Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.
Assessing and Treating Patients With Sleep/Wake Disorders
Persistent insomnia continues to plague individuals, wreaking havoc on their daily lives. Its detrimental effects are far-reaching, leading to a diminished quality of life in adults and even fatal consequences or impairments among young adults. Insomnia manifests as a relentless struggle to fall asleep or remain asleep, resulting in a dearth of restful nights and hampering daily functioning due to the burden of stress and exhaustion. Extensive research has linked insomnia to an array of illnesses, encompassing anxiety, post-traumatic stress disorder (PTSD), addictive behaviors, depression, diabetes, suicidal ideation, and hypertension (Gaffey et al., 2020). Additionally, diagnostic criteria for insomnia focus on various factors, including sleep initiation and maintenance difficulties, disrupted sleep-wake patterns, abrupt awakenings, and the consequent inability to perform optimally during the day. Notably, socio-economic stressors such as low-income levels, limited education, and relationship strife further compound the complexity of insomnia.
In evaluating insomnia, it is imperative to conduct comprehensive mental and physical examinations. These assessments entail a thorough evaluation of key indicators, such as neck circumference, airway examination for potential sleep apnea, and body mass index. Such evaluations serve a dual purpose, as they not only aid in diagnosing insomnia but also offer insights into the presence of other underlying disorders and concomitant conditions (Gaffey et al., 2020).
Presently, a 31-year-old male patient seeks medical assistance due to his ongoing battle with insomnia. The severity of his condition has escalated over the past six months, significantly disrupting his ability to initiate and sustain sleep. While he admits to having never been a sound sleeper, his difficulties have intensified following the tragic loss of his fiancée. The debilitating impact of his sleep deprivation is acutely felt in his job performance as a forklift operator at a chemical plant. Distressed by the undesired side effects of diphenhydramine, a sleep aid he has previously utilized, the patient is reluctant to resort to its use. Lamentably, his struggle with sleeplessness has led to instances of unintentional dozing off during work hours. It is important to note that the patient has a documented history of opioid dependence stemming from an ankle fracture years ago, which was managed with hydrocodone/adrenaline phosphate for acute pain relief. Although pain management prescriptions have ceased for the past four years, the patient has resorted to alcohol consumption—four bottles of beer—to facilitate sleep. Notwithstanding these challenges, the patient’s mental examination reveals a lucid and alert individual who is well-oriented to person, place, and time. He maintains appropriate eye contact and exhibits suitable attire for the circumstances. His cognitive faculties, including perception, reasoning, and grasp of reality, are intact, and he denies experiencing auditory or visual hallucinations, as well as any suicidal or homicidal thoughts.
Decision # 1: Trazodone 50–100 mg daily at bedtime
In selecting Trazodone as a treatment option, I took into consideration the patient’s difficulty sleeping and staying asleep, which has been exacerbated by the recent death of his fiancée. Trazodone is not only FDA-approved for depression but also used off-label for insomnia. Its advantages outweigh the risks, as it has shown efficacy in managing insomnia by regulating cortisol repression in the adrenal, pituitary, and hypothalamic axis (Vgontzas et al., 2020). Additionally, its short half-life of three to six hours allows for initiating and maintaining sleep without excessive drowsiness.
Other medications like zolpidem and hydroxyzine were not chosen for this particular client’s therapy. Zolpidem, authorized for short-term insomnia, has a shorter half-life and is not suitable for prolonged sleep problems. Moreover, zolpidem primarily targets sleeplessness and does not address anxiety or depressive symptoms, which the client is experiencing due to the loss of his fiancée. Additionally, when combined with alcohol, zolpidem can lead to hallucinations, CNS depression, angioedema, and behavioral abnormalities (Bouchette et al., 2022). Similarly, hydroxyzine was not selected due to potential side effects like rapid heartbeat, trouble urinating, mood swings, and shaking, which may not be ideal for the client’s situation.
The ethical consideration here lies in the clinician’s responsibility to conduct a comprehensive evaluation before prescribing insomnia medications, especially for individuals whose occupations require alertness and concentration. Medications with shorter half-lives may be more suitable for these individuals. It’s worth noting that younger individuals often experience distress and sleep problems due to various factors such as strained relationships, financial limitations, and unfulfilled life goals. By selecting an appropriate medication like Trazodone, the goal is to help the client improve his sleep quality and develop healthier coping mechanisms for dealing with the loss of his fiancée..
