Psychopharmacologic Approaches To Treatment Assignment

Psychopharmacologic Approaches To Treatment Assignment

Psychopharmacologic Approaches To Treatment Assignment

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One

Select what you should do:
Zolpidem: 10 mg daily at bedtime

Trazodone: 50–100 mg daily at bedtime

Hydroxyzine: 50 mg daily at bedtime

Decision Point One

Tr Trazodone: 50–100 mg daily at bedtimeazodone: 50–100 mg daily at bedtime

RESULTS OF DECISION POINT ONE

· Patient returns to clinic in 2 weeks

· Patient states medication works well but gives him an unpleasant side effect of a prolonged erection of the penis, approximately 15 minutes after waking

· Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning

· Patient denies auditory/visual hallucinations and is future oriented

Decision Point Two

Decrease trazodone to 25 mg daily at bedtime

RESULTS OF DECISION POINT TWO

· Patient returns to clinic in 2 weeks

· Patient states trazodone is very effective for sleep

· Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night

· Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.