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 Discussion NURS 6630  Diagnosis and Treatment of Insomnia

 Discussion: NURS 6630  Diagnosis and Treatment of Insomnia


Diagnosis and Treatment of Insomnia

According to this case study the patient, who has a Past Medical History of Diabetes Mellitus,
Hypertension, and Major depressive disorder, complains of insomnia. Difficulty in initiating or
maintaining sleep, and early morning awakening with an inability to return to sleep are the major
characteristics associated with insomnia (Fietze et al., 2021). Common symptoms of insomnia
include daytime sleepiness, fatigue, mood swings, lack of energy, impaired memory, poor
concentration, and lack of energy.
Questions to ask the patient
1. Do you nap during the day?
This question will help understand the patient's sleeping pattern and eventually decide on the
appropriate treatment.
1. Do you use caffeine, tobacco, or alcohol before going to bed?
This question will help the nurse practitioner to know if it is substance-induced insomnia or not.
1. Is your sleeping environment conducive?
It will help us know if her insomnia is caused by noise, light, or unconducive temperature.
People in the patient’s life to get feedback from
The most appropriate people to take to and find further information about the patient are her
family members, mainly her children, and her Primary care physician. The questions that I
could ask her children would include:
1. Is there any family member who has complained of the same?
This question is important because it will help the nurse practitioner understand whether the
condition runs in the family since it can be inherited (Lind and Gehrman, 2016). After
Understanding this, we can find the appropriate treatment for the condition.
1. Does she snore loudly, gasp, or stop breathing during sleep?
Snoring loudly, gasping, and choking during sleep may be related to obstructive sleep apnea.
This condition causes insomnia.
A question that I could ask her primary care physician could be;

What is the general condition of the patient?
The physical care physician understands the patient more. Therefore, we can save time by asking
for a summary of the patient's condition.
Appropriate physical tests and diagnostic exams
According to this case study, the patient's condition might be related to the death of her
husband. However, it is important to carry out a physical examination since Insomnia can also be
caused by physical conditions. A physical examination will be done by examining the neck,
nose, and throat for any enlarged tonsils or a narrow throat. A blood test can also be done to
check for any thyroid disease. The most appropriate test is the use of a wrist actigraph which
detects movement and can therefore give information about the periods of sleep or movement
(Krystal et al., 2019).
Differential Diagnosis
The possible diagnosis for this patient’s symptoms could be Medication-related insomnia,
anxiety disorder, or post-traumatic stress disorder. Medication-related insomnia might be caused
by the numerous drugs the patient takes. The patient lost her husband which might have caused
separation anxiety disorder which is a common cause of insomnia. The most likely differential
diagnosis is post-traumatic stress disorder caused by the death of her husband. The loss of a
loved one is the most traumatic experience and can cause difficulty in initiating or maintaining
sleep (Keyes et al., 2014).
Appropriate pharmacologic agents
Benzodiazepines and "Z" drugs have been approved by U.S. Food and Drug Administration,
but they cannot be used by older adults because they can cause convulsion and memory
impairment. Control-release melatonin and doxepin are mainly recommended as first-line agents
in older adults. Doxepin improves sleep quality in patients with insomnia if taken at a low dose.
It increases the sleeping time and reduces any risks of waking in the middle of the night.
Compared to Melatonin, doxepin is more effective and has few side effects. Decreased melatonin
production or disrupted timing of melatonin release can contribute to insomnia. I could
recommend Doxepin because it is highly effective and has few side effects. Monitoring should
be done continuously to ensure that the patient is responding well to the medication and to decide

whether the medication should be changed or dosage increased. Doxepin dosage should not
exceed 150mg per day.


Fietze, I., Laharnar, N., Koellner, V., & Penzel, T. (2021). The different faces of
insomnia. Frontiers in Psychiatry, 12. https://doi.org/10.3389/fpsyt.2021.683943
Keyes, K. M., Pratt, C., Galea, S., McLaughlin, K. A., Koenen, K. C., & Shear, M. K. (2014).
The burden of loss: unexpected death of a loved one and psychiatric disorders across the
life course in a national study. American Journal of Psychiatry, 171(8), 864-
871. https://doi.org/10.1176/appi.ajp.2014.13081132
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of
insomnia: An update. World Psychiatry, 18(3), 337-
352. https://doi.org/10.1002/wps.20674
Lind, M., & Gehrman, P. (2016). Genetic pathways to insomnia. Brain Sciences, 6(4),
64. https://doi.org/10.3390/brainsci6040064

Week 7 Discussion

Case: An elderly widow who just lost her spouse.

Subjective: The  patient is a 75 Year old who  presents to your primary care office today with
chief complaint of insomnia. She reports that 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. Patient normally sees PCP once or twice a year. Patient denies any suicidal
ideations. Patient arrived at the office today by private vehicle.

Past Medical History:
DM, HTN, and MDD

Currently 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

Insomnia is a disorder characterized by difficulty with falling or staying asleep which is
linked to increased impairment in daytime functioning with symptoms such as fatigue, malaise,
diminished attention, concentration or memory and impaired social, family and occupational
performance  It is considered a risk factor for major depressive disorders, anxiety disorders,
substance use disorders, suicidality, high blood pressure and diabetes mellitus (Krystal, Prather
& Ashbrook, 2019).
Three questions that I might ask the patient:
Can you tell me about your current sleep pattern?
When did you start experiencing difficulty with your sleep pattern or routine?
What sleep aids or agents have you tried and how effective have they been?
People in the patient’s life that I might speak to:
With the patient’s consent, I will speak to the members of her family if applicable and her
close friends. The patient’s immediate family members, such as her children, her siblings and
close friends are secondary sources of patient’s data. They can provide additional information
that might be beneficial to the development of the patient’s treatment plan resulting in positive
patience outcome. Specific questions that I will ask them include:
Have you noticed any changes in the patient’s behavior, mood, concentration, attention or
daily functioning?
When did you start noticing these changes? Prior to or after she lost her husband.
Have you ever known the patient to be depressed or has the sleeping difficulties
contributed to her depression?
Is the patient always compliant with her medication and treatment?
Are there any members of the family with a history of depression or sleeping problems?
Appropriate Physical Exams or Diagnostic Tests
An approved diagnostic test for insomnia is polysomnography. Polysomnography
typically shows impairments of sleep continuity such as increased sleep latency and time awake
after sleep onset and decreased sleep efficacy or percentage of time in bed asleep indicating
increased stage 1 sleep and decreased stages 3 and 4 sleep (APA, 2013). The use of this
diagnostic test reveals the severity of the sleep impairment since the patient subjective
presentation does not fully estimate sleep duration and wakefulness.
Differential Diagnosis for this patient includes:
 Depression
 Obstructive Sleep Apnea
 Sleeplessness and Circadian Rhythm Disorder.

The differential diagnosis that I think is for this patient is depression. The patient is suffering
from depression due to the loss of her spouse. As a result, she is having difficulty sleeping,
leading to insomnia. In addition, insomnia is considered a risk factor for major depressive
disorders, anxiety disorders, high blood pressure and diabetes mellitus.
Two Pharmacological Agents and their dosing
The two medications that I selected based on the patient antidepressant therapy are
Ramelteon and Suvorexant. Ramelteon (Rozerem) is a melatonin agonist indicated for sleep-
onset insomnia. The recommended dose is 8mg and the total daily dose should not exceed 8mg.
Ramelteon should be taken within 30 minutes before bedtime (Lie, Tu, Shen & Wong, 2015).
Suvorexant (Belsomra) is an orexin receptor antagonist indicated for sleep-onset and sleep –
maintenance insomnia. The recommended dose for Suvorexant is 10mg and the total daily dose
should not exceed 20mg. Suvorexant should be administered once per night within 30minutes of
going to bed.
Contraindications to use or alterations in dosing
There is no contraindication for this patient with these two medications. Alcohol use
should be avoided with the use of both medications. Ramelteon should not be taken immediately
after a high-fat meal and Suvorexant’s effect may be delayed if taken with food (Lie et al, 2015).
Check points at 4 weeks follow-up
The patient is scheduled for a follow up visit in 4 weeks to assess for reduction in the
patient’s symptoms and improved sleep pattern.

Lie, J. D., Tu, K. N., Shen, D. D., & Wong, B. M. (2015). Pharmacological Treatment

of Insomnia. P & T : a peer-reviewed journal for formulary management, 40(11),
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of

insomnia: an update. World psychiatry : official journal of the World Psychiatric
Association (WPA), 18(3),  –352. https://doi.org/10.1002/wps.20674
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5 th  ed.) https://doi.org/10.1176/appi.books.9780890425596
Discussion: Treatment for a Patient With a Common Condition


Insomnia is the inability to fall asleep, stay asleep, or wake up early. To be diagnosed with
insomnia disorder, an individual must exhibit symptoms at least three times per week for a minimum of
three months (Riemann et al., 2020). Insomnia is associated with bereavement. Bereaved individuals are
more likely to experience sleep problems. Sleep disturbances are more prevalent during the first few
months following a loss, but they can improve over time (Lancel et al., 2020). A 75-year-old woman who
recently lost her 41-year-old husband presented to the client with a complaint of insomnia. The patient
stated that her depression and sleep habits have gotten worse since her husband died.
List three questions you might ask the patient if she were in your office. Provide a rationale for
why you might ask these questions.
1.           Is your depression interfering with your day-to-day activities, or have you lost interest in formerly
enjoyed pursuits? Do you have any family members or friends who can lend a hand? If depression is not
addressed promptly, it might progress to suicidal or homicidal ideas. When a depressed person begins to
give up beloved possessions to others, the person may experience feelings of hopelessness and
worthlessness, as well as the inability to perform tasks that were formerly valued. This may lead to self-
harm. Depression can be reduced and behavioral therapy can be improved with the help of family or
social support.
How many hours do you get to sleep at night? 2. Has it been difficult for you to fall asleep or to stay
awake? In order to develop a treatment plan and determine the type of medications to be delivered, it is
necessary to determine the number of hours that one sleeps at night. Being aware of the patient's sleep
pattern assists the health care practitioner in making an accurate diagnosis and encouraging the patient
to sleep in a peaceful atmosphere in order to promote sleep.
3. What is the length of time you have been taking Sertraline 100 mg orally for depression? Do you take
any type of sleeping medicine? What medications do you take over the counter, and if so, what is the
name of the medication that you take? Do you know how long you've been taking the medications? What
is the frequency with which you take your medications? Have you seen any side effects or symptoms as a
result of taking the medications? Do you have any sensitivities to foods, medications, or seasonal
changes? It is vital to determine whether or not the patient is complying with her meds, whether or not the
medications are effective, whether or not a change in medication is necessary, and whether or not the
medication should be titrated or discontinued. The answers to these questions are critical in order to
provide appropriate treatment.
•            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
When dealing with a patient's disease process, it is critical that she maintains her confidentiality. Because
she is attentive and oriented, the patient's power of attorney should be the most appropriate person with
whom to discuss the patient's health issues, with or without the patient's knowledge or authorization. The
second individual could be one of the patient's children, if they are present at the time of the assessment.
It is possible that the third person is one of the patient's siblings, if any are present. If the patient's family
members have seen any behavioral changes in the individual, it is necessary to inquire about the drugs
that the patient is taking, the patient's food, and whether the patient's vital signs have been consistent or
irregularly fluctuating. How many pharmacies does the patient utilize for her meds? Is the patient taking
her scheduled pills as prescribed by the health care provider? Is the patient in the process of giving up
her most prized possessions to others? Has she expressed concern about dying? Have they observed
any signs of the patient engaging in self-injurious behavior? Have any of your relatives had depression,
diabetes, hypertension, or insomnia as a result of their medical or mental history? Obtaining the following
information from the patient's loved ones will allow the health care practitioner to be aware of the patient's
activities at home, which will aid in the delivery of effective treatment therapy.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the
patient and how the results would be used.
To detect gray matter decrease in the frontal lobes of the brain, magnetic resonance imaging (MRI)
studies can be performed. Complete blood count (CBC) and complete metabolic panel (CMP) tests can
be performed on a regular basis to detect abnormalities. A Consensus Sleep Diary with specific questions
can be used to get extra information about a patient's sleep history. Environmental elements such as the
temperature of the bedroom, the intensity of the light, and the sound level should be considered. The
patient should have an insomnia evaluation, which includes a medical history and physical examination to
rule out medical and psychological conditions that can cause insomnia. When it comes to treating

insomnia, behavioral and cognitive behavioral therapies can be advised as first-line therapeutic choices
(Patel et al., 2018).
•            List a differential diagnosis for the patient. Identify the one that you think is most likely
and explain why.
The differential diagnosis for this patient includes insomnia, which is secondary to depression because
the patient is grieving the loss of her husband and may not be able to sleep as a result of this.
•            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.
The patient was taking sertraline 100 mg orally once a day for the treatment of depression. This
medication was causing this patient to have greater depression and insomnia; as a result, the prescription
should be shifted to a different type of medication. For this treatment, the drugs Trazodone
(Antidepressant – Serotonin-2 Antagonist-Reuptake Inhibitors (SARIs) and Mirtazapine (Antidepressant –
Alpha-2 Receptor Antagonists (NaSSAs) are used to treat depression and anxiety. Patients suffering from
mental illnesses such as serious depression are treated with sedating antidepressants such as
Trazodone and Mirtazapine to alleviate the symptoms of sleep disruptions. These drugs are not
authorized for the treatment of insomnia that is not accompanied by a mental illness (Riemann et al.,
2020). The patient can be started on Trazodone 50 mg orally daily at bedtime for insomnia and
Mirtazapine 15 mg orally daily at bedtime for depression, and the dose can be increased or decreased
depending on the effectiveness of the medication. Besides exerting an alpha-adrenergic blocking activity,
trazodone also has a minor histamine blocking effect, which results in a sleepy effect. It can also
suppress the vasopressor response to norepinephrine, which decreases blood pressure (Jones & Bartlett,
2018). (Jones & Bartlett, 2018). Mirtazapine has been shown to raise neuronal serotonin and
norepinephrine levels, as well as to improve mood. After 2 weeks of treatment, Mirtazapine showed a
substantial improvement in sleep latency, sleep efficiency, and awakenings after sleep onset, whereas
Trazodone did not show a significant change in any of these variables. It only has sedative effects
because it inhibits the activity of histamine receptors (Patel et al., 2018).
• 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?
Mirtazapine should be used with caution in senior patients, and patients should be continuously
monitored for suicidal thoughts, particularly when therapy is initiated or dose changes are made, because
depression may temporarily worsen (Jones & Bartlett, 2018). Because of the patient's advanced age,
medication should be taken in the manner advised by the health care practitioner to avoid injury to the
•            Include any “check points” (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.
On a weekly basis, it is necessary to check on the patient's health state, symptoms, and any bad
responses. It is necessary to receive an updated report on the patient's sleep pattern and depression.

Jones & Bartlett. (2018). Nurse’s Drug Handbook (17th ed.). Burlington, MA: Jones & Bartlett Learning.

