A 22-year-old man comes to the office due to difficulty concentrating and sleeping. The patient lost his job and moved in with his parents 2 months ago. Although he has been looking for work and revising his resume, he gets distracted and easily loses focus. The patient has not received any interview invitations and is worried that he will be living with his parents for a long time. He feels that he has "reverted to my high school self," playing video games most evenings and going out with friends on the weekends. The patient gets annoyed with his parents occasionally but states that he knows they are "just trying to be helpful." He has been eating more than usual since moving, gaining 3 kg (6.6 lb) and feeling tired during the day. The patient takes 2-3 hours to fall asleep each night and frequently checks the time while in bed. He drinks 3 or 4 beers a week and does not use recreational substances. Vital signs are within normal limits. Physical examination shows no abnormalities. The patient states that his mood is "okay," and he has a full range of affect. He reports no suicidal ideation. In addition to recommending psychotherapy, which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 22-year-old man comes to the office due to difficulty concentrating and sleeping.  The patient lost his job and moved in with his parents 2 months ago.  Although he has been looking for work and revising his resume, he gets distracted and easily loses focus.  The patient has not received any interview invitations and is worried that he will be living with his parents for a long time.  He feels that he has "reverted to my high school self," playing video games most evenings and going out with friends on the weekends.  The patient gets annoyed with his parents occasionally but states that he knows they are "just trying to be helpful."  He has been eating more than usual since moving, gaining 3 kg (6.6 lb) and feeling tired during the day.  The patient takes 2-3 hours to fall asleep each night and frequently checks the time while in bed.  He drinks 3 or 4 beers a week and does not use recreational substances.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  The patient states that his mood is "okay," and he has a full range of affect.  He reports no suicidal ideation.  In addition to recommending psychotherapy, which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d778_38f7_bc81_2bd81af8b78b_MD0003_00 This patient's symptoms of insomnia and impaired concentration, developing within 3 months of an identifiable stressor (eg, job loss, moving back in with his parents), are consistent with an adjustment disorder. Patients with adjustment disorder experience an excessive response to a stressful life event that impairs daily functioning. Short-term psychotherapy is the primary form of treatment and focuses on stress reduction, cognitive reframing, definition of realistic goals, and coping skills enhancement. In general, pharmacotherapy is used as an adjunct to psychotherapy when more rapid symptom relief is desired. In this patient, short-term or as-needed treatment with zolpidem can be used as an adjunct to sleep hygiene and psychotherapy to help obtain the restorative sleep needed to function. Zolpidem, a nonbenzodiazepine benzodiazepine receptor agonist, has demonstrated efficacy in the treatment of sleep-onset and sleep-maintenance insomnia. (Choice A) Alprazolam is a benzodiazepine that can be used for short-term management of generalized anxiety and panic disorders. Alprazolam has a fast onset and short duration of action; therefore, it is less likely than zolpidem to improve sleep hygiene. In addition, because of the risk of misuse, it is not recommended in the treatment of maladjustment to stressful life events. (Choice B) Lithium is a mood stabilizer that can be used to treat bipolar disorder. Although this patient has difficulty focusing, he has intermittent irritability and low energy; he is not experiencing the sustained affective symptoms (eg, persistent irritability, elevated mood) or excessive energy seen during a manic episode. (Choice C) Methylphenidate is a stimulant used to treat attention deficit hyperactivity disorder, which is characterized by childhood onset and chronic impairments in attention and concentration. This patient's recent onset of distractibility and inability to maintain focus following a stressful life event is more consistent with an adjustment disorder. (Choice D) Although quetiapine is sedating, an antipsychotic medication would not be appropriate as a sleep aid in a patient without a comorbid psychotic or mood disorder when safer choices are available. Educational objective: Patients with adjustment disorder experience an excessive response to a stressful life event that impairs daily functioning, including sleep. Short-term pharmacotherapy for insomnia can be used as an adjunct to psychotherapy when more rapid symptom relief is desired. References: Zolpidem for insomnia. (http://www.ncbi.nlm.nih.gov/pubmed/22424586)

A 22-Year-Old Man Comes to the Office Due to Difficulty