depressive episodes.

Treatment goals: The anticipated patient care results include improved sleep patterns, decreases depressive symptoms, and reduced anxiety. The therapist also wanted to improve the client’s productivity during the daytime.

Achieved results - When the client visited the facility after two weeks, he reported that the mediation had significantly improved his sleep patterns. However, the patient reported that he experienced a next-day feeling similar to other medications after taking hydroxyzine. He also

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reported extreme dryness of the eyes and mouth in the morning. The client, however, denied hallucination.

Decision #2 Choice: decrease hydroxyzine dose to 25 mg at bedtime.

Justification- The therapist reduced the hydroxyzine dose from 50mg to 25mg since the drug had effectively improved sleep but produced some side effects. A large dose of hydroxyzine had produced anticholinergic effects like xerophthalmia and xerostomia Rejected alternatives: Hydroxyzine was not discontinued at this point as it had eradicated insomnia. The current does was not maintained due to the side effects. Although the side effects are common with hydroxyzine, they can lead to noncompliance hence making it hard to attain the anticipated therapeutic outcomes. Temazepam was not a suitable choice for the clients since it produces numerous side effects that could have affected compliance. Temazepam can also lead to physical dependence and abuse.

Treatment goals- The therapist’s main intention was to eradicate the side effects and maintain positive sleep patterns. The therapist also wanted to ensure that insufficient sleep at night and fatigue did not disrupt the client’s productivity during the day.

Achieved results- The client returned to the facility after two weeks and reported that dose reduction helped prevent the dryness of the eyes. However, he noted that his sleep problems had returned. He was still experiencing difficulties in maintaining and initiating sleep at night. He did not report hallucinations.

Decision #3 Choice: Discontinue hydroxyzine and replace it with Trazodone 50–100 mg nightly at bedtime.

The client to be followed up in 4 weeks

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Justification- The therapist selected trazodone since it is a potent pharmacological substance for treating insomnia. Systematic literature by Jaffer et al. (2017) revealed that trazodone is effective for primary and secondary insomnia. The studies also revealed that this agent is effective in the treatment of dementia and depression. Jaffer et al. (2017) also reported that trazodone effectively treats insomnia in depressive persons.

Rejected alternatives: The client could not carry on with the current hydroxyzine dose since it was not achieving the anticipated sedative effects. It is inappropriate for the therapist to encourage the client to carry on with ineffective pharmacological substances. The client could not augment hydroxyzine with diphenhydramine 25mg considering its anticholinergic effects had already led to non-compliance to this medication.

Treatment goals - The therapist wanted to improve the client’s sleep patterns besides eradicating the anticholinergic effects.

Achieved results – the client reported improved sleep and minimal side effects. He was no longer experiencing anticholinergic effects. He also reported improved energy and productivity during the day. He was able to operate the forklift without experiencing fatigue.

Ethical consideration Treating insomnia requires compliance with the ethical guidelines of psychiatric practice as indicated by the Mental Healthcare Act of 2017 (Bipeta, 2019). Mental health professionals have a moral and legal obligation to uphold the rights of people with psychiatric conditions. The Mental Healthcare Act encourages clinicians to advocate for the client’s privacy and confidentiality by ensuring that health information is not leaked to unauthorized persons.

Professionals should only share patient data with the mental health team members. Disclosure to other parties can only be done after the client has granted permission (Bipeta, 2019).

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Importantly, clinicians must integrate the principles of beneficence and nonmaleficence into patient care. These principles guide health care professionals to provide clients with appropriate treatment interventions. Clinicians must ensure that any selected intervention does not increase the risk of adverse effects. Ethical principles also prohibit any form of discrimination against the client (Bipeta, 2019). Clinicians should treat everyone seeking psychiatric care respectfully. The mental healthcare act states that no one should be denied psychiatric services based on racial and ethical backgrounds.

Conclusion Insomnia is a prevalent condition associated with underlying disorders such as depression, PTSD, anxiety, and physical health issues. Insomnia may occur progressively following a traumatic incidence. Insomnia disrupts a person’s life by causing fatigue, poor concentration, decreased productivity and inability to interact with others. Clinicians must identify the cause of insomnia to treat this condition effectively. Treatment involves psychiatric medications and psychotherapy. The patient is given medications that decrease alertness and induce sedation. These medications are taken at night to improve sleep patterns without affecting daytime alertness. The clinician must follow ethical principles to ensure the selected interventions work for the client. Antidepressants and sedatives are the best medications for a depressive person with insomnia.

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References Avers, D., & Wong, R. (2019). Guccione's Geriatric Physical Therapy E-Book. Elsevier Health Sciences.

Bispeta R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian journal of psychological medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19 Bushnell, G. A., Compton, S. N., Dusetzina, S. B., Gaynes, B. N., Brookhart, M. A., Walkup, J. T., Rynn, M. A., & Stürmer, T. (2018). Treating Pediatric Anxiety: Initial Use of SSRIs and Other Antianxiety Prescription Medications. The Journal of clinical psychiatry, 79(1), 16m11415. https://doi.org/10.4088/JCP.16m11415 CDC (2021). Data and Statistics: Short Sleep Duration among US Adults. https://www.cdc.gov/sleep/data_statistics.html Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., ... & Ishak, W. W. (2017).

Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(78), 24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/ Olfson, M., Wall, M., Liu, S. M., Morin, C. M., & Blanco, C. (2018). Insomnia and impaired quality of life in the United States. The Journal of clinical psychiatry, 79(5), 0-0. https://www.psychiatrist.com/jcp/sleep/insomnia-and-impaired-quality-of-life/

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