Lancel, M., Stroebe, M., & Eisma, M. C. (2020). Sleep disturbances in bereavement: A systematic review.
Sleep Medicine Reviews, 53, 101331. https://doi.org/10.1016/j.smrv.2020.101331
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A Review. Journal of Clinical Sleep
Medicine: JCSM : Official Publication of the American Academy of Sleep Medicine, 14(6), 1017–1024.
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression.
Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology,
45(1), 74–89. https://doi.org/10.1038/s41386-019-0411-y

Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with a 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. Patient arrived at the
office today by private vehicle. Patient currently takes the following medications:

 Discussion NURS 6630  Diagnosis and Treatment of Insomnia

Discussion NURS 6630  Diagnosis and Treatment of Insomnia

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 Metformin 500 mg 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

Major depressive disorder (MDD) is characterized by various symptoms including depressed mood, loss
of interest or pleasure, diminished energy, fatigue, difficulties with concentration, changes in appetite and
sleep disturbances. MDD and insomnia have a bidirectional relationship.Insomnia is the major complaint
among those patients with MDD. (Ying-Sheue, 2012)
List three questions you might ask the patient if she were in your office. Provide a rationale for why you
might ask these questions.
Question #1 : Are you taking your medication as prescribed
Reviewing her medication history showed that she was already taking SSRI antidepressant (Zoloft). It will
be important to know when the sertraline was started and if she was taking it correctly as prescribed.This
may assist in eliminating any issue with non compliance or non adherence to medications. Patients with

MDD can be fatigued with low energy for daily activities of living and poor concentration which may result
in forgetting things as simple as taking their medications. Poor adherence can lead to poor clinical
outcomes (Traeger, Brennan & Herman, 2016).
Question #2 : Any changes in your diet or environment that can contribute to your lack of sleep. Elderly
patients that drink lots of caffeinated drinks such as coffee may have sleep disturbances because caffeine
is a stimulant.
Question #3:Do you have any  difficulty falling asleep or initiating sleep? Do you wake up repeatedly
during the night (repeated nocturnal awakenings), wake up too early in the morning and be unable to get
back to sleep (awakening too early), and waking up during the night and having a hard time getting back
to sleep (difficulty getting back asleep). This will give the clinician a good understanding of how to treat
the patient.

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.
The PNP should speak to family members such as her children, siblings and caregiver if the patient is not
independent.Since MDD is a mental illness that affects mood, cognition, behavior and impairs
functionality. It will be important to focus on those areas. Secondly, the clinician needs to  know how long
the patient has been taking sertraline because it takes at least 6-12 weeks to determine the effectiveness
of sertraline. Questions should include
Any changes in the patient’s mood, cognition and behavior
Any feelings of sadness or hopelessness?
How is her diet? Has she been eating well?
Is she taking her medication as prescribed?
How long has she been taking sertraline?
Do you know if she has been sleeping well?
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how
the results would be used
Clinicians should use the following instruments such as mini mental exam, geriatric depression scale and
hamilton depression rating scale HAM-D to assess and evaluate the patient. Chronic and physical
diseases are risk factors for depression in the elderly (Abdoli et al., 2019). Physical conditions like stroke,
hypertension, atrial fibrillation,diabetes, cancer, dementia, and chronic pain further increase the risk of
depression (Abdoli et al., 2019). Diagnostic work up should include lab work such as  fasting blood
glucose, hemoglobin a1c, liver profile and electrolytes.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
Major depressive disorder is the primary diagnosis. Most patients with MDD always exhibit symptoms
such as depressed mood, loss of interest, depression or energy, fatigue, difficulties with concentration,
changes in appetite and sleep disturbance (Fava & Papakostas, 2016).
Bipolar depression is another diagnosis. Clinicians should be mindful that DSM-5 criteria for a depressive
episode are identical for unipolar and bipolar depression. When a patient presents with clinically

significant depressive symptoms, bipolar depression should always be ruled out before a diagnosis of
unipolar depression is made (Montana et al., 2020).
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 otherFor 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 “check points” (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.

The first option is to increase Sertraline to 150 mg by mouth daily since the scenario did not say how long
the patient has been on sertraline. It is recommended that the patient be on antidepressant for 6-12
weeks before determining its efficacy and the adequate dosage in the absence of side effects should be
“pursued aggressively” (Fava & Papakostas, 2016). The only problem is that Increasing sertraline will
worsen her insomnia. Another option is to add low dose trazodone 25 to 150mg by mouth at night to
sertraline. This can be used to treat insomnia secondary to antidepressant use. Trazodone is a serotonin
receptor antagonist. Sedation, which is one of the most common side effects of trazodone, will improve
the patient’s insomnia (Fava & Papakostas, 2016). The clinician may need to reduce the dose of the two
antihypertensive drugs that she takes because of  other side effects such as orthostatic hypotension and
headache. The clinician should educate the patient and her family on the significance of monitoring her
blood pressure daily and notify the doctor of any orthostatic hypotension. The third option is to add an
alpha-2 adrenergic receptor agonist (low dose Mirtazapine 7.5mg by mouth at night) to sertraline.
Increasing sertraline may not improve her insomnia, adding mirtazapine will help her insomnia. The only
concerns are the side effects of weight gain. Weight gain in the elderly can worsen his chronic illness
such as diabetes, hypertension and hyperlipidemia which can increase his risks for myocardial infarction,
strokes and other cardiovascular diseases. Other side effects with mirtazapine are dizziness, dry mouth,
constipation and orthostatic hypotension. If the patient’s experiences dizziness and orthostatic
hypotension coupled with the fact that she takes antihypertensive (losartan & HCTZ) may increase her fall
risks (Fava Papakostas, 2016). Falls among  the elderly can lead to complications such as fractures and
injuries and death.
The patient will be encouraged to keep a sleep log and document how many hours of sleep and quality of
sleep that she has each night. The patient will be expected to follow up with the PMHNP in four weeks.
Hopefully, she will be sleeping better, if not trazodone can be increased to 50mg and reevaluated in
another four weeks.

Abdoli, N., Salari, N., Darvishi, N.,Jafarpour, S., Solaymani, M.,Mohammadi, M., Shohaimi, S. (2019). The
global prevalence of major depressive disorder (MDD) among the elderly: A systematic review and meta-
analysis,Neuroscience & Biobehavioral

Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J. F.
Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp.
27–43). Elsevier.

Rolin, D., Whelan, J., & Montano, C.B.  (2020). Is it depression or is it bipolar depression?. Journal of the
American Association of Nurse Practitioners, 32, 703-
713. https://doi.org/10.1097/JXX.0000000000000499
Ying-Sheue, C. (2012). Association between chronic insomnia and depression in elderly adults.
Journal of the Chinese Medical Association, 75, 195-196. https://doi.org/10.1016/j.jcma.2012.04.001

week 7



Questions To Ask

1. Sleep disturbance: For how long do you sleep at night? Do you have difficulty getting
sleep? Have you experienced frequent awakenings at night and difficulty regaining sleep? When
do you wake up? Do you feel refreshed when you wake up? Do you feel exhausted during the
day? For how long have you had this problem?  How often does it occur in a week? How has this
affected your day-to-day activities? Responses to these questions are needed to make a diagnosis
based on the diagnostic criteria for insomnia.
2. Depression: Do you feel your ability to think or focus has changed? Have you experienced
feelings of worthlessness? Has your interest in your hobbies reduced? Is your insomnia worse
when you’re depressed? According to Riemann et al. (2019), depression is strongly associated
with insomnia, with over 80 percent of depressed patients exhibiting insomnia, and this may be
the case here.
3. Medication: Do you take all your medications as prescribed? Have your dosages changed
recently? Brietzke et al. (2019) found that patients who were non-compliant on antidepressants
developed severe depression and were more likely to develop insomnia. Additionally, co-morbid
conditions such as hypertension and diabetes cause neurophysiological damage and may result in
insomnia, so their control on medication should be established.
Corroborative history

Caretaker: The patient’s caretaker may expound on the patient’s progress, daily functioning,
and medication compliance. Questions include: Have you noticed any changes in the patient’s

behavior? Does the patient still show an interest in doing things? How well does the patient
comply with her medication? A corroborative history from close observers such as caretakers
helps complete the history and may identify symptoms that the patient is not even aware of.
Children: The patient’s recent loss of a spouse is the most likely stressor leading to these
symptoms. Family members provide information on grief handling, and how it has affected the
patient. Questions about how their mother has changed since they lost their dad and how family
interactions have been affected by the mother’s condition help evaluate the severity of the
condition. Family members may also provide information on drug compliance, family history of
similar illnesses, and medical conditions that may explain the symptoms.
Appropriate Physical Examination and Diagnostic Tests

An objective examination of the patient includes assessment of the pulse for
tachycardia, the hands for fine tremors, the neck for enlarged masses, and the eyes for
exophthalmos and lid retraction, features present in hyperthyroidism. Additionally, the skin
temperature and moistness, which vary with metabolic conditions, should be assessed. As stated
by Humer et al. (2020), metabolic disorders including hyperthyroidism and hyperglycemia may
present with psychiatric manifestations such as insomnia and mood changes and should
therefore be examined for.
Diagnostic tests to be performed on this patient include thyroid function tests to
rule out both hyperthyroidism and hypothyroidism, shown by thyroxine levels.
Additionally, glycated hemoglobin levels should be assessed in this patient to determine
the level of control of diabetes. Uncontrolled diabetes presents with nocturia, polydipsia,
and in advanced cases, neural damage, conditions that may lead to sleep disturbances
(Humer et al. 2020). A complete blood count should be performed to detect hemoglobin
levels, as anemia is associated with an increased risk of insomnia, especially in the
elderly. An evaluation of the sleep patterns and visualization of sleep waves using
polysomnography should also be done.

Most Likely Diagnosis

Insomnia disorder in MDD
According to the American Psychiatric Association (2013), insomnia forms part of the
diagnostic criteria for major depressive disorder (MDD). Additionally, over three-quarters of
patients with MDD present with insomnia, with the incidence higher in elderly patients (Brietzke
et al., 2019). The patient presents with insomnia and has recently been diagnosed with MDD.
The stressor, which is the loss of a spouse, is still present, making insomnia secondary to MDD
the most likely diagnosis. The onset of insomnia points to worsening depression that should be

Differential Diagnoses
Medication-Induced Sleep Disorder, Insomnia Type
According to Gebara et al. (2018), SSRIs may cause sleep disturbances, due to
increased activation of the stimulatory serotonin receptors that increase brain activity. In
particular, sertraline has been found to reduce sleep duration and
increase sleep latency (Gebara et al., 2018). The patient is on a high dose of sertraline
100 mg, and this could explain her symptoms.
Acute Insomnia.
Acute insomnia refers to sleep disturbance that rapidly arises and may last for
days to weeks. According to Riemann et al. (2019), acute insomnia results from adverse
life events and presents with sleep disturbances, unsatisfactory rest, and daytime
sleepiness, causing impairment of the patient’s functioning. This is a possible diagnosis
as the patient presented with insomnia following significant life events.


Appropriate pharmacological agents given would be Agomelatine 25mg per day and
Doxepin 25 mg per day. Agomelatine acts as an agonist on melatonin receptors and blocks
serotonin receptors, lowering neural activity responsible for insomnia. According to Alston et al.
(2018), agomelatine started at 25 mg per day significantly relieves depression symptoms and
is well tolerated in older patients with marked insomnia.  Doxepin, a modified TCA,

inhibits serotonin and norepinephrine uptake in nerve terminals and blocks cholinergic
receptors. Brietzke et al. (2019) state that doxepin started at 25 mg/day in patients with
MDD, reduces nighttime disturbances and increases the quality and duration of sleep.
Elderly patients have altered pharmacokinetics with reduced metabolism of
drugs. They are also more susceptible to drowsiness and anticholinergic effects
associated with TCAs. According to Alston et al. (2018), agomelatine has a minimal effect
on cholinergic receptors, unlike TCAs like doxepin, and thus fewer anticholinergic
effects. Additionally, doxepin affects norepinephrine reuptake, which increases blood
pressure and should be avoided in patients with hypertension. These conditions make
agomelatine the preferred choice of the two. and it will be used together with the
sertraline the patient is already on.

Drug Contraindications

Agomelatine use is contraindicated in patients with significant hepatic
impairment. According to Alston et al. (2018), ninety percent of agomelatine is
metabolized in the liver, and thus reduced metabolic activity may cause toxic
accumulation of the drug and undesirable effects on the patient. Alcohol consumption
should be strictly avoided in patients on agomelatine. According to Alston et al. (2018),
the interaction of alcohol and agomelatine worsens drowsiness, leading to increased
falls and fractures, especially in the elderly.
Check Points

The patient should return for evaluation after four weeks. According to Brietzke et
al. (2019), agomelatine effects may be experienced within two weeks, but it takes up to
four weeks to show full effect. On evaluation, the dosage of agomelatine can be
maintained if a full response has been achieved, or titrated upwards in 25mg increments
if a partial response has been achieved. Once a full response is achieved after week
eight, the patient may be introduced to cognitive-behavioral therapy (CBT) to manage

her insomnia and depression. Intolerable adverse effects on the patient warrant drug
change to a different melatonin agonist or other class of insomnia medication.


Alston, M., Cain, S. W., & Rajaratnam, S. M. (2018). Advances of melatonin-based therapies in
the treatment of disturbed sleep and mood. Sleep-Wake Neurobiology and
Pharmacology, 305-319. https://doi.org/10.1007/164_2018_139
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.).
Brietzke, E., Vazquez, G. H., Kang, M. J., & Soares, C. N. (2019). Pharmacological treatment
for insomnia in patients with major depressive disorder. Expert Opinion on
Pharmacotherapy, 20(11), 1341-1349.
Gebara, M. A., Siripong, N., DiNapoli, E. A., Maree, R. D., Germain, A., Reynolds, C. F.,
Kasckow, J. W., Weiss, P. M., & Karp, J. F. (2018). Effect of insomnia treatments on
depression: A systematic review and meta-analysis. Depression and Anxiety, 35(8),
717-731. https://doi.org/10.1002/da.22776
Humer, E., Pieh, C., & Brandmayr, G. (2020). Metabolomics in sleep, insomnia and sleep
apnea. International Journal of Molecular Sciences, 21(19), 7244.
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2019). Sleep, insomnia, and
depression. Neuropsychopharmacology, 45(1), 74-89.

week 7 discussion


Case Study 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. Patient normally
sees PCP once or twice a year. Patient denies any suicidal
ideations. Patient arrived at the office today by private vehicle. 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

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.
I would ask the patient when did she notice the depression becoming worse
along with the insomnia and did something happen to trigger the increased
depression and insomnia, after taking Zoloft for 10 months. I would ask
these to see if a specific event after her husband dying is also influencing her
current mood and insomnia.
I would ask her about her sleep patterns. Is it hard to fall asleep or stay
asleep, how many hours a night do you sleep, how many times do you way
up during the night, is it hard to fall back asleep after waking up?
I would ask these questions because, “insomnia disorder is characterized by
dissatisfaction with sleep quantity or quality, associated with difficulty
falling asleep, frequent nighttime awakenings with difficulty returning to
sleep, and/or awakening earlier in the morning than desired” (Levenson,
Kay, & Buysse, 2015).
I would also ask her is her diabetes under control and if her HTN is
controlled, is she having highs or lows in her blood sugar and/or her blood
I would ask these questions because improving cardiovascular health and
diabetes control may play a role in the response to depression symptoms
(Martín-Peláez, et al., 2022). Also, by improving the underlying health

conditions the onset of depression could be prevented or improved in the
elderly (Martín-Peláez, et al., 2022).
 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.
I would want to speak to her children. I would want to ask them is she
sleeping during the day, as it would be hard to sleep at night if she is not
tired at night. Has she had any change in appetite, up or down that they have
I would want to speak to her close friends. Have they noticed her not
wanting to leave the house, has she been participation in actives that have
given her pleasure in the past, do they notice her speaking more slowly and/
or acting fidgety or restless?
I would ask these questions because the PHQ 9 questionnaire has some
valuable questions you can also ask family and friends to help determine the
severity of depression. Then the full questionnaire can be given to the
patient, the PHQ 9 has been more accurate in older people than younger
ones, to determine major depression (Levis, Benedetti, Thombs, 2019)
 Explain what, if any, physical exams, and diagnostic tests would be appropriate
for the patient and how the results would be used.
I would want to know the patient’s A1C and a lipid panel, cardiovascular
disease and diabetes control can also affect depression symptoms (Martín-
Peláez, et al., 2022). A cbc could be ordered to make sure her wbc and rbc
are normal, to rule out infection and anemia. A CMP to determine liver and
kidney function, which could determine how well the patient is metabolizing
medications. A tsh and a free t4 to determine if her thyroid is functioning
normally and not contributing to insomnia or feeling tired and having low

 List a differential diagnosis for the patient. Identify the one that you think is most
likely and explain why.
Major depression disorder, recurrent and severe. Depression often affects the
inability to sleep (Abbot, 2016).

