A 42-year-old man comes to the office due to insomnia for the past month. He often awakens in the middle of the night anxious about his job performance and is unable to go back to sleep. He says, "I think I'm getting only 5 hours of sleep. All I really need is something to knock me out." The patient is an accountant for a furniture store; he has been very tired at work and has difficulty concentrating from lack of sleep. He adds, "Last month I made several accounting errors. My boss was really understanding about it, but he isn't going to be understanding for long if I keep making mistakes." Further questioning indicates that the patient has not felt like himself for several months. He has been uncharacteristically irritable with his wife and children and has lost interest in going to the gym and socializing with his friends and coworkers. On weekends, he stays in bed until noon and then lies on the couch for the rest of the day. The patient believes it is inevitable that he will lose his job and feels very guilty that he is letting his family down. He has no medical or psychiatric history. There is a family history of Sjögren syndrome in his mother and obesity, hypertension, and heart disease in his father and paternal grandfather. He says, "If I can just get some sleep, maybe things will be better." Physical examination and laboratory test results are unremarkable. Which of the following is the most appropriate next step in management of this patient?

Question

A 42-year-old man comes to the office due to insomnia for the past month.  He often awakens in the middle of the night anxious about his job performance and is unable to go back to sleep.  He says, "I think I'm getting only 5 hours of sleep.  All I really need is something to knock me out."  The patient is an accountant for a furniture store; he has been very tired at work and has difficulty concentrating from lack of sleep.  He adds, "Last month I made several accounting errors.  My boss was really understanding about it, but he isn't going to be understanding for long if I keep making mistakes."  Further questioning indicates that the patient has not felt like himself for several months.  He has been uncharacteristically irritable with his wife and children and has lost interest in going to the gym and socializing with his friends and coworkers.  On weekends, he stays in bed until noon and then lies on the couch for the rest of the day.  The patient believes it is inevitable that he will lose his job and feels very guilty that he is letting his family down.  He has no medical or psychiatric history.  There is a family history of Sjögren syndrome in his mother and obesity, hypertension, and heart disease in his father and paternal grandfather.  He says, "If I can just get some sleep, maybe things will be better."  Physical examination and laboratory test results are unremarkable.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Although this patient's chief symptom is insomnia, his presentation is consistent with a major depressive episode (loss of interest, increased irritability, insomnia, fatigue, impaired concentration, and excessive guilt for more than 2 weeks). Some patients with major depression do not experience sadness or depressed mood but may have increased irritability, as in this patient. The best treatment approach is to target the patient's underlying depressive disorder rather than treat the insomnia symptom in isolation. The selective serotonin reuptake inhibitor citalopram is a first-line antidepressant that treats both depression and associated insomnia, thereby addressing all of this patient's symptoms (rather than just one). (Choice B) This patient's insomnia is a symptom of his depression. Polysomnography is indicated for insomnia only if another sleep disorder, such as obstructive sleep apnea, is suspected. If this patient continues to have insomnia after adequate treatment of his depression, a polysomnogram could be considered. (Choice C) Although poor sleep hygiene causes insomnia in many individuals, this patient's depression is more likely responsible for his poor sleep. Education on proper sleep hygiene (eg, regular sleep schedule, exercise, avoiding alcohol and caffeine) can be provided in addition to the antidepressant. (Choice D) Trazodone is most often used in low doses to treat insomnia. It is not a first-line antidepressant as the high doses required to treat depression typically result in intolerable daytime sedation. In addition to sedation, it has a significant side effect profile, including dry mouth, orthostatic hypotension, and, rarely, priapism. (Choice E) Zolpidem is a non-benzodiazepine hypnotic used in the short-term treatment of insomnia. It is not effective in treating major depression. Educational objective: Patients with insomnia should be evaluated for depression. When a diagnosis of depression is made, treatment with antidepressant medication, rather than hypnotics, is indicated. References: Insomnia in patients with depression: a STAR*D report. (http://www.ncbi.nlm.nih.gov/pubmed/20625372)

A 42-Year-Old Man Comes to the Office Due to Insomnia