NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders

Walden University NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders-Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders                     

The introduction for the Walden University NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

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How to Write the Body for NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders                     

After the introduction, move into the main part of the NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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A Sample Answer For the Assignment: NURS 6630 Week 8 Therapy for Patients With Sleep/Wake Disorders

For this discussion, the case of a young adult male patient with a history of insomnia has been used. The patient is 31 years old and presents with insomnia as the chief complaint. He reports that the lack of sleep has been getting worse over the past 6 months. According to him, sleeping problems have never created a great concern as he is used to them. However, it has been worse ever since the death of his fiancé, as he struggles to fall and stay asleep. This has greatly compromised his quality of life as his job performance has reduced.

He also claims that due to poor sleep at night, he sometimes falls asleep at the workplace. He confirms that he has been taking diphenhydramine to help him sleep in the past, but is unhappy with the way it makes him feel the next morning. His previous physician reports that the patient has a history of opiate abuse following his ankle fracture in a skiing accident that led to the use of hydrocodone/APAP (acetaminophen) for the management of pain. He has however not used analgesics for the past 4 years. The patient however confirms to be taking alcohol to help with his sleeping. Mental status examination results reveal that the patient current healthcare need is only insomnia.

Several patient factors affect their pharmacokinetic and pharmacodynamic processes hence must be considered when making decisions concerning which drug to prescribe to the patient. For this patient, some of such factors include his male gender, adult age, diagnosis of insomnia, previous use of diphenhydramine, substance use history of opiate abuse, and use of alcohol. The purpose of this paper is thus to consider the above patient factors and determine the most effective choice of drugs for the management of the patient’s insomnia, and necessary medication adjustments based on the treatment outcomes.

Decision Point One

Selected Decision and Rationale

Based on the patient-specific factors, the initial decision was to administer trazodone 50mg orally at bedtime. Despite trazodone being approved by the FDA for the management of depression, evidence demonstrates that its off-label use in the management of insomnia has surpassed its antidepressant indications (Bollu & Kaur, 2019). Trazodone mode of action is associated with the inhibition of serotonin reuptake, antagonizing serotonin, antagonizing alpha1 (α1) adrenergic receptors, and inhibitor of serotonin reuptake transporter (Levenson et al., 2015; Medalie & Cifu, 2017).

It is effective for patients with diphenhydramine withdrawal (Krystal et al., 2019: Bollu & Kaur, 2019). The drug is also rapidly absorbed from the GI when administered orally with a short onset of action of between 1 to 2 hours, hence appropriate in helping the patient fall asleep easily (Sateia et al., 2017). Its half-life is also short promoting its safety profile as a result of reduced toxicity risks (Zhand & Milin, 2018).

It was not necessary to consider zolpidem as the medication can only be prescribed in case there is no other better option for the management of the patient’s insomnia, as the drug has increased risks of adverse events such as hallucination and amnesia (Krystal et al., 2019; Palagini et al., 2020).Hydroxyzine on the other hand could also not be selected given that it is an antihistamine just like diphenhydramine (Levenson et al., 2015). As such, it will lead to similar side effects to the ones that made the patient stop using the drug, to begin with (Sateia et al., 2017).

Expected Outcome

The patient’s insomnia should be getting better with the use of trazodone for the following four weeks. He should be able to easily fall asleep and stay asleep (Bollu & Kaur, 2019). Achievement of 50% remission of symptoms within the first four weeks, is demonstrated as a positive response to the medication (Levenson et al., 2015).

Ethical Considerations

When deciding on which medication to prescribe to the patient, the PMHNP must demonstrate a high level of critical thinking with the patient’s interest at hand (Krystal et al., 2019). Ethical guidelines recommend all healthcare professionals uphold the patient’s autonomy and promote their health while preventing harm (Sateia et al., 2017; Medalie & Cifu, 2017).

The patient is a male patient who is 31 years old and has insomnia. Since he lost his fiancé, the sleeplessness has been worse over the past six months. The patient claimed that although he hasn’t always been a “great sleeper,” he now has trouble going to sleep or staying asleep at night. The patient claims that his inability to sleep is now impairing his performance at work as a forklift operator at a chemical plant, where he is dozing off in the course of his duties. He usually takes diphenhydramine to fall asleep, but the morning after is unpleasant.