 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.
Welbutin150 mg XL once a day PO. Since the patient has been on a SSRI
for 10 months it is appropriate to change to a different class of medication,

Wellbutrin is a NDRI, it is approved the FDA for major depressive disorder
(Camprodon & Roffman, 2016). Also, the patient is obese with a BMI of 33,
Wellbutrin does not cause weight gain and can reduce appetite (Stahl, 2021).
This medication is not habit forming and food does not affect absorption
(Stahl, 2021).
Since the patient has been on Zoloft for 10 months with some success it can
be appropriate to add an augmenting therapy. Often Trazodone 50 mg dose
at HS can be added to an SSRI to help boost the action of the SSRI and help
with insomnia (Stahl, 2021). Trazodone is a SARI and is metabolized by
CYP450 3A4 (Stahl, 2021). This medication does not raise BP but may
lower bp as it is a blockade of alpha adrenergic 1 receptors (Stahl, 2021).
 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?
Wellbutrin can raise BP, the patient should monitor her BP at home and at
visits (Stahl, 2021). If this does occur, her bp medications could be adjusted,
especially if she is having a good response to the medication. Ethically, the
lowest dose should be started in the elderly as they may tolerate the lower
doses better (Stahl, 2021). Concentration of the medication could increase
with lower kidney function, the CMP should tell me her BUN and creatinine
level to determine kidney function (Stahl, 2021).

 Include any “check points” (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.
Wellbutrin dose can be changed after 4 days, but usually the effect is not
noticed for 2-4 weeks (Stahl, 2021). I would want to see the patient back in 4
weeks, the dose could then be changed to 300 mg a day (Stahl, 2021). After
8 weeks the dose could then go to 450 mg, which is the max for XL (Stahl,
2021). If showing improvement with depression symptoms but still having
residual insomnia after 12 week,s Trazodone 50 mg HS could be added
(Stahl, 2021). If the patient’s appetite is changed dramatically and she starts
losing too much weight the medication would have to be changed. If there is
a marked increase to bp, the medication would also have to changed.

Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-

Camprodon, J. A., & Roffman, J. L. (2016). Psychiatric neuroscience:
pathophysiology into clinical case formulation. In T. A. Stern, M. Favo, T. E.
Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital
psychopharmacology and neurotherapeutics. Elsevier.
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of
insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Levis, B., Benedetti, A., Thombs, B. D., & DEPRESsion Screening Data
(DEPRESSD) Collaboration (2019). Accuracy of Patient Health Questionnaire-9
(PHQ-9) for screening to detect major depression: individual participant data meta-
analysis. BMJ (Clinical research ed.), 365, l1476.
Martín-Peláez, S., Serra-Majem, L., Cano-Ibáñez, N., Martínez-González, M. Á.,
Salas-Salvadó, J., Corella, D., Lassale, C., Martínez, J. A., Alonso-Gómez, Á. M.,
Wärnberg, J., Vioque, J., Romaguera, D., López-Miranda, J., Estruch, R.,
Tinahones, F. J., Lapetra, J., Fernández-Aranda, F., Bueno-Cavanillas, A., Tur, J.
A., Martín, V., … Sánchez-Villegas, A. (2022). Contribution of cardio-vascular
risk factors to depressive status in the PREDIMED-PLUS Trial. A cross-sectional
and a 2-year longitudinal study. PloS one, 17(4), e0265079.
Stahl, S. M. (2021). Essential psychopharmacology Prescriber's Guide (7th
ed.). Cambridge
University Press.

Week 7 Discussion

Depression and Insomnia
The three questions I will ask this patient are as follows:
 Have you seen any professional for your depression or since your depression got worse?
 Who is your support system?
 Tell more about your sleeping patterns or habits?

Since this patient reported that her depression has gotten worse since her husband died 10
months ago, I am curious to know if she had sought professional help from a counselor,
psychiatrist, or psychologist among others before today ‘s visit. This will help establish
continuity of care or interprofessional relationship to better care for the patient. I am also
interested in knowing this patient ‘s support system if any to better understand how best to
provide care and the resources she might need down the road to achieve full recovery. Since this
patient ‘s chief complaint is insomnia, I am interested to know this patient ‘s sleeping habits

including hours of sleep, sleep patterns, what she does before going to bed like watching TV, and
what she eats before going to bed, among others.
The people in this patient ‘s life I would like to speak to are his family, support system,
spiritual group, and medical team. I would like to speak to this patient ‘s children and close
relatives. This group understands the patient better and could have seen her mental health
changes and struggles. The professional medical team that has overseen this patient and
understands this patient ‘s health, medication changes and health history which is crucial for
proper diagnosis, treatment, and continuity of care. It is also important to talk to this patient ‘s
spiritual team to understand the role spirituality plays in this patient ‘s health and wellbeing. The
possible questions the PMHNP should ask this group include: Is there a history of mental health
or insomnia in the patient ‘s family? When did they start to notice a change in this patient ‘s
mental health or insomnia? Does this patient take illicit drugs or alcohol? Is there anything that I
need to know about this patient that will help me provide adequate care for this patient?
This patient will need a head-to-toe physical examination, mental health exam, Labs
(CBC with diff, BMP, vitamin D hydroxy, Vitamin B12) and Head CT scan. The reason for
conducting a head-to-toe exam is to rule out a physical illness contributing to insomnia, and if
the patient is physical healthy then shift to the mental health contributing to insomnia.
Conducting a mental health examination is essential to getting a correct diagnosis followed by
the right treatment plan.  Labs and imaging are important diagnostic tests for confirming the
presence of a condition in a patient. Vitamin D deficiency, for example, can be a contributing
factor in depression in women (Amini, et al., 2019). Similarly, CT scans help in diagnosing
chronic conditions like schizophrenia and dementia in older adults (Saiga, et al., 2021). The
results can be used are important in getting this patient the right treatment.
The differential diagnoses for this patient include sleep apnea, medication related
insomnia, depression, restless syndrome and sleeplessness and circadian rhythm disorder.  The
most appropriate diagnosis for this patient is insomnia related to depression. Research has shown
that a disturbance of sleep continuity in patients with depression revealing a decrease in slow
wave sleep, disinhibition of REM sleep and depression of total sleep time (Riemann, et al.,
2020). This can be because of progression of the disease or from the result of the medication this
patient is taking since some psychotropic medications are known to contribute to insomnia.
The pharmacological agents that will be appropriate for this patient are mirtazapine and
trazodone which are popular with the elderly. Bothe Mirtazapine and Trazodone rapidly improve
sleep but have the potential of causing problems in long-term treatment due to oversedation
(Wichniak, et al., 2017). For optimum sleep promotion, the best results are achieved with very
low doses, administered before bedtime, and supplemented with other interventions like behavior
modifications to treat insomnia (Stern, et al., 2016). For Trazodone, I will start with a dose of
25mg at bedtime and maintain the Sertraline antidepressant. This strategy of using trazodone
secondary to an antidepressant is common and results in the improvement of depressive
symptoms. I will start Mirtazapine at the low dose of 7.5mg because of slow elimination by the
elderly and risk of sedation which could lead to falls. Mirtazapine is as effective as SSRIs and
Venlafaxine in the treatment of MDD.
In the case of this patient, I will select trazodone over Mirtazapine. The use of
Mirtazapine will complement the therapeutic effects of Sertraline with minimal side effects. This
is in line with doing what is best for the patient by avoiding Mirtazapine which has more adverse
side effects like sedation and weight gain. Other side effects of Mirtazapine are constipation,
dizziness, dry mouth, and orthostatic hypotension. It will be unethical to select a medication like

this for an elderly woman since these adverse side effects affect the elderly more. The elderly
already have issues with falls, constipation and dehydration which can be exacerbated by
Mirtazapine adverse side effects. Besides, this patient is already weighing 88kgs meaning
additional weight gain will be problematic.
I will have a check-up with the patient after 4 weeks to see if there is any improvement in
depressive symptoms and insomnia, or sooner if there are unpleasant adverse side effects that
need immediate attention. If there is some improvement in depressive symptoms and insomnia
after 4 weeks of use, I will maintain the same dosage otherwise, I will increase the dosage to
50mg of trazodone. I will review the patient progress after 8 weeks of use and if there is more
than 50% improvement in depressive symptoms and insomnia, I will incorporate behavioral
therapy like CBT to increase remission and achieve lasting healing.


Amini, S., Jafarirad, S., & Amani, R. (2019). Postpartum depression and vitamin D: A
systematic review. Critical reviews in food science and nutrition, 59(9),
1514–1520. https://doi.org/10.1080/10408398.2017.1423276
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and
depression. Neuropsychopharmacology : official publication of the American College of
Neuropsychopharmacology, 45(1), 74–89. https://doi.org/10.1038/s41386-019-0411-y
Saiga, R., Uesugi, M., Takeuchi, A., Uesugi, K., Suzuki, Y., Takekoshi, S., Inomoto, C.,
Nakamura, N., Torii, Y., Kushima, I., Iritani, S., Ozaki, N., Oshima, K., Itokawa, M., Arai, M.,
& Mizutani, R. (2021). Brain capillary structures of schizophrenia cases and controls show a
correlation with their neuron structures. Scientific reports, 11(1),
11768. https://doi.org/10.1038/s41598-021-91233-z
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General
Hospital Psychopharmacology and Neurotherapeutics. 1 st  Ed. Elsevier.
Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of
Antidepressants on Sleep. Current psychiatry reports, 19(9),
63. https://doi.org/10.1007/s11920-017-0816-4

Week7-Discussion Approaches to Treatment

Treatment of Patient with Insomnia

Insomnia is one of the common disorders found in the geriatric population
that impacts the quality of life. Insomnia is marked with difficulty falling asleep,
staying asleep, waking up early in the morning, difficulty going back to sleep,
numerous periods of waking up at night and dissatisfaction with sleep that maybe
quantitative or qualitative (Patel, Steinberg, & Patel, 2018). The patient in the case

study is a 75 year’s old female with comorbidities of diabetes, hypertension, and
major depressive disorder.
The questions to ask the patient will include assessing if she is taking all her
prescribed medications daily and regularly, to assess for medication adherence. The
second question will be ask if she is taking any over the counter medications or
herbal supplements, this is to assess for medication interactions or any factors that
might impact sleep.  Third, the provider should ask the patient about her sleep habit,
that is when she goes to bed, how many hours she sleeps at night and ask about
environmental factors such as noise and comfort that may be impacting her sleep
Asses if the patient is checking her blood sugar levels and what the blood
sugar levels are. Patients with insomnia are at greater risk for metabolic syndrome.
Insomnia can contribute to diabetes, hypertension, heart diseases, strokes, mood
disorders, weight gain and obesity (Cleveland Clinic, 2020). Insomnia may be short
term last for a few days or weeks or chronic which occurs at least 3 times a week for
three months or more (Cleveland Clinic, 2020). Use of over-the-counter medications
or supplements that may impact sleep such decongestant or cold medications or
The patient is on hydrochlorothiazide which may be a contributing factor, if
the patient wakes up frequently during the night to void.  Assess the patient’s social
history such as the use of alcohol or tobacco. Assess sleep history and environment
such as good use of comfortable mattress, television, noise, dark or light room
(Hensley, & Beardsley, 2020).
Insomnia is a clinical diagnosis and there is no imaging or laboratory studies
that can be used to confirm or rule out insomnia (Hensley, & Beardsley, 2020). To
make a diagnosis of insomnia, the provider should conduct a thorough physical,
mental and medical health assessment A complete history and physical assessment
related to medical and psychiatric disordered that may exacerbate insomnia (Patel,
Steinberg, & Patel, 2018).
Questionnaires can help determine the severity of insomnia and presence of
depression and anxiety (Hensley, & Beardsley, 2020). A two-week sleep diary,
Insomnia Severity Scale (ISI) or Patient Questionnaire Survey-9(PHQ-9) which is used
to screen for depression and anxiety (Hensley, & Beardsley, 2020). The two-week
sleep diary is indicated an important tool that can aid the patient and provider to
gather information that identifies good and poor patterns of good over a two-week
period (Hensley, & Beardsley, 2020). The provider can use the Insomnia Rating Scale
(IRS) which to evaluate the severity of her insomnia.
Patient Questionnaire Survey-9(PHQ-9) which is used to screen for depression
and anxiety (Hensley, & Beardsley, 2020). The Pittsburgh Sleep Quality Index can be
used which is used to assess for depression and anxiety which in this patient can be
used to evaluate her depression due to history of depression. The two-week sleep
diary is indicated an important tool that can aid the patient and provider to gather
information that identifies good and poor patterns of good over a two-week period
(Hensley, & Beardsley, 2020).
Differential Diagnosis
Restless syndrome causes sensation and tingling is the legs that occurs mostly at
nighttime and common is people aged 65 year and older.

Anxiety: Anxiety is commonly associated with sleeping disorders. It is difficulty to
stay asleep or fall asleep which can lead to insomnia.  Lack of sleep worsens anxiety
and can results to a negative cycle of insomnia and sleep disorders (Suni, 2022). In
this patent, anxiety is most likely a diagnosis. Anxiety may be an underlying
factor for the insomnia. The provider should rule out anxiety and assess for
possible triggers.
Obstructive sleep apnea: This is a sleep disorder that has been found to be
associated with high rates of mental disorders such as depression, anxiety and panic
disorder (Suni, 2022).
Nonpharmacological treatment should be used in conjunction with
medications for treatment. The patient should be educated on methods to improve
sleep, such as not taking stimulants before going to bed, restricting sleep during the
daytime and cognitive behavioral therapy. Cognitive and behavioral therapy are
recommended as the first line of treatment for insomnia (Patel, Steinberg, & Patel,
2018). Cognitive behavioral therapy and sleep restriction are proven to
be effective in treating insomnia (Hensley, & Beardsley, 2020).
There are several medications available to treat insomnia which can be
challenging because of medication side effects and non-availability of long-term trial
of medication indication or the safest and most effective medication (Updates in
Insomnia Diagnosis & Treatment, 2019). Most SSRIs SNRIs and TCA can be used for
treating insomnia with patient who have significant mood disorder, but patient
should be closely monitored, and medication avoided when there are serious
adverse effects (Updates in Insomnia Diagnosis & Treatment, 2019).

Antidepressants are widely prescribed for insomnia notwithstanding that it is
not indicated for the treatment of insomnia and there is limited evidence regarding
its effectiveness for insomnia (Everitt, Baldwin, Stuart, et al., n.d.).  Hypnotics such as
benzodiazepines should be avoided due to potential for addiction and dependency
(Everitt, et al., n.d.).
For this patient the choice medication of choice will be mirtazapine 7.5 mg
one tablet oral at bedtime. Although mirtazapine is an antidepressant, and it is not
approved by the Federal Food & Drug Administration and for the treatment of
insomnia. Mirtazapine improves mood by restoring natural chemical of the
neurotransmitters This medication will help teat the patient’s underlying depression
and subsequently the insomnia. The mediation will be stared at a low dose of 7.5mg
oral daily. Continuous use or increase in dose of mirtazapine will be based on
patients response to initial drug therapy.
The patient will be reassessed in two to four weeks for medication
effectiveness or adverse effects. Mirtazapine is an antidepressant that is commonly
used in patients which have comorbid insomnia and depression especially in older
adults who need to gain weight (Updates in Insomnia Diagnosis & Treatment, 2019).
Mirtazapine given in low doses of 7.5 mg to 15mg has more sedating effects and a
higher dose can be helpful for depression (Updates in Insomnia Diagnosis &
Treatment, 2019). Mirtazapine, and educating patient on measures to maintain
consistent sleep habit can help improve sleep.
A medication of choice for this patient because of her age will be melatonin.
Melatonin has the least side effects, but it may be less effective that other
medications available for insomnia (Updates in Insomnia Diagnosis & Treatment,

An ethical condition to determine is patient age. The patient is 75 years old
and is at increased risk for medication side effects and falls. The American Geriatric
Society Beers Criteria does not recommend the use of antipsychotics, antihistamines,
tricyclic antidepressants except doxepin lower in a low dose, the Z and BZRA drugs
for treating insomnia in the elderly population (Reynolds, & Adams, 2019). The use of
off label medications should be carefully reviewed by the provider.
Insomnia can worsen medical and psychiatric conditions. The patient should
be treated promptly to avoid long term adverse effects and enhance quality of life.
Mediations of choice should be individualized based on presenting
symptoms. Antidepressant are used for patients especially those with mood
disorders, doxepin in low dose of 3mg or 6mg are beneficial and has been
established to reduce sleep latency and increased sleep without impairing sleep
quality, but the medications are expensive (Updates in Insomnia Diagnosis &
Treatment, 2019).