Decision # 2: Explain that priapism is a side effect of Trazodone that should diminish over time. Continue dose
I made the decision to maintain the patient’s current dosage of Trazodone at 50 mg, as it has already proven effective in improving his sleep quality. While priapism, an uncommon side effect in men, did occur, it eventually subsided, and no further adverse effects were reported. Instead of immediately switching to suvorexant 10 mg, I chose to continue with Trazodone because it has demonstrated the ability to alleviate the client’s insomnia, with priapism being the only drawback. Lowering the dosage to 25 mg at bedtime was not considered since studies have shown that 50 mg effectively addresses the client’s sleeplessness after just two weeks of use. Reducing the dose would not eliminate the occurrence of priapism, as it is a known side effect that diminishes over time (Vaesen & Sempels, 2023). Furthermore, zolpidem was not selected as an alternative due to the rare adverse effect of somnambulism or sleepwalking during the rapid eye movement (REM) phase of sleep, which can lead to injuries and cognitive impairments. It is crucial to avoid the risks associated with sleepwalking.
By maintaining the current medication regimen, my expectation was that the client’s priapism would gradually diminish, and his sleeplessness would be further alleviated. The goal was to strike a balance between addressing the adverse effects and providing effective treatment for insomnia. Considering the positive impact Trazodone had on sleep quality, it seemed reasonable to manage the side effect rather than abruptly switching to a different medication. Monitoring the client’s progress and addressing any concerns promptly would be essential in this case.
The ethical consideration arises regarding whether it is appropriate to encourage the client to continue taking a medication that has caused an undesired side effect. However, as of now, the client has not experienced any adverse effects that would necessitate a dosage reduction. By fully informing the client about the normalcy of these adverse effects and assuring them that they will subside over the course of treatment, achieving compliance can be possible through proper education. The decision to continue with Trazodone hinges on providing the client with all the necessary information, ensuring their understanding, and addressing any concerns they may have.
Decision # 3: Continue dose. Explain to the patient he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks.
Trazodone, an SSRI with a reduced risk of adverse effects, has been my choice for continued use due to its favorable profile. Notably, Trazodone has been clinically proven to improve sleep patterns within a short period of time, and its benefits often outweigh any potential drawbacks. This makes it an ideal option for individuals seeking a reliable sleep aid. To avoid complications with sleep patterns, it is generally not recommended to immediately start taking a new medication like Sonata. Another reason I did not select Hydroxyzine is because it is an antihistamine with potent tranquilizing properties. Current studies, such as the one conducted by Burgazli et al. (2023), have shown that many people experience sleepiness as a side effect of Hydroxyzine. Furthermore, individuals have reported negative anticholinergic effects, including dry mouth and dry eyes, the day after using this medication.
Considering the drowsiness experienced by the client as an adverse effect, it would be prudent to reduce the dosage of trazodone by half and reassess the client’s condition in four weeks. With this adjustment, I am hopeful that by the time the client returns to the facility, the sleepiness will have diminished, and the problem of sleeplessness will have significantly improved.
At this point, an important ethical consideration is to involve the client in the decision-making process, ensuring they fully comprehend the rationale behind continuing the medication. Effective communication between the practitioner and the client will enable the exchange of vital information, including potential adverse effects associated with the prescribed medicine. This will facilitate the implementation of appropriate adjustments to ensure the client’s complete recovery while minimizing the risk of any adverse health effects.
In conclusion, sufficient sleep is not a luxury but a fundamental requirement for optimal health. By understanding the detrimental effects of sleep deprivation and addressing the factors that contribute to disrupted sleep patterns, we can pave the way for improved well-being, enhanced cognitive function, and a healthier society as a whole. It is important to prioritize the importance of sleep and work towards creating environments that facilitate restful nights, ultimately nurturing a generation that thrives both physically and mentally.
Bouchette, D., Akhondi, H., & Quick, J. (2022). Zolpidem. https://europepmc.org/article/nbk/nbk442008
Burgazli, C. R., Rana, K. B., Brown, J. N., & Tillman, F. (2023). Efficacy and safety of hydroxyzine for sleep in adults: Systematic review. Human Psychopharmacology: Clinical and Experimental, 38(2). https://doi.org/10.1002/hup.2864
Gaffey, A. E., Redeker, N. S., Rosman, L., Mullington, J. M., Brandt, C. A., Haskell., S. G., & Burg, M. M. (2020). The role of insomnia in the association between posttraumatic stress disorder and hypertension. Journal of Hypertension, 38(4), 641-648. https://doi.org/10.1097/hjh.0000000000002311
Vaesen, F., & Sempels, M. (2023). Refractory ischemic priapism due to trazodone. Revue Medicale de Liege, 78(1), 4-6.
Vgontzas, A. N., Puzino, K., Fernandez-Mendoza, J., Krishnamurthy, V. B., Basta, M., & Bixler, E. O. (2020). Effects of trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: A preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009-2019. https://doi.org/10.5664/jcsm.8740