Review of the patient’s medical file reveals that he has a history of opiate usage dating back more than 4 years, when he was prescribed hydrocodone for an ankle fracture sustained in a skiing accident. Prior to going to bed, the patient has been consuming about 4 beers and using diphenhydramine to put him to sleep. The patient is awake, alert, and aware of place, time, people, and events. The patient denies experiencing auditory or visual hallucinations and is adequately dressed. He is future-focused, denies SI or HI, and has sound insight and judgment.

Decision one

The patient was first given 50 mg of trazodone PO at bedtime. Trazodone is a drug that belongs to the category of a serotonin reuptake inhibitor and antagonist. Trazodone is an off-label treatment for insomnia and has FDA approval as an antidepressant. For those with chronic alcohol use like the patient in question, trazodone is a secure pharmaceutical option. Alcohol consumption may not interact with hydroxyzine or zolpidem to provide an additional sedative effect. Since the patient has been taking diphenhydramine as a supplement, hydroxyzine may not be as beneficial because it works on comparable receptors.

Zolpidem may cause sleepwalking and other unusual sleep habits, which are undesirable side effects. The option with less negative effects was trazodone. Trazodone may be able to address two issues since the patient also sounds like he may be having difficulties adjusting to the death of his fiancé.

Alcohol and substance abuse can be a bad coping mechanism for depressive disorders, and depression and sleeplessness are frequently co-occurring disorders. As the other two do not have antidepressant characteristics and can cause further sedations when combined with alcohol, trazodone would be the better option. Zolpidem in combination with alcohol can lead to further respiratory depression and death (Jaffer et al., 2017).

Decision two

When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.

An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Settimo et al., 2018).

When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented.

The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime. An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Schifano et al., 2022).

Decision three

The patient returns to the clinic two weeks after the trazodone dosage is reduced and notes that while the trazodone is good for promoting sleep, the 25mg dose is occasionally insufficient for a full night’s rest. He rejects auditory or visual hallucinations and is future oriented. The choices were to keep taking the medication, encourage good sleeping habits, or return in four weeks. Stop taking trazodone and replace it with remolten 8 mg at bedtime. Follow up in four weeks.

Trazodone should be stopped, and hydroxyzine 50 mg should be prescribed at bedtime, with a follow-up after 4 weeks. The decision was made to advocate good sleeping habits and then reevaluate in four weeks. Because the trazodone was effective and he had only sometimes complained of not being able to sleep through the night, it was decided to continue using it.

If the medicine is changed, the patient may become irritated and less likely to follow instructions because it may be necessary to try several different medications and doses and run into options that don’t work (Krzystanek et al., 2020).

Because hydroxyzine has CNS depressive and sedative effects that may intensify with alcohol, causing dizziness and stumbling and a hangover effect the next morning, it is not a viable alternative to diphenhydramine. Ramelteon is a highly selective melatonin receptor agonist for MTI and MT2.This medicine may help with insomnia and enhance several aspects of sleep.

Alcohol and ramalteon both intensify each other’s effects. Ramelteon was not chosen due to the increased side effects of the drug and alcohol as well as the fact that trazodone is effective and only rarely causes interrupted sleep, making it unwise to start a new treatment (Uchiyama et al., 2019).

Conclusion

Insomnia can accompany depression or cause it, as well as result in poor work performance, anxiety, and substance abuse. The guy has been grieving the loss of his fiancé for six months and has trouble sleeping. Trazodone is an effective sedative antidepressant that affects serotonin neurotransmitters and can help with depression and sleep-related issues. The histamine class of drugs includes hydroxyzine, and the patient has been using diphenhydramine with minimal effects and lingering effects of lethargy the next day.

Since trazodone had some negative effects, reducing the dose could lessen them while maintaining the medication’s current level of effectiveness. Poor sleep hygiene can reduce most people’s capacity to sleep, making it a crucial factor to consider. Changing a patient’s drug regimen on a regular basis can result in noncompliance and frustration if the patient continues to experience unwanted side effects (Riemann et al., 2017).