Cleveland Clinic (2020).  Insomnia.
Retrieved https://my.clevelandclinic.org/health/diseases/12119-
Everitt, H., Baldwin, D. S., Stuart, B., Lipinska, G., Mayers, A., Malizia, A. L., Manson,
C. C., Wilson, S., & Everitt, H. (n.d.). Antidepressants for insomnia in adults.
Cochrane Database of Systematic Reviews, 5.

Hensley, J. G., & Beardsley, J. R. (2020). Insomnia treatment in the primary care
setting. Advances in Family Practice Nursing, 2,
125–143. https://doi.org/10.1016/j.yfpn.2020.01.012
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A review. Journal of
clinical sleep medicine: JCSM: official publication of the American Academy
of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172.
Reynolds, A. C., & Adams, R. J. (2019). Treatment of sleep disturbance in older
adults. Journal of Pharmacy Practice & Research, 49(3),
296–304. https://doi.org/10.1002/jppr.1565
Suni, E. (2022). Anxiety and sleep. Retrieved from
Updates in Insomnia Diagnosis & Treatment. (2019). International Journal of
Psychiatry in Medicine, 54(4/5), 275–289.
week 7 main post

Treatment for a Patient with a Common Condition

(1) List three questions you might ask the patient if she were in your office. Provide a rationale for why
you might ask these questions.
As a PMNP, I will start by doing a thorough an assessment on the patient on the patient. I will ask her the
following questions;
(a) What brings you in today/ How are you feeling? The general question will help the client open up and
explain to me exactly what she is feeling and give me details of her currently problem. This will help me
find out what is the possible underlying cause of her symptoms.

(b) How is your sleeping pattern? This will help provide an overview of the characteristics and nature of
her insomnia. It will provide information such as length of sleep, what time she normally goes to bed, what

she does to help her sleep, how she feels after sleeping, and the lack of sleep has affected her daily

(c) Has this had any effect on your cognitive and physical wellbeing lately? This will help me determine
the client’s thought process and rule out any other diagnosis that might be causing the insomnia.

(2) 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.

(a) Children. It is important to find out from the client’s children if she does have any for more
background information about what has been going on with the patient recently.

(b) Friends/Relatives. It will be important to talk to the client’s friends and relatives because they
are the people she may have been confiding in and sharing her problems.
(c) Primary Care Physician (PCP). By reaching out to the patient’s PCP, I’m hoping to get more
insight of client’s history especially regarding to her depression. Also, collaboration with her PCP
(who has known her for years) for assessment, care planning, and management may also be beneficial to
ensure the delivery of patient-centered care.

(3) Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient
and how the results would be used.

Focused physical examination: A general physical examination may help assess certain organic
pathologies such as chronic obstructive pulmonary diseases (COPD), asthma, or restless leg
syndrome which may disturb sleep.

Blood tests: Blood tests may help to rule out subtle manifestations of thyroid diseases, iron
deficiency anemia, and vitamin B12 deficiency (restless leg syndrome).

Polysomnography: The Polysomnography is considered the gold standard for measuring sleep.
electroencephalogram (EEG), electrooculography (EOG), electromyography (EMG), electrocardiography
(ECG), pulse oximetry, and air flow are used to reveal a variety of findings like periodic limb movement
disorder, sleep apnea, and narcolepsy (Saddichha, 2010)
Psychiatric evaluation: A thorough mental health assessment would be important to assess the
patient's symptoms, thoughts, feelings, and behavior patterns in association with the specified criterion in
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The patient will also be requested to
complete a condition-specific questionnaires such as Beck Depression Inventory, Hamilton Depression
Rating Scale, Zung self-rating scale for depression, and The Anxiety Symptoms Questionnaire.
(4) List a differential diagnosis for the patient. Identify the one that you think is most likely and
explain why.
Disorders to consider in the differential diagnosis of insomnia include the following:
 Depression
 Obstructive Sleep Apnea (OSA)
 Restless Legs Syndrome

 Sleeplessness and Circadian Rhythm Disorder (Chawla, 2022)
The one that I think is most likely would-be depression. Depression is be described as persistent
hopelessness and despair (NIMH, 2018). It can manifest following major events in one's life, such as
death or loss, which was experienced by the patient when she lost her husband 10 months ago. Signs
and symptoms include a hopeless outlook, which may be matched with her verbalization of "depression
has gotten worse", increased fatigue and sleep problems, anxiety, and irritability.

(5) 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.
The two pharmacologic agents I will suggest are;
a. Trazodone 100mg daily. Studies showed that administering 50 mg to 100 mg per day of trazodone
helped nonorganic insomnia due to depressive disorder, with 100 mg dosage as most effective to
improve sleep. Trazodone may be available as immediate-release (IR) tablets, prolonged-release tablets,
and in some cases, oral drops and injection solutions (Shin & Saadabadi, 2022). Trazodone will help with
depression as well as insomnia
b. Fluoxetine (Prozac). This is one of the most common antidepressants prescribed due to its recorded
high effectivity rate. Prozac is an SSRI. It increases the neurotransmitter serotonin which improves overall
mood and well-being. I considered Prozac given that it's one of the few antidepressants that the FDA has
approved for children, teenagers, and elderly use. It was also documented to be safe in patients with
diabetes (like the patient) and undergoing diabetes treatment regimen, as this does not increase sugar
levels (Ullman, 2000).
(6) 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?

It is imperative to understand when to prescribe certain medications based on the client’s health history.
For instance, combining serotonergic antidepressants with MAOIs involves the risk of serotonin syndrome
(Abukarr, 2018)
Hypersensitivity to fluoxetine or any component in its formulation
Individuals with a history of seizures.
(7) Include any “check points” (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.
(a) Trazadone may be administered after meals to decrease lightheadedness and postural hypotension.
Begin with evening administration of 75 mg to 150 mg before bedtime, as a prolonged-release once a day
administration. This regiment helps to optimize its purpose as an antidepressant, and it elicits higher
compliance (Shin & Saadabadi, 2021)
(b) Fluoxetine (Prozac). Do not stop taking fluoxetine, even when you feel better. With input from you,
your health care provider will assess how long you will need to take the medicine. Missing doses of
fluoxetine may increase your risk for relapse in your symptoms. Stopping fluoxetine abruptly may result in
one or more of the following withdrawal symptoms: irritability, nausea, dizziness, vomiting, nightmares,
headache, and/or paresthesia (prickling, tingling sensation on the skin) (NAMI, 2020)

Aboukarr, A., & Giudice, M. (2018). Interaction between monoamine oxidase B inhibitors and selective
serotonin reuptake inhibitors. The Canadian journal of hospital pharmacy. Retrieved April 13, 2022,
from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6019085/
Chawla, J. (2019, November 9). What are questions to ask in the sleep history for insomnia? Latest
Medical News, Clinical Trials, Guidelines – Today on Medscape. Retrieved April 13, 2022, from
Fluoxetine (Prozac). NAMI. (2020). Retrieved April 13, 2022, from https://www.nami.org/About-Mental-
Saddichha, S. (2010, April). Diagnosis and treatment of chronic insomnia. Annals of Indian Academy of
Neurology. Retrieved April 13, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924526/
Shin, J., & Saadabadi, A. (2021, August). Trazodone – StatPearls – NCBI Bookshelf. Retrieved April 14,
2022, from https://www.ncbi.nlm.nih.gov/books/NBK470560/
U.S. Department of Health and Human Services. (2018). Depression. National Institute of Mental Health.
Retrieved April 13, 2022, from https://www.nimh.nih.gov/health/topics/depression

Week 7 discussion


List three questions you might ask the patient if she were in your office. Provide a
rationale for why you might ask these questions.
1. Can you tell me about your family?
Family dynamics are as individual as fingerprints. What may be normal to your family may not be to
mine. Some families suffer through domestic abuse, sexual abuse, substance abuse, emotional abuse,
financial exploitation, spousal relationships, family relationships, etc. Other families communicate, are
supportive, love unconditionally, and respond when a family member is in crisis.
Family dynamics refers to the patterns of interactions among relatives, their roles and relationships,
and the various factors that shape their interactions. Because family members rely on each other for
emotional, physical, and economic support, they are one of the primary sources of relationship
security or stress. Secure and supportive family relationships provide love, advice, and care, whereas
stressful family relationships are burdened with arguments, constant critical feedback, and difficult
demands. Interpersonal interactions among family members have lasting impacts and influence the
development and well-being of an individual via psychosocial, behavioral, and physiological
pathways. Therefore, family dynamics and the quality of family relationships can have either a
positive or negative impact on health. (Jabbari & Rouster, 2021).
1. Can you explain to me how you have dealt with stressful situations in the past?
How people deal with stress determines the outcome of their stress. Managing stress while staying
mentally competent can be hard to do and some people find themselves on the wrong side of the law,
friends, family, or their job.

Lead researcher David M. Almeida, Ph.D., professor of human development and family studies at Penn
State College of Health and Human Development, told Healthline that, at the outset, he and his
colleagues expected life to be more stressful for people now compared to the ’90s. What surprised them
was this discrepancy between middle-aged people and other age groups. “We thought that younger
people in late 20s or early 30s would be most stressed, with people coming out of an economic
recession and low job prospects, entering economic uncertainty,” he said. “But it was people about 50
to 64 who were the most stressed out. That stood out, shockingly so.” People in their middle years seem
to have more demands and pressures placed on them, naturally elevating stress levels that might not be
as existent for younger adults (Mastroianni, 2020).
1. What type of social organizations do you belong to or attend?
Having support alleviates some of the depression people feel. Having a friend, organization, or Church
group to attend allows a person to voice their feelings to others that they can trust and makes a person
feel as if they are a part of society or are important to others.
Humans have a profound need to connect with others and gain acceptance into social groups.
Furthermore, people suffer when relationships deteriorate, and social bonds are severed. Although
feeling disconnected from others and experiencing a lack of belonging bothers everyone, depressed
people may be particularly sensitive to these painful social encounters. By focusing on people's
reactivity in their ongoing social environments, we gain a more reliable picture of life as it is lived.
People with greater depressive symptoms appear to find greater satisfaction and meaning in their lives
when they meet their need to belong, suggesting an important role for positive social relationships in
reinforcing these important cognitive perspectives on life (Steger & Kashdan, 2010).
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.
I would want to talk to the lady’s children or grandchildren, whoever is close to her and lives by her. This
patient is going to probably need some assistance such as housekeeping, grocery shopping,
transportation to medical appointments or errands, etc. Who will be assisting her with these needs, or
does she need a personal care attendant (PCA) if eligible or can she pay someone privately to assist her
with these needs or companionship?
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and
how the results would be used.
A PHQ-9 gives a baseline and when consistently used at future depression screening appointments,
allows the provider to see any changes which can factor into prescribing medications or doing other
treatment options.
The validity of the questionnaire has been assessed against an independent structured mental health
professional interview. PHQ-9 score ≥10 had a sensitivity and a specificity of 88% each for major
depression. It has also been specifically validated for use over the telephone and in the primary care
setting. The Geriatric Depression Scale self-report instrument was developed by researchers at Stanford
University and has been studied in multiple settings. There is a five-item version and a 15-item version
of this measure. Further details can be found
at http://www.stanford.edu/~yesavage/GDS.html. Cornell Scale for Depression in Dementia
incorporates both observer- and informant-based information and helps evaluate cognitively impaired
patients (such as those with dementia) for depression. The questionnaire and scoring guidelines can be
at http://www.scalesandmeasures.net/files/files/The%20Cornell%20Scale%20for
%20Depression%20in%20Dementia.pdf (Williams, 2014).
Glucose monitoring, A1c, CBC laboratory testing could be done as the patient takes medications that can
interfere with one another, and these three drug-drug interactions are possible:

1. Treatment with sertraline may occasionally cause blood sodium levels to get too low, a condition known
as hyponatremia, and using it with hydrochlorothiazide can increase that risk.
2. Hydrochlorothiazide can increase blood sugar levels and interfere with diabetic control. You may need a
dose adjustment or more frequent monitoring of your blood sugar to safely use both medications.
3. Hydrochlorothiazide may interfere with blood glucose control and reduce the effectiveness of sitagliptin
and other diabetic medications. Monitor your blood sugar levels closely. You may need a dose
adjustment of your diabetic medications during and after treatment with hydrochlorothiazide.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain
Differential Dx: Hyponatremia possibly in elderly patients and patients taking diuretics or who are
otherwise volume-depleted may be at greater risk of developing hyponatremia with SSRIs and SNRIs.
I think this patient is still grieving the loss of her husband of 41 years. She probably living alone and as
she states her depression has gotten worse. She may need an increase in her antidepressant or possibly
an additional SSRI or SNRI.
"Usually, an antidepressant that's worked for a patient will keep working," says Paul Nestadt, M. D.,
psychiatrist and co-director of the Jack and Mary McGlasson Anxiety Disorders Clinic at Johns Hopkins.
"But sometimes, a new episode of depression might come up that's not as responsive to that
medication, or the medication might just stop working altogether." Multiple factors can change the way
your body responds to an antidepressant, including:
 Drug or alcohol use. Illicit drug use and alcohol can cause strong mood changes, which can make
antidepressants ineffective.
 Pregnancy. Your body's weight and blood volume increase when you're pregnant. Talk to your doctor
about taking antidepressants while pregnant, and about potentially adjusting your dosage to continue
relieving symptoms.
 New stressors. A new stressful situation at home or work can result in a mood response for which the
antidepressant can't compensate.
 Other medications. Interactions between antidepressants and medications for other health
conditions can affect how well an antidepressant works (Nestadt, 2022).
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.
Escitalopram (Lexapro) Initial dose 10 mg once daily; recommended dose 10 mg once daily; maximum
dose 20 mg once daily for MMD in adults. In elderly patients, 10 mg once daily is recommended dose.
Black Box warning for suicidal thoughts or behaviors in pediatric and young patients. Common adverse
effects include insomnia, nausea, increased sweating, sexual dysfunction, decreased libido, fatigue, and
somnolence. Well absorbed following oral administration, with peak plasma concentration usually
attained within 5 hours. Commercially available tablets and oral solutions are bioequivalent. An
antidepressant effect usually occurs within 1–4 weeks. Food does not affect absorption. In geriatric
patients, AUC is increased by approximately 50%. Plasma protein binding is approximately 56%.
Extensively metabolized in the liver to less pharmacologically active metabolites by multiple enzyme
systems, including CYP3A4 and CYP2C19. Eliminated principally in urine. Half-life 27–32 hours. In
geriatric individuals, the half-life is increased by approximately 50%. Hepatic impairment decreases
racemic citalopram oral clearance by 37% and doubles its half-life. Mild to moderate renal impairment

