Treatment for Patients with a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott. 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients, as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.

Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness health?
For this Discussion, review the case Leaming Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs,

Case. An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse, as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. The patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. The patient arrived at the office today by private vehicle. The patient currently takes the following medications:
• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86

The Discussion
Post a response to each of the following:
• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
• Include any ‘checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

Treatment for Patients with a Common Condition: Insomnia
Insomnia is one of the most prevalent medical conditions encountered in primary care. It is a common symptom of numerous mental health disorders including anxiety, depression, schizophrenia, and attention deficit hyperactivity disorder (ADHD) (Abbott, 2016). Research demonstrates the bidirectional relationship between insomnia and mental illness; approximately 50% of adults with insomnia have a co-occurring psychiatric condition, while up to 90% of individuals with depression experience sleep disturbances (Abbott, 2016). Due to this interconnected psychopathology, it is crucial for primary care providers to understand how certain psychopharmacologic treatments may impact both a patient’s underlying mental illness and sleep patterns.
A 75-year-old female patient presented with worsening insomnia and depressive symptoms following the death of her husband 10 months prior. She reported difficulties initiating and maintaining sleep, in addition to depressed mood, low motivation, and social withdrawal. Her medical history was significant for diabetes mellitus, hypertension, and major depressive disorder. A comprehensive assessment, including evaluation of sleep hygiene, mood, support systems, and basic lab work, was conducted.
Based on her presentation and diagnostic criteria outlined in the DSM-5, a diagnosis of major depressive disorder appeared most appropriate. A differential of bereavement was also considered but her symptoms had persisted beyond the typical 2-month duration. Treatment with sertraline 100mg daily was initiated given her current use of this selective serotonin reuptake inhibitor (SSRI) and its efficacy and tolerability in geriatric patients.1 Close monitoring for side effects, adherence, and clinical response was planned through weekly follow-ups initially, with laboratory work and potential dosage adjustments at 4-6 and 8-12 weeks respectively.
Insomnia is a prevalent complaint in primary care that requires a biopsychosocial approach. For patients with co-occurring psychiatric conditions, it is paramount providers understand treatment impacts on both mental illness and sleep to optimize outcomes. Further research exploring insomnia-specific therapies and their effects on comorbid psychopathology could also improve patient care.

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