References

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(7-8), 24. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/

Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in      the treatment of insomnia–superstitions and evidence. Pharmacotherapy in      Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33-   40.       Doi:10.33450/fpn.2020.04.003

Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … &             Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of    insomnia. Journal of Sleep Research, 26(6), 675-700. Doi: 10.1111/jsr.12594.

Schifano, N., Capogrosso, P., Boeri, L., Fallara, G., Cakir, O. O., Castiglione, F., … & Salonia,    A. (2022). Medications mostly associated with priapism events: Assessment of the     2015–2020 Food and Drug Administration (FDA) pharmacovigilance database entries. International Journal of Impotence Research, 1-5. Doi: 10.1038/s41443-022-  00583-3

Settimo, L., & Taylor, D. (2018). Evaluating the dose-dependent mechanism of action of trazodone by             estimation of occupancies for different brain neurotransmitter         targets. Journal of Psychopharmacology, 32(1), 96-104. Doi:    10.1177/0269881117742101

Uchiyama, M., Sakamoto, S., & Miyata, K. (2019). Effect of ramelteon on insomnia severity:      evaluation of         patient characteristics affecting treatment response. Sleep and Biological   Rhythms, 17(4), 379-388. https://link.springer.com/article/10.1007/s41105-019-00224-1

From negative changes in mood to problems concentrating, sleep/wake disorders can have a tremendous impact on patients’ lives. When patients suffer from these disorders, they often seek medical care with the intent of receiving medications to manage symptoms.

However, many of the medications used to treat sleep/wake disorders may be addictive, making thorough patient assessments and close follow-up care essential. To prescribe appropriate therapies with patient safety in mind, you must understand not only the pathophysiology of these disorders but also the pharmacologic agents used to treat them.

This week, as you study therapies for individuals with sleep/wake disorders, you examine the assessment and treatment of patients with these disorders. You also explore ethical and legal implications of these therapies.

Learning Objectives

Students will:

• Synthesize concepts related to the psychopharmacologic treatment of patients
• Assess patient factors and history to develop personalized therapy plans for patients with sleep/wake disorders
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for sleep/wake disorders
• Synthesize knowledge of providing care to patients presenting for sleep/wake disorders
• Analyze ethical and legal implications related to prescribing therapy for patients with sleep/wake disorders

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (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(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

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Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

Required Media (click to expand/reduce)

Case study: Pharmacologic approaches to the treatment of insomnia in a younger adult
Note: This case study will serve as the foundation for this week’s Assignment.

Assignment 1: Short Answer Assessment

As a psychiatric nurse practitioner, you will likely encounter patients who suffer from various mental health disorders. Not surprisingly, ensuring that your patients have the appropriate psychopharmacologic treatments will be essential for their overall health and well-being.

The psychopharmacologic treatments you might recommend for patients may have potential impacts on other mental health conditions and, therefore, require additional consideration for positive patient outcomes. For this Assignment, you will review and apply your understanding of psychopharmacologic treatments for patients with multiple mental health disorders.

Photo Credit: Getty Images/Collection Mix: Sub

To Prepare

• Review the Learning Resources for this week.
• Reflect on the psychopharmacologic treatments that you have covered up to this point that may be available to treat patients with mental health disorders.
• Consider the potential effects these psychopharmacologic treatments may have on co-existing mental health conditions and/or their potential effects on your patient’s overall health.

To complete:

Address the following Short Answer prompts for your Assignment. Be sure to include references to the Learning Resources for this week.

1. In 3 or 4 sentences, explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?
2. List 4 predictors of late onset generalized anxiety disorder.
3. List 4 potential neurobiology causes of psychotic major depression.
4. An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.
5. List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific.

By Day 7

This Assignment is due.

Submission and Grading Information

To submit your completed Assignment for review and grading, do the following:

• Please save your Assignment using the naming convention “WK8Assgn1+last name+first initial.(extension)” as the name.
• Click the Week 8 Assignment 1 Rubric to review the Grading Criteria for the Assignment.
• Click the Week 8 Assignment 1 link. You will also be able to “View Rubric” for grading criteria from this area.
• Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn1+last name+first initial.(extension)” and click Open.
• If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
• Click on the Submit button to complete your submission.