decreases racemic citalopram oral clearance by 17%. Pharmacokinetics not studied in patients with
severe renal impairment (Cl cr  <20 mL/minute) (Escitalopram, 2022).
Duloxetine (Cymbalta) Initial dose 20 mg BID up to 30 mg BID; recommended 30 mg BID; maximum dose
60 mg BID for MMD in adults. Black box warning for suicidal thoughts or behaviors in children,
adolescents, and young adults. Common adverse effects include nausea, dry mouth, constipation,
diarrhea, decreased appetite, vomiting, fatigue, somnolence, insomnia, dizziness, asthenia, agitation,
hyperhidrosis, and decreased sexual function. Well absorbed following oral administration, with peak
plasma concentration usually attained in 6 hours. Food decreases the rate and marginally decreases the
extent of absorption. In patients with end-stage renal disease, AUCs and peak plasma concentration of
duloxetine and its metabolites are increased. Plasma protein binding >90%. Extensively metabolized to
numerous metabolites. Metabolized by CYP isoenzymes, principally CYP2D6 and CYP1A2. Excreted
principally in urine as metabolites (about 70%) and unchanged drug (<1%), and in feces (20%). Half-life is
approximately 12 hours. In patients with hepatic impairment, metabolism and clearance are
decreased (Duloxetine, 2021).
Lexapro would be the better choice d/t lower protein binding, less common adverse effects, and a
longer half-life of the medication.
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?
Serotonin Syndrome: Serotonin syndrome has been reported with SSRIs and SNRIs, including Lexapro,
both when taken alone, but especially when co-administered with other serotonergic agents (including
triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines,
and St. John’s Wort).  If such symptoms occur, discontinue Lexapro, and initiate supportive treatment.
Discontinuation of Treatment with Lexapro: A gradual reduction in the dose rather than abrupt
cessation is recommended whenever possible. Seizures: Prescribe with care in patients with a history of
seizures. Activation of Mania/Hypomania: Screen patients for bipolar disorder. Hyponatremia: Can occur
in association with SIADH. Abnormal Bleeding: Use caution in concomitant use with NSAIDs, aspirin,
warfarin, or other drugs that affect coagulation. Interference with Cognitive and Motor Performance:
Use caution when operating machinery. Angle Closure Glaucoma: Angle-closure glaucoma has occurred
in patients with untreated anatomically narrow angles treated with antidepressants. Use in Patients
with Concomitant Illness: Use caution in patients with diseases or conditions that produce altered
metabolism or hemodynamic responses. Sexual Dysfunction: Lexapro may cause symptoms of sexual
dysfunction (Drugs@FDA: FDA-Approved Drugs, n.d.).
When discontinuing or stopping antidepressants they can cause weird side effects like “brain zaps.”
Brain zaps are electrical shock sensations in the brain. They can happen in a person who is decreasing or
stopping their use of certain medications, particularly antidepressants. People who were experiencing
brain zaps, people described them as a brief, electrical shock-like feeling in the brain, a short period of
blacking out or losing consciousness, dizziness or vertigo, a zap paired with a buzzing sound, “hearing
their eyes move,” or feeling disoriented (a “brain blink”). Some people also reported a painful sensation,
headache, or seizure-like feeling, but these were less common than other symptoms. Brain zaps are not
harmful and will not damage the brain. However, they can be bothersome, disorienting, and disruptive
to sleep. There is no cure for brain zaps, and they usually go away over time. Once a person’s body has
adjusted to the change in antidepressant dosage, brain zaps and some other side effects may decrease.
I have generalized anxiety disorder and have tried several SSRIs and an SNRI. I have experienced these
nasty “brain zaps” even tapering off medications as suggested, and I would not want my patients to
have to experience them if possible.

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 option chosen.
Lexapro should generally be administered once daily, morning or evening with or without food. Before
initiating treatment with Lexapro or another antidepressant, screen patients for a personal family
history of bipolar disorder, mania, or hypomania. No dosage adjustment is necessary for patients with
mild or moderate renal impairment. Lexapro should be used with caution in patients with severe renal
impairment. If concomitant use of Lexapro with other serotonergic drugs including, triptans, tricyclic
antidepressants, fentanyl, lithium, tramadol, buspirone, tryptophan, amphetamine, and St. John’s Wort
is clinically warranted, patients should be made aware of potential increased risk for serotonin
syndrome, particularly during treatment initiation and dose increases. Treatment with Lexapro and any
concomitant serotonergic agents should be discontinued immediately if the above events occur, and
supportive symptomatic treatment should be initiated. Patients should be monitored for these
symptoms when discontinuing treatment with Lexapro. A gradual reduction in the dose rather than
abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a
decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed
dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more
gradual rate (Drugs@FDA: FDA-Approved Drugs, n.d.).
The recommended daily dose of Lexapro in the elderly is 10 mg daily; however, 20 mg daily dose is the
maximum for this drug in MMD in adults. F/U should be completed at 4, 8, and 12 weeks. If no change at
4 weeks, a slight increase, and if no change at 8 weeks switch to something that will work.


Berry, J. (2020, April 2). Brain zaps: Everything you need to know. Retrieved from
MedicalNewsToday: https://www.medicalnewstoday.com/articles/brain-zaps
Drug Interaction Report. (2022). Retrieved from Drugs.com Know more. Be sure:
Drugs@FDA: FDA-Approved Drugs. (n.d.). Retrieved from U.S. Food & Drug Administration:
Duloxetine. (2021, September 21). Retrieved from Drugs.com Know more. Be Sure:
Escitalopram . (2022, January 25). Retrieved from Drugs.com Know more. Be Sure.:
Jabbari, B., & Rouster, A. S. (2021, July 16). Family Dynamics. StatPearls [Internet]. Retrieved from
Mastroianni, B. (2020, May 17). Why Americans Are More Stressed Today Than They Were in the
1990s. Retrieved from healthline: https://www.healthline.com/health-news/people-more-
Nestadt, P. (2022). Why Aren't My Antidepressants Working? Retrieved from John Hopkins Medical:

Steger, M. F., & Kashdan, T. B. (2010, April 27). Depression and Everyday Social Activity, Belonging, and
Well-Being. Journal of Counseling Psychology, 56(2), 289–300. doi:10.1037/a0015416
Williams, N. (2014, February 19). PHQ-9. Occupaitional Medicine, 64(2), 139–140.

Week 7 Discussion Main Post


A 75-year-old female presents to the office with her chief compliant being insomnia. She
came to the office by a private car. The patient states her husband passed away ten months ago.
They were married for forty-one years. The patient states she has been having difficulty sleeping,
and her depression has increased after her husband’s death. Patient states she has no past history
of depression. Patient states she has no thoughts of harming herself. She states she goes to her
primary care physician one or two times a year depending on her medical condition. She reports
she has a medical history of diabetes mellitus, hypertension, and major depressive disorder. The
patient states she takes these medications: sertraline 100 mg daily by mouth,
hydrochlorothiazide (HCTZ) 25 mg by mouth daily, losartan 100 mg by mouth daily, Januvia
100 mg by mouth daily, and metformin 500 mg twice a day by mouth. The patient is alert and
oriented times three. The patient’s vital signs are temperature 98.6 0  F, blood pressure 132/86. Her
current height is 5’4”. Her current weight is 194 lbs.
During the interview there are three questions. The first question is what are the times
you get into bed at night and get out of bed in the morning? This question gives the provider
information on whether there is a set schedule for sleep. There are other questions that can be
askes as follow up such as is a light or tv kept on during the night or is reading and watching tv
done in bed? The second question is are daytime naps taken and if so, how many? Elderly
individuals are known to take daytime naps which can be related to boredom due to lack of
emotional stimulation or activities. The third question is if the patient has had any changes in
eating habits since her husband’s death. Research shows an individual can resort to overeating
when they are depressed. The overeating can cause weight gain which can result in sleeping
problems such as insomnia (Chand, 2021). The patient has a current body mass index of 33.3.
Information about the patient’s life can also be attained by talking with children, siblings,

friends, caregivers, or a pastor. Does the patient have a daily routine? Does the patient drive?
How does the patient deal with activities of daily living? Does the patient do their own
shopping? Do they attend activities outside the home (Stern et al., 2016)?
A geriatric depression scale (GDS-15) could be given to the patient, or the provider can
fill out a Hamilton Rating Scale for Depression (HRSD) to help determine the patient’s degree of
depression (Chand, 2021). In determining sleeping issues which could be related to medical
problems in the patient’s body, a diagnostic workup should include renal function tests, complete
blood count, liver function tests, thyroid function tests and glycosylated hemoglobin. The renal
function tests will help tell if the patient is experiencing faster kidney function decline as a result
of less sleep (Chand, 2021). The patient already has one risk factor for possible faster kidney
function decline which is diabetes mellitus. The complete blood count gives a good view of the
patient’s overall health (Chand, 2021). An individual who does not receive enough sleep on a
constant basis will have a lower immune system which will be verified by a lower white blood
count. The liver function tests can determine abnormal ALT and NAFLD and elevated liver
enzymes which researchers have shown happens in individuals that have sleep deprivation. The
glycosylated hemoglobin can determine if the patient is controlling their diabetes, and research
shows that patients with levels greater than 6.5 have a history of poor sleep (Chand, 2021).
Thyroid functions tests will see if the thyroid is working properly. If the thyroid is not making
enough hormone, the individual will have problems with their circadian rhythm and difficulty
falling asleep (Chand, 2021).
The patient could have a differential diagnosis of depression, central sleep apnea, restless
leg syndrome, sleeplessness and circadian rhythm disorder. The most likely diagnosis would be
depression, with prevailing factors such as being she is elderly, a widow, and has comorbidities
such as obesity, diabetes, hypertension, and reports insomnia for the last 10 months (Chand,
In helping the patient with their current problem of insomnia along with their major
depressive disorder (MDD), the choice of pharmacologic agents would be to increase the
sertraline dose to 150 mg with follow up after four weeks to see if the patient has had any
positive results or taper the patient off sertraline and start escitalopram at 10 mg by mouth

daily (Singh & Saadabadi, 2021). I would choose to taper the patient off the sertraline and start
them on escitalopram (Landy et al., 2022). They are both selective serotonin reuptake inhibitors
(SSRIs), but they have similarities and differences (Stern et al., 2016). Sertraline and
escitalopram target the serotonin transporter (SERT) binding to the 5-HT binding site on the
transporter. This action on the transporter produces antidepressant effects which lead to an
increase in 5-HT levels resulting in a decrease in depressive symptoms (Yohn et al., 2017). The
choice of escitalopram over sertraline is that research has shown it has worked better for
depression, especially for individuals who have experienced loss. Based on pharmacokinetics
and pharmacodynamics research, escitalopram has shown to be better than sertraline (Landy et
al., 2022). To help the patient with their complaint of insomnia, I would supplement with either
melatonin 6 mg by mouth at night or magnesium 500 mg by mouth daily, as research has shown
they both help with sleep (Arab et al., 2022). Melatonin aids in falling asleep faster and
magnesium levels hold an important role in regulating sleep.
As with all SSRIs, escitalopram has contraindications for patients because of the risk of
causing serotonin syndrome and the possibility of QT prolongation. The patient should not take
any monoamine oxidase inhibitor (MAOI) either while on escitalopram as it can result in
serotonin syndrome (Landy et al., 2022). For individuals who have poor metabolizers that affect
the CYPC19 liver enzyme, research has shown that escitalopram should not be taken because it
would allow a larger amount of escitalopram in the blood causing drug-drug interactions.
Patients can have genetic testing done to rule this out (Landy et al., 2022). When prescribing
medications to individuals, it is important to cover all aspects of the medication, especially if
they have a chance of having interactions with other medications the patient is taking. When
looking at choosing a drug therapy that will help the individual, it is best to choose a medication
that has the least side effects so the patient is willing to adhere to the treatment (Stern et al.,
2016). This patient has a history of hypertension and is elderly, so there must be follow up
appointments to ensure the medication is working and there are no adverse effects.  The patient
could experience electrolyte disturbances and QT prolongation. Follow up appointments occur at
four-week intervals and will allow for the provider to see if the medication is being therapeutic
or if further medication changes need to be made. During the second meeting, an

electrocardiogram (EKG) and basic metabolic panel can be done to establish if the medication is
causing any physical issues.


Arab, A., Rafie, N., Amani, R., & Shirani, F. (2022). The Role of magnesium in sleep health: a
systematic review of available literature. Biological Trace Element Research .
Chand, S. A. (2021). Depression. StatPearls.
Landy, K., Rosani, A., & Estevez, R. (2022). Escitalopram. StatPearls.
Singh, H. K., & Saadabadi, A. (2021). Sertraline. StatPearls.
Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. (2016). Massachusetts General
Hospital Psychopharmacology and Neurotherapeutics (1st ed.). Elsevier.
Yohn, C., Gergues, M., & Samuels, B. (2017). The role of 5-HT receptors in
depression. Molecular Brain, 10(28). doi:10.1186/s13041-017-0306-y

Bailey Zaruba Main Post


An Elderly Widow Who Just Lost Her Spouse

Questions with Rationale

What is your current sleep pattern? With this question, I would ask the patient to
elaborate on her sleep and wake cycles, nighttime routine, and functionality during the
day. Gathering this sleep history can help to determine a diagnosis and develop a care
plan. Even further elaboration can include medications trialed for sleep disturbance.
This is important to ask, as it can impact the patient's care plan and interact with other
Since the loss of your husband, what has your support system looked like? Who
is involved? Have you been referred to any support groups? A support group that may
be beneficial to this patient is a loss or bereavement group. These groups are beneficial
to the patient because they can reinforce that grief is a normal process. These groups
can help reduce said grief in a setting where others are having mutual feelings.
Since the initiation of your antidepressant, has there been a change in your
depression symptoms? Have you lost interest or pleasure in normal activities? It is

crucial as a provider to continue to assess the patient’s depression to prevent relapse
and to evaluate the treatment progress.

Feedback from Others

In order to speak to people in the patient’s life, verbal or written consent needs to
be obtained from the patient. Specific people I would speak with include the patient’s
family and primary care provider. I would question the patient’s mood and behavior prior
to starting the sertraline and compare that to now. I would ask about changes in
behavior, moods, and functionality. Has the patient reported difficulty sleeping before
the death of her spouse? I would like to also ask about medication compliance. Has her
lack of sleep affected ADLs? All of these questions can benefit the patient and the
treatment plan by improving patient outcomes.

Physical Exams/Diagnostic Tests

A physical exam should be completed to help identify underlying medical
disorders. The Hamilton Depression Scale (HAM-D) should be performed. This will
determine the severity of the patient's depression. The higher the score, the increased
severity of depression. Answers of symptoms with details can be classified as 0-absent,
1-mild, 2-moderate, 3-severe, and 4-incapacitating. Answers of symptoms that are
difficult to obtain answers for can be classified as 0-absent, 1-doubtful, 2-present.
Scores of 10-13 indicate mild depression, 14-17 mild to moderate depression, and
greater than 17 moderate to severe depression (Hamilton, 1967). The insomnia severity
index is a total of severe questions that score sleep difficulty. Questions that are scored
include difficulty falling asleep, difficulty staying asleep, problems waking up too early, if
satisfied or dissatisfied with current sleep pattern, if sleep pattern is impairing quality of
life, worries regarding sleep pattern, and interference with daily functioning. A total
score of 0-7 indicates that there is no clinically indicated insomnia, 8-14 subthreshold
insomnia, 15-21 moderate clinical insomnia, and 22-28 severe clinical insomnia (Morin,
n.d.). Utilizing these scales can help determine treatment options.

Differential Diagnosis

The patient has already been diagnosed with MDD. I would diagnose this patient
with insomnia. Insomnia is classified as a disorder in which patients report poor sleep
quantity or quality, difficulty falling asleep, difficulty staying asleep, and awakening early
before desired. This also includes complaints of daytime functioning impairment,
daytime sleepiness, cognitive decline, and mood disturbances. Stressors are a main
predisposing factor that could contribute to her sleep patterns (Levenson et al., 2015).
Insomnia is also common with mental health disorders such as depression (Abbott,

Pharmacologic Agents

The patient’s past medical history includes MDD, which is being treated with
sertraline 100mg. The patient reports increased depression and difficulty sleeping.
Based on this information, I would prescribe zaleplon (Sonata) and doxepin (Silenor).
Zaleplon is a nonbenzodiazepine hypnotic in the drug class pyrazolopyrimidine. It is a
benzodiazepine receptor agonist. This drug acts quickly without feeling groggy in the
morning. Zaleplon would be prescribed at 5mg PO at HS. The max dosing for this drug
is 10mg in elderly patients (Bhandari & Sapra, 2021).
Doxepin is a tricyclic antidepressant that is utilized for insomnia and MDD. It has
antagonistic properties in the CNS that block histamine, alpha-1 adrenergic, and

muscarinic receptors while also inhibiting sodium and potassium channels (Almasi &
Meza, 2022). I would prescribe doxepin 3mg PO @ HS. I would choose zaleplon for
initial treatment.
Another option that could be considered trialing first is melatonin 3mg at HS.
Evidence suggests that low doses of melatonin can improve sleep quality in the elderly
with insomnia (Rikkert & Rigaud, 2001). Melatonin is also well tolerated with low
potential for abuse with minimal side effects and no withdrawal effects. It is known for
being the safer alternative without the risk of withdrawal. These elderly just need to be
aware of falls with this medication.


Zaleplon is typically used after the first line is ineffective. Taking zaleplon with
losartan and hydrochlorothiazide can lower blood pressure, so educate on taking blood
pressure before medication administration. Zaleplon with sertraline can increase
dizziness, drowsiness, confusion, and difficulty concentrating. Education is crucial to
ensure the patient is knowledgeable of these side effects and to avoid driving. A high-fat
or heavy meal can also delay the onset of sleep when taking zaleplon. Alcohol should
be avoided as it can increase the side effects of zaleplon- dizziness, drowsiness, and
impairment in thinking and judgment (Bhandari & Sapra, 2021).

Abott, J. (2016). What’s the link between insomnia and mental illness? Health. What's
The Link Between Insomnia And Mental Illness? (sciencealert.com)
Almasi, A., & Meza, C. E. (2022, January 3). National Library of Medicine-
Doxepin. Doxepin – StatPearls – NCBI Bookshelf (nih.gov)
Bhandari, P., & Sapra, A. (2021, September 18). National Library of Medicine-
Zaleplon. Zaleplon – StatPearls – NCBI Bookshelf (nih.gov)
Hamilton, M. (1967, December). Development of a rating scale; for primary depressive
illness. British Journal of Social Psychology, 6(4), 278-296.
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of
insomnia. Chest, 147(4), 1179-1192.
Morin, C. M. (n.d.). Insomnia severity index. InsomniaIndex (ons.org)
Rikkert, M. G. O., Rigaud, A. S. (2001, December). Melatonin in elderly patients with
insomnia. A systematic review, 34(6), 491-
497. https://doi.org/10.1007/s003910170025
Week 7


List three questions you might ask the patient if she were in your office. Provide a rationale for
why you might ask these questions.
1. "What about your sleep habits have been worse since the passing of your husband?" Knowing if the
patient is sleeping too much or sleeping too little is an important factor to know. Gaining a better
understanding of the symptoms that the patient is experiencing is needed in order to provide proper
2. "Are you compliant with your current medications?" Knowing if the patient is compliant with their current
medications can be useful in order to determine if their current treatment is effective. In addition, this can
also help identify if the patient is experiencing any type of adverse reactions to their current medications.
3. "Have you ever completed a sleep study or seen a sleep specialist?" Asking if the patient has ever
seen a sleep specialist will identify if they have ever been treated for prior. In addition, it will help to know
if they have ever had prior diagnostic testing done and if they have been on previous medications. This
information will help to create a more efficient treatment plan for the patient and possibly avoid
unnecessary diagnostic testing.
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.
I would like to get feedback from family members, specifically, I would like to know if there is a family
present in the home that has noticed a difference in the patient's sleep habits. In addition, it would be
beneficial to know if there is someone there to help with the patient's care or if the patient is currently
receiving aid from home health. If there is someone there that is able to help with the patient they may be
able to help enforce healthy sleeping habits and ensure that the patient is adhering to the medication
regimen prescribed.
In addition to family, I would like to speak with the patient's PCP to get a proper background on the
patient's history. I would be curious to know if the patient has been experiencing insomnia since she
started the sertraline or if it occurred prior to beginning this medication.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient
and how the results would be used.
The patient should have a sleep study (polysomnography) completed to assess for alternative reasons
the patient may be having difficulties with her sleep. This study looks at brain waves, oxygen levels in the
blood, leg movement, heart rate, and breathing.  An EEG will be completed as well to detect brain waves
and possible hyperarousal during sleep time. This study could identify if the patient may be experiencing
difficulties in sleep for other reasons such as sleep apnea or restless leg syndrome which may need
alternative methods of treatment.
List a differential diagnosis for the patient. Identify the one that you think is most likely and
explain why.
Major depressive disorder: Major depressive disorder (MDD) is a very common mood disorder
characterized by low mood, loss of interest, and general feelings of hopelessness. The patient has a
previous diagnosis of MDD, which may now be exacerbated by the recent loss of her husband. In
addition, the patient is currently on the antidepressant Sertraline which has a side effect of insomnia and
REM suppression (Murphy & Peterson, 2015). The sleep disturbances that she is experiencing may be in
conjunction with her increased depression and a side effect of her current medication, for this reason, I
believe that MDD is the most likely diagnosis for this patient.
Insomnia: The patient is reporting poor sleep habits since the death of her husband. Insomnia is
characterized by difficulty falling asleep, difficulty staying asleep, difficulty returning to sleep, or wakening
earlier in the morning than desired. In general, this will cause dissatisfaction with sleep quantity or quality.
The disorder may also cause an impairment in daily functioning, cause fatigue, and create mood
disturbances (Levenson et al., 2015).

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.
Trazodone: This medication can be used in small doses to treat insomnia and in larger doses to treat
depression. This would be my first choice due to the sleep disturbances likely being caused by her
depression since her husband's death. Trazadone simultaneously inhibits SERT receptors, 5-HT2A
receptors, and 5-HT2C receptors (Shin & Saadabadi, 2021). In addition, it is an effective antidepressant
therapy that does not cause insomnia the way that other antidepressants such as SSRI's and SNRI's may
cause. Trazodone would be my preferred method of treatment for this patient due to its dual effects in
treating both insomnia and depression.
Zolpidem: Zolpidem is a benzodiazepine receptor agonist that is inhibitory of GABA activity and therefore
is an effective treatment for insomnia (Levenson et al., 2015). However, in combination with the
antihypertensive medications, this medication may cause low blood pressure and increase risk of falls for
this patient making it more risky to prescribe.
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?
Trazodone's known side effects mainly occur over time and with higher doses of 150–200 mg daily. It can
cause an increased risk of drowsiness and caution should be taken in elderly patients (Sotto et al., 2015).
Dosage may need to be changed if the patient is beginning to experience dizziness in order to decrease
her risk for falls. On a low dose of trazodone, sedative effects occur due to the antagonism of the 5-HT-
2A receptor, H1 receptor, and alpha-1-adrenergic receptors (Shin & Saadabadi, 2021).
Include any “check points” (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.
The patient should have a follow-up appointment in 4 weeks in order to determine if the patient is
responding well to the medication. This can help identify if that patient is having any adverse reactions
and if medication needs to be reevaluated and changed. If the patient is not receiving therapeutic levels
of the medication then the medication may need to be increased in order to reach an effective dosage.
The patient should know to report any side effects of the medication and to disclose if she is experiencing
any onset of suicidal thoughts as this can be a serious side effect of the medication.
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4),
1179–1192. https://doi.org/10.1378/chest.14-1617
Murphy, M. J., & Peterson, M. J. (2015). Sleep Disturbances in Depression. Sleep medicine clinics, 10(1),
17–23. https://doi.org/10.1016/j.jsmc.2014.11.009
Shin, J. J., & Saadabadi, A. (2021, August 6). Trazodone – StatPearls – NCBI Bookshelf. Trazodone.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470560/
Sotto Mayor, J., Pacheco, A. P., Esperança, S., & Oliveira e Silva, A. (2015). Trazodone in the elderly:
risk of extrapyramidal acute events. BMJ case reports, 2015, bcr2015210726. https://doi.org/10.1136/bcr-
WEEK 7 discussion


Three questions to ask the patient and a rationale for asking these questions.
1) Have you ever suffered from depression in the past? I would ask the patient if she had
experienced any depression before her spouse’s death? What, if any non-pharmacologic coping
mechanisms are being utilized

2) How are you coping with each day after the loss of your loved one?
3) Do you take your medications regularly? I would ask the patient about how she takes her
medication and the last time she had her blood sugar checked?
The reasons for asking these questions are as follows. It is important to know what the patient's
mental health was like before the death of her husband, and whether the patient is recurrent
depression. It is equally important to know if the patient has a support system
after the husband. Lonely, the patient can find it harder to function in life. The reason why the
patient is to be checked if she is regularly taking medications as prescribed is the mere reason that
many patients lose interest in things after the loss of the loved one as part of the grieving process.
People in the patient's life for further evaluation of the patient.
I first get this information and see if she has her children and may have a guardian for her.
Based on this information and whom I would like to hear more information and explanations
about her life situation, socioeconomic status.  I want to ask her about her sleeping habits. Does
she sleep during the day? What does she do before bed?
Physical and diagnostic tests
HGBA1C- Because the patient is one metformin for diabetes to see how controlled her diabetes
is. Heart rhythm due to the medical history of hypertension and being on HTN
medications. Diagnostic tests suitable for patients include polysomnography. The
main purpose of this test is to measure the patient's sleep pattern.

Differential diagnoses
1. generalized anxiety disorder,
2. major depressive disorder (MDD)
3. Insomnia
4. Diabetes
5. Hypertension
MDD probably explains why the patient is currently suffering from insomnia. Some of the main
outcomes may be loss of concentration, loss of appetite, and feelings of hopelessness (Keller et
al., 2019). After her husband's death, the patient may have developed depression,
which later affects her sleep patterns. Patients with sleeping problems in their life are more likely to
be diagnosed with a sleep disorder- insomnia in that case (Bollu & Kaur, 2019).

1. Increase Zoloft to 200mg PO daily- I would choose to continue the patient on her present therapy of
Sertraline but increase it to 200mg and augment with another medication. I chose not to add another
SSRI as it may increase or cause side effects of the antidepressant. Benzodiazepines appear to improve
treatment outcomes when anxiety disorder co-occurs with depression or for depression characterized
by anxious features. Specifically, they may provide benefits both in terms of speed of response and
overall response.
2. Alprazolam (Xanax) o.25mg as needed at bedtime for insomnia- I will start the patient on Xanax at a low
dose to help calm the anxiety and promote relaxation during sleep and then schedule a follow-up
appointment in 4 wks to evaluate effects and progress (Dunlop,2008). Alprazolam works quickly and is
best for anxiety and may also help with her insomnia. I will instruct the patient not to drink any alcohol
or grape juice.
Drug therapy contraindications
Sertraline may increase plasma alprazolam concentrations by inhibiting its CYP450 3A4
metabolism (Puttrevu,2020).
The patient will be assessed after a four-week interval to determine if the symptoms have
improved. If the symptoms have not improved after four weeks, Zoloft will be switch to a
different antidepressant, and may increase the dosage of Xanax. If within the first four
weeks the symptoms would have changed positively, then the dosage is maintained till the
patient completes the dosage in which the sleep problem would be effectively managed.
Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri
medicine, 116(1), 68–75.
Dunlop, B.W., Davis, P. (2008). Combination Treatment With Benzodiazepines and SSRIs for
Comorbid Anxiety and Depression: A Review. Primary Care Companion to The Journal of
Clinical Psychiatry. Retrieved from: ncbi.nlm.nih.gov/pmc/article
Keller, A. S., Leikauf, J. E., Holt-Gosselin, B., Staveland, B. R., & Williams, L. M. (2019).
Paying attention to attention in depression. Translational psychiatry, 9(1),
279. https://doi.org/10.1038/s41398-019-0616-1
Puttrevu, S. K., Arora, S., Polak, S., & Patel, N. K. (2020). Physiologically Based
Pharmacokinetic Modeling of Zoloft and Its Metabolites for the Evaluation of Disposition

Week 7 – Threaded Discussion, Treatment for a Patient With Insomnia
Post by Day 3 of Week 7 (Wednesday, 11:59 pm MT) and respond to your colleagues on two
different days by Day 6 of Week 7 (Saturday, 11:59 pm MT).

For this Discussion, review the case Learning 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. Patient normally sees PCP once or twice a year. Patient denies
any suicidal ideations. Patient arrived at the office today by private vehicle.

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

By Day 3 of Week 7

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
 Include any “check points” (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.

Read a selection of your colleagues' responses.

By Day 6 of Week 7

Respond to at least two of your colleagues on two different days in one of the following ways:
 If your colleagues’ posts influenced your understanding of these concepts, be sure to share
how and why. Include additional insights you gained.
 If you think your colleagues might have misunderstood these concepts, offer your
alternative perspective and be sure to provide an explanation for them. Include resources to
support your perspective.

The following are wonderful additional resources:
GlobalRPh – Benzodiazepines and Insomnia
Meds: https://globalrph.com/drugs/benzodiazepines/
GlobalRPh – Antidepressants: https://globalrph.com/drugs/anti-depressants/

Approximate equivalent dosages of antidepressants:
Citalopram 20 mg
Escitalopram 5-10 mg
Fluoxetine 20 mg
Paroxetine 20 mg
Sertraline 50-75 mg
Venlafaxine 75 mg

Week 7 Discussion: Initial Post


Case Analysis: An elderly widow who just lost her spouse

Comorbid conditions were experienced by the elderly female patient in this case.
She was suffering from insomnia as one of the chief complaints though other conditions
like depression and suicide were also noted. The circumstances following her late
husband’s passing contributed significantly to her emotional changes over the past few
years. At the time of diagnosis, she did not mention suicidal ideation though she might
have entertained these ideas in previous cases. There are a few questions I would ask
the patient to gain better insight into their condition.

 How can I help you today?
 For how long have you had trouble sleeping?”,
  Do you use nicotine or alcohol?
 How frequent is your insomnia and when did it start?
 Are there certain moods or thoughts that affect how well you sleep?
 What are your thoughts about mental health medication?
 How regularly do you take prescriptions or other forms of treatment?
 What makes you get depressed or start to feel anxious?
  Do certain trigger events or phrases create feelings that contribute to your
 Are there other symptoms that you want us to talk about?


The purpose of these questions is to identify underlying factors that affect the
patient’s main concern– insomnia. Substantiating their environmental and emotional
situations is a pragmatic way of contextualizing their problems at large. Having these
details may require collaboration between the patient and her family members. Since
her family may be somewhat involved in her day-to-day affairs the insight of children
and others caring for the patient would be essential to fulfill.

Clinician Questions for the Patient with Rationale

1. Finding out if the patient has close relatives or friends is important to the management of her situation.
It also can make a difference when addressing whom she has a support system.
2. Any information on the patient’s sleep or factors that deter them from sleeping must be taken into
consideration. These patterns could be recorded by anyone responsible for her care overnight.
3. What other mental health or behavioral concerns are there for the patient?
These details will help rule out ancillary conditions and identify the mental faculties of
the patient. Knowing how well she can process information is critical to the long-term
success of managing this case.


Since the patient is a senior it makes sense to take an MRI. This can help identify
problems associated with cognition and the decline of psychological functions early
on. Insomnia and depression can actually present as symptoms of many other
physically illnesses, so I feel that it would be important to obtain lab work and ensure
that nothing is out of normal range before making a definite diagnosis. The Geriatric
Depression Scale (GDS) greatly affects seniors and is an integral part of gauging the
patient’s standards of operation. assessments such as Beck Depression Inventory
(BDI), Center for Epidemiologic Studies Depression Scale (CES-D), or Hamilton
Depression Rating Scale (HAM-D).

Differential Diagnosis

 Major Depressive Disorder (MDD) is the primary diagnosis. It makes a big difference in this
patient’s case because it could explain some of her recent beliefs and fears. Since her husband
had passed away a short bought of depression may not have constituted this diagnosis.
However, the prolonged state of stress that has affected her sleep, as well as other areas

 Chronic Insomnia is a diagnosis that would fit the persistence of the patient’s problems
sleeping. More information could clarify whether she struggles with falling or staying asleep.
Psychological therapy is also important for managing insomnia of this variety (Bressert, 2019).

 Sleep Apnea may be an accurate diagnosis for the accompanying problems with sleepiness
and fatigue. Headaches and problems focusing were also mentioned by the patient which could
constitute this diagnosis (Stahl, 2013).