Grading Criteria

To access your rubric:

Week 8 Assignment 1 Rubric

Check Your Assignment Draft for Authenticity

To check your Assignment draft for authenticity:

Submit your Week 8 Assignment 1 draft and review the originality report.

Submit Your Assignment by Day 7 of Week 8

To participate in this Assignment:

Week 8 Assignment 1

Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders

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.

_Reference: 

_{Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018}

To prepare for this Assignment:

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.

The Assignment: 5 pages

Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

The case scenario provided is of a 31year old male whose chief complaint is insomnia that has been worse in the past 6 months. Previously, he reports enjoying restful sleep although for the past 6months he has experienced both difficulties in falling and staying asleep. He even associates the onset of these sleep problems with the loss of his fiancé consequently leading to the loss.

During the interview with the clinic, he explains that the problem is a bother because it has interfered with his job where because he experiences sleepiness during the day thus affecting his concentration and productivity at the workplace. He reports recent dependence on alcohol to help him fall asleep. The mental status examination performed on him revealed no abnormality in the orientation appearance, insight, and judgment.

A comprehensive assessment of this case study shows that the patient’s insomnia might be related to his psychological dysfunction resulting from the loss of his fiancé 6months ago. The sudden loss of a dear one triggers a myriad of psychiatric conditions even if the individual has no prior history of psychiatric conditions (Seiler et al., 2020). One of these psychiatric conditions is depression which is especially triggered by

complicated grief. The affected individual would therefore present with low mood, intense sadness, low energy, and loss of interest in activities of pleasure. They may also report sleep disturbances with insomnia being more common than hypersomnolence (Hasin et al., 2018).

Managing the depression through medications or psychotherapy would help to relieve the patient’s symptoms such as insomnia that is suspected to arise from depression. The objective of this paper is to discuss how the patient in the case study was managed by describing the therapeutic options at Decision points 1, point 2, and point 3.

Decision Point One

For the initial management of the patient, I would prescribe 50mg of trazodone to be taken orally at bedtime daily. Trazodone is a drug that acts in the brain by reducing the reuptake of different neurochemicals in the brain such as serotonin but antagonizing the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019). By so doing, the serotonin levels in the brain are increased as well as the intensity of their action.

Given depression results from an imbalance of brain neurochemicals such as serotonin and norepinephrine, increased serotonin levels resulting from trazodone use can lead to improved serotonergic actions thus treating depression and its symptoms (Hasin et al., 2018). When trazodone is therefore prescribed, the symptoms of depression including insomnia, appetite changes, and mood changes are corrected (Wang et al., 2020). It would therefore be the first-line medication for this patient.

At decision point one, the foregone options are the 10mg zolpidem taken daily at bedtime or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in the management of insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile which includes drowsiness, complex sleep-related behavior and volition usually limit its use as a first-line medication for insomnia (Edinoff et al., 2021).

Hydroxyzine has also been foregone because of its anticholinergic effects such as xerophthalmia and xerostomia (Hasin et al., 2018). Further, neither of these drugs is effective for the management of depression that has been linked with the patient’s insomnia.

The ethical principles require that the health care providers do not harm the patient. At point one, increasing the pill burden by prescribing the antidepressants separately from the drugs addressing insomnia would pose the risk of adverse drug reactions as well as increase the incidence of poor drug compliance (Bipeta, 2019).

The ethical principle of non-maleficence would therefore require for prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication to the other provided options.

Decision Point Two

After 2 weeks of therapy with 50mg of trazodone at bedtime daily, the patient reports experiencing a prolonged erection in the morning that lasts 15 minutes but is undesired and affects his morning preparation for work although his sleeping has improved.

At this point, the choice is to be made on how to address the prolonged erection. My decision at this step would be to explain to the patient that this prolonged erection is not priapism and would resolve over time. Thereafter, the current drug dose could be continued for patient care.

One of the undesired side effects of trazodone use is the prolonged erection caused. Through its α-adrenergic antagonism, the drug can lead to dilatation of vessels in the penis thus resulting in prolonged erection (Cuomo et al., 2019). The patient in the case study reports such prolonged undesired erection that lasts for approximately 15 minutes and thus cannot be considered priapism which usually lasts for up to 4hours (Hasin et al., 2018).

However, the patient requires reassurance about the side effect profile of the drug, especially with the emphasis that the symptoms would dissipate with time (Cuomo et al., 2019). This would enhance adherence to therapy despite the drug’s side effects.

The other options at decision point 2 were either to discontinue trazodone and initiate 10mg suvorexant daily therapy or to decrease the dose of trazodone to 25mg daily at bedtime. The negative side effect of suvorexant includes daytime drowsiness thus its contraindication for this patient who operates a forklift.

On the other hand, decreasing the dose of trazodone to 25mg daily may not be adequate to correct insomnia (Seiler et al., 2020). Patient education on the drug’s side effects, as well as reassurance, would therefore be opted for at this step.

At this decision point 2 where the patient reports the drug’s side effects, it would be ethical to truthfully educate him on the drug’s side effects to anticipate. Medications may be discontinued if necessary to prevent more harm to the patient (Bipeta, 2019). These honor ethical principles of beneficence and non-maleficence.

Decision Point Three

2 weeks after reassuring and educating the patient on the side effects of trazodone, he now reports that the priapism has resolved although he now experiences increased drowsiness during the next day. His insomnia has also resolved at 50mg of trazodone. At this step, I would continue the patient therapy at 50mg although the dose is split in half, and the patient is reassessed after a month.

As had been alluded to, trazodone is associated with increased drowsiness that may limit its use although the occurrence of such side effects is either rare or mild. However, when such drowsiness occurs, a reduction of the drug dose by 50% may be necessary as this may result in a reduction in drowsiness (Cuomo et al., 2019).

The patient should however be adequately educated on how to split the drug dose so that the required drug dose is maintained. Further, patient follow-up within 4weeks would also be indicated to help in reassessing the effectiveness of the drug as well as the persistence of the drowsiness at 50% of the dose (Wang et al., 2020).

The other options provided at decision point 3 included either discontinuing trazodone and initiating sonata at 10mg nightly or replacing trazodone with 50mg of hydroxyzine at bedtime. Both of these options are not appropriate as they involved replacing trazodone that the patient has shown partial response to. Further, both sonata and hydroxyzine have worse side effect profile that limits their administration in this patient (Hasin et al., 2018).

At this decision point, the ethical principle of patient autonomy may affect further care. For instance, the patient may prefer either sonata or hydroxyzine to the in-use trazodone thus they can be prescribed despite their side effect profile (Bipeta, 2019). Such prescription seeks to promote the role of patients in their treatment.

Conclusion

Individuals presenting with any signs and symptoms at the clinic should be suspected and examined for any underlying conditions responsible for such presentation. For instance, a patient with insomnia may have underlying anxiety or depression. In managing these patients, the drugs prescribed should aim at correcting the underlying psychological disorder instead of addressing the signs and symptoms such as insomnia. specifically for this patient whose insomnia was thought to result from depression due to complicated grief, trazodone which is an antidepressant was prescribed at decision point one because of its effectiveness in managing insomnia (Cuomo et al., 2019).

When he returns to the clinic with complaints of prolonged erection, the patient would be reassured with the emphasis that the symptoms would disappear with time. The patient would also be adequately educated on the adverse effects of the drugs to encourage drug compliance as they would be anticipating these side effects (Hasin et al., 2018).

Thereafter, when he comes complaining of drowsiness, the drug dose would be reduced by 50% to resolve the symptoms. At either of the steps, the drugs’ side effects profile, as well as effectiveness, are compared before an effective drug with the least side effects is prescribed.

References

Bipeta, 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

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista Di Psichiatria, 54(4), 137–149. https://doi.org/10.1708/3202.31796

Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and side effects for insomnia. Health Psychology Research, 9(1), 24927. https://doi.org/10.52965/001c.24927

Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry (Chicago, Ill.), 75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602

Seiler, A., von Känel, R., & Slavich, G. M. (2020). The psychobiology of bereavement and health: A conceptual review from the perspective of Social Signal Transduction Theory of Depression. Frontiers in Psychiatry, 11, 565239. https://doi.org/10.3389/fpsyt.2020.565239

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620

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