Low-dose antidepressants, including doxepin and trazodone, are helpful in
patients suffering from comorbid depression and have a low potential for abuse
compared with other sleep aid options such as benzodiazepines (Schroeck et al.,
2016). While they are not indicated for primary insomnia, in patients with depression
with insomnia, they can be a valuable adjunct to therapy to offset insomnia created
by depressive symptoms and by insomnia that may develop from medications, such
as sertraline (Schroeck et al., 2016).
Doxepin has been shown to improve sleep maintenance (Schroeck et al.,
2016). To treat sleep difficulties, only low doses are required, thus minimizing the risk
of adverse effects (Schroeck et al., 2016). Doxepin is only available as a brand
name, presenting the issue of possible financial difficulty with some older adults
(Schroeck et al., 2016). Doxepin is a tricyclic antidepressant and as such, carries the
risk for anticholinergic effects, which can be severe in elderly patients (Schroeck et
al., 2016).
Trazodone promotes sleep through the blockage of alpha-adrenergic and
histamine receptors, prolonging slow-wave sleep (Schroeck et al., 2016). Because
Trazodone is metabolized in the liver and is also a substrate of CYP2D6 as well as
CYP3A4, there is also a risk for potential drug interactions, and complications with
co-morbid conditions (Schroeck et al., 2016). Caution is needed regarding rare, but
serious side effects of serotonin syndrome because the patient is already on the
SSRI sertraline (Schroeck et al., 2016). Otherwise, trazodone presents an effective
treatment option due to its efficacy among many sleep parameters and low side-
effect profile compared with other treatment options (Schroeck et al., 2016).

Contraindications and Dosing Alterations Based on Ethnicity
While ethnicity is not specified in the noted scenario, the clinician needs to
inquire about the patient’s ethnic background during their evaluation. Ethnic
differences exist regarding CYP2D6 metabolizers (Myers et al., 2020). For example,
Caucasians have variations across both spectrums with both poor and ultra-rapid
metabolizers of CYP2D6 (Myers et al., 2020). As a result, over 10% of Caucasians
are either insufficiently dosed or inappropriately dosed (Myers et al., 2020). Ethnic
groups from Saudi Arabia and Ethiopia are more susceptible to CYP2D6 duplication,
making them more likely to be ultra-rapid metabolizers, requiring an upward dose
adjustment (Myers et al., 2020).
“Check Points” to Evaluate Treatment Regimen
Trazodone has a relatively short half-life so it can be titrated as early as three
to four days to achieve the desired response (Schroeck, 2016). Significant
improvements are typically seen in two weeks, and again between weeks four
through six (Schroeck et al., 2016). Therefore, the clinician should follow-up with the
patient during these time periods.


Bressert, S. (2019). Depression Symptoms (Major Depressive Disorder). Psych Central.
Retrieved from https://psychcentral.com/depression/depression-symptoms-
Myers, B., Reddy, V., Chan, S., Thibodeaux, Q., Brownstone, N., & Koo, J. (2020).
Optimizing doxepin therapy in dermatology: Introducing blood level monitoring
and genotype testing. Journal of Dermatological Treatment, 20, 1471-1753.

Olsen, C., Pedersen, I., Bergland, A., Enders-Slegers, M. J., & Ihlebæk, C. (2019).
Engagement in elderly persons with dementia attending animal-assisted group
activity. Dementia, 18(1), 245-261.
Schroeck, J. L., Ford, J., Conway, E. L., Kurtzhalts, K. E., Gee, M. E., Vollmer, K. A., &
Mergenhagen, K. A. (2016). Review of safety and efficacy of sleep medicines in
older adults. Clinical Therapeutics, 38(11), 2340–2372. https://doi-
Stahl, S. M. (2013). Stahl's essential psychopharmacology: Neuroscientific basis and
practical applications (4th ed.). New York, NY: Cambridge University Press
Week 7 Discussion
Initial Post

Treatment for a Patient with a Common Condition

One of the most common mental health issues pediatric nurses deal
with is insomnia. Constant nightmares and difficulty getting back to sleep are
the most typical symptoms of insomnia disorder, affecting one in five people
(Patel et,. 2018). Half of the people with insomnia suffer from another mental
health issue, and 90 percent of adults with depression have sleep problems.
As a result of the death of her husband, an elderly widow has been plagued
by despair and insomnia for ten months. Sertraline, a depression medication,
is part of her current regimen. In addition, she says she has been unable to
sleep since the loss of her spouse. This post discusses various facets of the
patient's decision-making process.

Questions to ask the patient

Question 1. Are the medications helping to alleviate the depressive
symptoms? When did you first begin taking your medicine, and was the
dosage altered at any point?

Rationale: To determine if any modifications to the current treatment plan may
be beneficial.
Question 2: Do you take your medication as prescribed? Have you ever
missed a dose?
Rationale: To see if the patient is adhering to her given dosage, this would
help determine the next step in the therapy procedure.
Question 3: Is there anything you like to do right before bed? Do you enjoy
solving crosswords? Read? Do you watch television?
Rationale: As a result of the brain's need for rest, a person gets into hyper-
arousal when they don't get enough of it. In the case of insomnia, hyper-
arousal can be described as the brain's mental and psychological processes,
which can cause both chronic and severe insomnia. Hence, the primary goal
of this inquiry is to find out how to make it more comfortable for the patient to
fall asleep. For instance, brainstorming techniques and ways to lower
excitement may be necessary for the client.
People in the patient's life who you would need to speak to and Specific


Her children
specific questions I will ask them are –
Q. Does she have problems falling asleep?
Q. Is she prone to waking up in the middle of the night??
Q. Is it normal for her to get up so early?
All of these inquiries are aimed at eliciting information about the disease's
severity and the family's genuine worry for her mother. She might be alone
after her husband's death, given that she drove alone to work.
2. Her relatives
Q. How frequently does she communicate with them??

Q. How often do they get together?
Q. Has she felt "down," melancholy, or hopeless much in the last month?.
With all of these inquiries, we can learn more about her social circle and the
people she is close to. A problem shared is a problem half, as we all know.
With the help of others, one's stress levels can be lowered, and one's stress
response system can be less activated.

Physical Exams and Diagnostic Tests

If her PCP doesn't already have a BMP and a CBC, I will get one to
check if any unexpected lapses or baseline values haven't been collected
(Patel et,. 2018).. In addition, I'd look at things like calcium, noradrenaline,
melatonin, ACTH, and cortisol, as well as other neurotransmitters and
hormones associated with insomnia. After doing these tests, the results would
be utilized to determine if the client has any anomalies or inadequacies that
require additional treatment, which could be the root cause of the issue, for
her insomnia. Also, I would utilize the DSM-5 or Hamilton's depression scale
to examine the impact of the treatment on her depressive symptoms
(Zimmermann et al,. 2019).

Differential Diagnosis

Among the possible causes of this patient's insomnia would be
depression in the context of a stressful situation. Due to the situational
sadness brought on by the death of her husband ten months ago, it is likely,
that the patient is still grieving and suffering and, in turn, suffering from

Pharmacologic Agents

Depression patients are usually started on a single dose of sertraline
50mg daily, either in the evening or morning. 75 or 100 mg/day with pauses of
at least one week may be prescribed, but no more than 200 mg/day should

be. I would recommend increasing the patient's daily dose of oral sertraline to
150 mg. As for insomnia, I would also start with 25mg of Trazadone at night
and gradually increase the amount as needed. It has long been known that
Trazadone is effective in treating depressive symptoms (Yiet al,. 2018) Its
antidepressant function has been superseded by its use in treating insomnia
off-label. Without tolerance or excessive daytime sleepiness, Trazadone is
effective even at the lowest daily dose of 25 mg.

Contraindications to Use or Alterations in Dosing

An unfortunate omission was that of the patient's ethnicity. However,
some groups are more susceptible to the cytochromes that activate and
increase antidepressant metabolic activity. There is a risk of rising
antidepressant toxicities in the brain due to these issues in antidepressant

Check Points and Therapeutic Changes

In the current instance, my primary goal would be to get the client back
to her typical routine in four weeks, but I would also check in with her by
phone on a daily basis to see how she is doing. As an added precaution, I'd
advise this patient to keep a sleep diary to track the duration and quality of her
slumber. My office would also be an excellent place to keep track of the
client's symptoms and the possible side effects of the recommended


Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical
Sleep Medicine, 14(6), 1017-1024.
Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., … & Zhou, X. Y.

(2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-
controlled trials. Sleep medicine, 45, 25-32.
Zimmermann, J., Kerber, A., Rek, K., Hopwood, C. J., & Krueger, R. F. (2019). A brief but
comprehensive review of research on the alternative DSM-5 model for personality
disorders. Current Psychiatry Reports, 21(9), 1-19.
Ijeoma's Main Post


Treatment for a Patient with a
Common Condition

Here is a case of a 75-year-old widowed 10 months ago, who developed depression
afterward and got worse. She arrived at the clinic today complaining of insomnia. She was
married to her late husband for 41 years. She is alert and oriented x 3 and denies suicidal
ideation. She sees her PCP every six months with PMH of HTN, MDD, and DM. Her current
medications are
 Metformin 500mg BID
 Januvia 100mg daily
 Losartan 100mg daily
 HCTZ 25mg daily
 Sertraline 100mg daily
Questions to ask the patient in
the clinic and rationales
How many hours do you sleep at night and how many hours of sleep do you get during
the day? This question will help the provider understand her sleeping pattern and how much
sleep she actually gets on a given day.
When did you start noticing you no longer sleep well? This puts a time to when the
problem started and might give a clue to the cause.

Do you sleep early part of the night and then stay awake for the remainder, or do you find
it hard to fall asleep initially, but later sleep late? To determine if she has early or late insomnia.
When did you start taking the medication sertraline? This might reveal if she is
experiencing the initial side effect of sertraline -insomnia.
People in the patient’s life to get feedback to further
assess the patient’s situation. The questions and why.
The people I will ask questions are the patients’ family if any; children, siblings, parents,
in-laws, and friends; friends from the neighbors, and friends from coworkers, of course with the
patients' consent.
The questions:
What is her general mood like? What are her emotional highs and lows like? Does she
like to mingle with people or stay alone? Does she steal the life of the show and constantly be in
the spotlight of an event? Is she irritable, gets agitated, or isolates herself when upset? How does
she handle emotions (positive and negative)? How is she mourning her husband or how did she
mourn? How is her mood now compared to when her husband was alive? Is she overwhelmed?
These questions will help give clues on what is going on in her life psychologically and
screen her for bipolar disorder (Pfizer, 2021).
Physical exams, and diagnostic tests
appropriate for the patient and how the results would be used.
Assess for bruising, motor symptoms like bruxism and akathisia, check weight, blood test
for hyponatremia, prothrombin time and platelet count, rash, diarrhea, hair loss, and tremor
(Pfizer, 2021).
These are assessing for side effects of SSRIs and would be used to determine how she is
reacting to the therapy and a guide to further decision making.
The differential diagnosis
for the patient. The most likely and why.
Major depressive disorder (MDD)
Treatment-Resistant Depression (TRD)
Obesity: Her BMI is 33.2, which means her weight is in the obese category for adults of her
height (CDC 2022).

Type 2 Diabetes Mellitus
Major depressive disorder is her most likely diagnosis, and her antidepressant sertraline
could be the cause of her insomnia. Although it is not certain how long she has been on
sertraline, she stated it is getting worse. It is probably not working for her. But TRD is said to be
an “inadequate response to at least 2 trials of antidepressant pharmacotherapy” (Voineskos, et al.,
2020, p. 221). Whereas Stern et al. (2016) stated it is an “inadequate response to at least one
antidepressant given in sufficient doses and for an appropriate duration” (p. 44).
Two pharmacologic agents and their dosing that would be appropriate for the
patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. A
rationale from a mechanism of action perspective for choosing one agent, and why it is
chosen over the other.
Lorazepam tablet 1mg P. O at bedtime: This is a benzodiazepine. This can be used to
augment the SSRI for short time and also help insomnia. It has a black box warning of profound
sedation, respiratory depression, coma, and death. This will not be the best for this patient,
because it cannot be used for a long term due to the risk of drug dependence, the potential for
abuse, and difficulty to discontinue. Other side effects are psychomotor and memory impairment
(Bausch health, 2021).
Trazodone tablet 300mg P.O at bedtime: Trazodone is an antidepressant, serotonin
receptor antagonist/agonist. It reduces levels of serotonin, noradrenaline, dopamine,
acetylcholine, and histamine which are neurotransmitters related to arousal effects. It has a
sedating effect which can help with her insomnia. It does this by antagonizing 5-HT-2A receptor,
H1 receptor, and alpha-1-adrenergic receptors. Its effect on the latter could cause postural
hypotension (Shin & Saadabadi, 2022; Pragma, 2018).  It has no abuse potential and can also
cause weight loss in this obese client. For the above reasons, trazodone would be best for this
Contraindications to the use or alterations in dosing of trazodone that may need to
be considered based on ethical prescribing or decision-making. Why the
contraindication/alteration exists. That is, what would be problematic with the use of this
drug in individuals based on ethical prescribing guidelines or decision-making

Discontinue sertraline before starting trazodone or decrease dose if used for augmentation
with SSRI sertraline. This is to reduce the risk for serotonin syndrome. Inform client and family
that trazodone has a black box warning for increased risk for suicidal thoughts (Pragma, 2018),
and to watch out for signs and report immediately
Inform the client of other available options and to monitor blood pressure and blood
sugar closely until it is determined how trazodone affects her. Inform patient of the need to
monitor for orthostatic hypotension and syncope, change position slowly, from lying to sitting to
standing. Using sedatives in the elderly should be done with caution and only when necessary.
Ensure benefits outweigh the risks of using trazodone.
The “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), any therapeutic
changes that should be made based on possible outcomes that may happen given this
treatment option.
Since trazodone can cause hyponatremia, monitor blood levels of sodium. Monitor
prothrombin time or platelet counts to rule out an increased risk for bleeding or bruising. Assess
for mania or hypomania. Monitor for suicidal behaviors or thoughts at every four weeks intervals
of visit – 4, 8, 12, and more. This will guide the titration or determine the need to switch.


Since it is noted that some cases of insomnia are related to mental illness, it is the duty of
the PMHNP to determine if this relationship exists and manage that accordingly. In this client's
case, it would be wise to access the possible cause which could be the depression or the SSRI she
is taking. With proper history taking and medication adjustment, she would be followed up in
four weeks to determine her response to the medication adjustment.

Bausch Health. (2021). Ativan
(Lorazepam) https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/017794s048l

CDC 2022 Adult BMI
Calculator. https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_ca
Pfizer (2021). Zoloft (Sertraline
hydrochloride). https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/019839s10
Pragma (2018). Desyrel (trazodone
hydrochloride). https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/018207s03
Shin, J., J, & Saadabadi, A. (2022). Trazodone. StatPearls
[Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470560/
Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts general
hospital psychopharmacology and neurotherapeutics. Elsevier.
Voineskos, D., Daskalakis, Z. J., & Blumberger, D. M. (2020). Management of Treatment-
Resistant Depression: Challenges and Strategies. Neuropsychiatric disease and
treatment, 16, 221–234. https://doi.org/10.2147/NDT.S198774

week 7 discussion


Depression can have a negative impact on an individual’s sleep pattern. According to
McCance & Heuter (2019), some of the characteristics of depression, include, but not limited to
sleep disturbances. It is the purpose of this discussion to provide some questions for the patient
with rationale, identify persons in the patient’s life that can provide feedback via questions,
explain the need for any physical or diagnostic tests, explaining how these may be useful, list
pharmacological agents that will be useful for the patient, identifying any contraindication for
use, and provide “check points’ that will indicate any therapeutic changes needed based on
possible outcomes.
According to Ball et al (2019), healthcare provider needs to recognize the background of the
patient and adopt to these needs. “How many hours of sleep to you get?”  “Do you take naps
during the days?’  Do you drink coffee or drink/beverages containing caffeine during the day or
before bedtime?”  These are questions that will help to determine the severity of the patient’s
insomnia and assess the need for need for any drug therapy.
Family involvement can positively impact the patient’s plan of care.  Asking family members
questions such as, “Is there any known family history of depression?’ “Is there any family
support?” can help to determine the treatment plan. For example, psychopharmacological

approach vs psychotherapy. According to Ball et al. (2019), depression is associated with both
genetic predisposition and family environmental influences.
Different diagnostic tests will be needed. This will include BMP and the use of the geriatric
depression scale.  This scale will help to track depression. De lima et al. (2017). According to
Funk et al (2018), it is important to monitor patients’ electrolytes that are at risk for imbalance
from taking medication such as thiazide diuretics.  The patient’s current medication list includes
HCTZ 25mg/day. Insomnia secondary to depression is a differential diagnosis. Insomnia is more
likely. The patient verbalizes changes in her sleep habits. According to Levenson et al. (2015),
insomnia disorder relies on self-report for diagnosis.
According to Freudenrich (2016), selection of antipsychotics agent is usually guided by the
side effects. Mirtazapine 15mg and trazadone 150mg are two pharmacologic agents that will be
used. Both drugs recommended dosage are approved by the FDA to treat depression. Trazadone
will be a better choice than mirtazapine. Weight gain is a known side effect of Mirtazapine.  The
patient is obese as seen with her height and weight (calculated BMI = 33.30). Trazadone on the
other hand, it is commonly used in the treatment of insomnia secondary to antidepressant use
with the absence of weight gain side effect. Fava & Papakostas (2016).   One of trazadone’s
contraindication to use, is its avoidance in the use of patients with known cardiac disease. This
contraindication exists because it has the inability to inhibit potassium channels. Fava &
Papakostas (2016). One of the requirements for the successful use of antidepressants is its use for
6 to 12 weeks to determine its effective use. Fava & Papakostas (2016).  A 4 week follow up will
be done to assess the effectiveness of treatment the dose will be decreased to 100mg/day for
possible sedation.
There are different pharmacological agents that can treat both depression and anxiety.
However, prior to treatment, risk factors such as the patient’s medical history, current
medication, family, and environmental factors, as well as certain diagnostic tests are important
information needed to guide the patient’s treatment plan.

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to
physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier
de Lima Silva, V., de Medeiros, C. A. C. X., Guerra, G. C. B., Ferreira, P. H. A., de Araújo
Júnior, R. F., de Araújo Barbosa, S. J., & de Araújo, A. A. (2017). Quality of life, integrative
community therapy, family support, and satisfaction with health services among elderly adults
with and without symptoms of depression. Psychiatric Quarterly, 88(2), 359–369.
Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, &
J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and
neurotherapeutics (pp. 27–43). Elsevier.
Funk, M.C., Beach, S., R., Bostwick. J.R., Celano, C.M., Hasnain, M, Pandurangi, A, Khandaj,A,

Taylor, A., Leverson, J.l., Riba, M., &  Kowacs, R.J. (2018). Resource document on QTc
prolongation and psychotrophic medications. American Psychiatric Association.

Archive/resource_ documents/Rresource-Document-2018-QTc-Prolongation -and-
Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M.
Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital
psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.
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/
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease
in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevie

Re: Discussion Main Post- Week 7 (Tameka Rodriguez)

NURS-6630N-37- Main Discussion Post -Week 7
Tameka Rodriguez

Insomnia is a problem of falling or staying asleep linked with severe
distress or impairment in daily function and occurs despite enough sleep
opportunities. Sleeplessness is linked to severe depression, anxiety disorders,
substance abuse problems, suicidality, high blood pressure, and diabetes
(Krystal et al., 2019). Symptoms must be present for at least three days per
week for at least three months to meet the criteria for chronic insomnia
according to the third edition of the International Classification of Sleep
Disorders or persistent insomnia according to the DSM5. According to Krystal
et al. (2019), short-term insomnia or episodic insomnia criteria are the same
as chronic insomnia, lasting for less than three months.

Questions to the Patient
 When did your insomnia start, and how often do you have difficulties sleeping? The advanced nurse is
doing this to get to the bottom of the problem and figure out why the patient isn't sleeping properly.
 Do you have someone in your family that has trouble sleeping? This is to show if the issue is related to a
genetic problem.
 What are your bedtime habits, and is any chronic pain preventing you from sleeping? One will see if
there is an issue preventing the patient from not sleeping. Discomfort and pain might contribute to
insufficient sleep (Newsom & DeBanto, 2020). Because pain and sleeplessness can become a vicious
cycle, with less sleep leading to increased pain, it is critical to ask the patient if their discomfort
interferes with their sleep.
Identification of Person in the Patient’s Life
With the facts in the case study, it is unclear whether the patient lives
alone or with a family member, such as children or grandkids. One will also
want to know if the patient is a nursing home resident. Given her husband's
death, knowing who is looking after this patient is essential. In addition, one
would like to communicate with the patient's caregiver or a family member
about any recent changes in her behavior, when they began, and whether she
has a family history of insomnia.
Explanation of Physical Exams and Diagnostic
An advanced nurse should do a thorough health history, physical
examination, and mental health examination to evaluate the patient's baseline
health. To diagnose and treat depression successfully, one would apply the
Hamilton Depression Scale (HAMD) and Diagnostic Criteria for post-traumatic
stress disorder (PTSD) scale to the patient. Also, a hemoglobin A1c test
would be performed to determine her glycemic control. In addition, one would
look into the patient's other medication that may cause side effects that can
contribute to the patient's insomnia and uncontrolled diabetes. A complete

blood count can also be ordered to look for abnormal lab results and baseline
values. Based on the patient BMI of 33.3 kg/m2 is considered obese; with this,
the patient diabetes may be uncontrolled. Also, the patient states that her
depression has gotten worse, so the Hamilton or (DSM-5) depression scale
may be abnormal.
Differential Diagnosis for the Patient
The most prevalent traumatic experience among individuals is the
unexpected death of a loved one. It is also one of the horrific events linked to
the most incidences of PTSD. As a result, PTSD with insomnia and
depression will be the differential diagnosis. According to the criteria for
diagnosing PTSD, an adult must exhibit all of the following symptoms for at
least one month: one re-experiencing symptom, one avoidance symptom, and
at least two arousal and reactivity symptoms. Based on the case study, the
patient lost her husband about ten months ago, and one would assume that
the patient may have been experiencing a sense of loss from that time.
However, the primary diagnosis for this patient would be Major Depression
Disorder. According to Fang et al. (2019), depressive disorders are one of the
most commonly diagnosed mental diseases, with a lifetime frequency of
around 16% and a link to sleep disruption.
Pharmacologic Agents and Dosing
Clinical practice guidelines (CPGs) for depression treatment based on
scientific data are critical for improving patient care. SSRIs were deemed a
first-line antidepressant treatment by all CPGs (Gabriel et al., 2020). As a
result, when selecting an antidepressant, the primary care physician should
consider the medication's side-effect profile, cost, and the patient's age. Also,
one should consider comorbid medical conditions, preference, history or

antidepressant response or non-response, current medications, and potential
drug-drug interactions (Ng et al., 2017).
Based on the case study, the patient is on sertraline 100mg orally daily
and states that her depression has gotten worse; as an advanced nurse, one
would continue with sertraline and increase the dose to 150mg orally daily.
Also, by increasing the amount, one would ensure the monitor for side effects
and follow up within the next four weeks to see if there are any changes in the
patient mood. Sertraline has a low inhibitory effect on CYP; hence it can be
used in patients taking numerous medications. Antidepressants should be
provided at significantly lower doses to older adults. The initial amount of
sertraline is 50 mg/day; typically, one should wait a few weeks to analyze drug
effects before raising the dose. However, 50 mg/day can be increased once a
week; maximum dose of 200 mg/day; single dose. Also, sertraline increases
serotonin while blocking the dopamine reuptake pump, possibly increasing
dopamine neurotransmission and its therapeutic effects (Stahl & Grady,
2021). Furthermore, if there are no changes in the patient mood, one would
consider tapering sertraline slowing and administering Trazodone 50mg orally
daily. In older patients, based on FDA guidelines, Trazodone can be given at
relatively low doses of 25-50 mg per day, with a maximum daily amount of
300 mg per day (Cuomo et al., 2021).
Furthermore, Trazadone is another drug that has been discovered to
treat insomnia, which is the best augmenting drug with sertraline. Trazodone
is an antidepressant that blocks serotonin 2A receptors and the serotonin
reuptake pump. The first dose is 150 mg/day in divided doses, which can be
increased by 50 mg/day every 3–4 days as needed, up to a maximum of 600
mg/day. Trazodone is metabolized by CYP450 3A4 and has a biphasic half-
life, with the first phase lasting 3–6 hours and the second lasting 5–9 hours

(Stahl & Grady, 2021). In addition, with the provided information, one would
choose sertraline 150 mg orally daily. Trazodone has excellent outcomes in
older individuals while maintaining high safety and tolerability criteria. It can
aid in treating insomnia and anxiety without the use of benzodiazepines. Also,
with an incidence of slightly more than 5%, somnolence or sedation,
dizziness, constipation, and impaired vision are common adverse effects.
Trazodone also has a favorable tolerability profile, with modest risks of weight
gain, sexual dysfunction, and anticholinergic side effects (Cuomo et al., 2021).
The patient in the case study has a BMI of 33.3 kg/m2, which is considered
obese; however, because Trazadone has a low risk of weight gain, the patient
will be at low risk of weight gain.
Identification of Contraindications or Alterations in Dosing
When prescribing for the elderly, extra consideration should be
exercised. Allowing the elderly and their families to participate in their
treatment and social support and cost-benefit analysis are examples.
Furthermore, many older folks, particularly women, encounter polypharmacy
due to people living longer with several medical issues. Polypharmacy is
especially relevant for older women since, due to sex- and gender-related
concerns, women are more at risk for drug-related adverse effects. Reducing
drug doses, terminating unsuitable drug therapy, and replacing them with
safer alternatives can enhance the quality of life for many older individuals if
done carefully and methodically (Rochon et al., 2021). According to Singh and
Saadabadi (2022), if the patient is on a monoamine oxidase inhibitor (MOI),
sertraline therapy should not begin until two weeks after the MOI has been
stopped to avoid serotonin syndrome toxicity.
Follow-up and any Therapeutic Changes

Once an antidepressant has been chosen, it should be begun at a
subtherapeutic dose to test tolerability before progressively increasing the
dose until a minimally effective dose is reached. The patient should be
evaluated two to four weeks after starting antidepressant medication or if self-
harm is a concern (Ng et al., 2017). During follow-up visits, the patient should
be asked about drug tolerability and adverse effects, and if necessary, the
dose should be adjusted. Furthermore, it is critical to keep an eye on patients
for indicators of worsening symptoms, such as unexpected changes in
behavior, anxiety, suicidality, or any other clinical signs. Also, one should
regularly examine for depression and suicidality, significantly if the dose of
sertraline is changed. Due to the danger of the syndrome of inappropriate
antidiuretic hormone or hyponatremia in senior patients, one should pay close
attention to the patient's mental status and check their sodium levels
frequently (Singh & Saadabadi, 2022). It is equally critical to educate all
patients prescribed sertraline on the potential side effects and how to avoid
and recognize sertraline toxicity. Patient education about drug use and
compliance will help patients achieve better results and ensure their safety.


Cuomo, A., Bianchetti, A., Cagnin, A., De Berardis, D., Di Fazio, I., Antonelli
Incalzi, R., Marra, C., Neviani, F., & Nicoletti, F. (2021). Trazodone: A
multifunctional antidepressant. Evaluation of its properties and real-

world use. Journal of Gerontology and Geriatrics, 69(2), 120–129.

Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep
disturbance: A review on a bidirectional relationship, mechanisms and
treatment. Journal of Cellular and Molecular Medicine, 23(4),
2324–2332. https://doi.org/10.1111/jcmm.14170

Gabriel, F. C., de Melo, D. O., Fráguas, R., Leite-Santos, N. C., Mantovani da
Silva, R. A., & Ribeiro, E. (2020). Pharmacological treatment of
depression: A systematic review comparing clinical practice guideline
recommendations. PLOS ONE, 15(4), e0231700.

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and
management of insomnia: An update. World Psychiatry, 18(3),
337–352. https://doi.org/10.1002/wps.20674

Newsom, R., & DeBanto, J. (2020). Aging and sleep: How does growing old
affect sleep? Sleep Foundation. Retrieved April 11, 2022, from

Ng, C., How, C., & Ng, Y. (2017). Managing depression in primary
care. Singapore Medical Journal, 58(8), 459–466.
Rochon, P. A., Petrovic, M., Cherubini, A., Onder, G., O’Mahony, D.,
Sternberg, S. A., Stall, N. M., & Gurwitz, J. H. (2021). Polypharmacy,
inappropriate prescribing, and deprescribing in older people: Through a
sex and gender lens. The Lancet Healthy Longevity, 2(5), e290–e300.

Singh, H. K., & Saadabadi, A. (2022). Sertraline. In StatPearls. StatPearls
Publishing. http://www.ncbi.nlm.nih.gov/books/NBK547689/

Stahl, S. M., & Grady, M. M. (2021). Stahl’s essential psychopharmacology:
Prescriber’s guide (7 th  ed., pp. 2066-2073). Cambridge University Press.

Elizabeth Y- Discussion week 7- initial post

Insomnia can be described simply as a person not being able to sleep well.  This may
include a person having difficulties falling asleep and/or maintaining sleep (Rosenthal &
Burchum, 2021). Insomnia can coexist in people who have psychiatric disorders including major
depression, generalized anxiety disorder, and posttraumatic stress disorders. Additionally,
patients who are experiencing grief over a loved one can have impairments in sleep and this can
be contributed to nighttime rumination over the loss or having dreams about the deceased loved
one (Szuhany et al., 2020).  This case study will discuss approaches to assess, diagnose, and treat
an elderly lady who recently lost her husband and is seeking treatment for insomnia.

Assessment Questions

Grief is a major stressful life event that can cause physical and mental problems for a
person (Lancel et al., 2020). Both complicated and normal grief has been associated with causing
a shorter sleep duration and a poorer quality of sleep for individuals who are experiencing a
death (Szuhany et al., 2020). When assessing the patient with regards to her insomnia, the

provider would want to focus on how long this has been occurring and inquire about her sleep
pattern.  One question the provider may ask the patient is “How long have you been having this
problem with not sleeping and did you ever experience this problem before your husband passed
away?” Additional questions could be asked about her sleep pattern and in particular about the
number of hours she is sleeping and if she is having difficulty falling asleep or staying asleep.
Another important factor to find out is if the patient has tried any medications or over-the-
counter remedies to help her with her sleep. One could ask “Have you tried to take anything to
help you with your insomnia?”  It would be necessary to obtain information about her current
medications and if she noticed her insomnia correlating with starting Zoloft. “Did your problems
with sleep start after you started taking Zoloft?”  One notable side effect of Zoloft in some
people can be insomnia as a result of increasing serotonin concentrations at the serotonin
receptors creating undesirable effects of serotonin in sleep (Stahl, 2013).

Support System

The provider should question the patient about her support system and if she has children
or other family members that have been supporting her with her grief.  The provider would need
to speak with whomever the patient identifies as her support person whether it be a family
member or a close friend to obtain collateral about the patient’s current situation. The provider
would specifically want to know how the patient is functioning and if she can care for herself.
Specifically, the provider would want to know from her identified support person “how often do
you see and speaks with the patient?”  The provider may want to ask “how has the patient been
functioning at home?” “Is she taking care of herself?” “Do you have any concerns about the
patient?” “Has she talked about wanting to die?” “Have you noticed any bizarre behaviors or her
making any bizarre statements?” “Have you noticed any memory impairments?” Friends or
family members of the patient can assist in the provider obtaining an accurate history because the
patient may fail to report important information especially if she is having memory
impairments (Gatchel et al., 2016). By obtaining feedback from people in the patient’s life, the
provider will be able to further assess the patient’s situation to determine an appropriate plan of


The provider may want to perform certain tests on the patient to assist with properly
diagnosing and before prescribing medication. Cognitive testing such as the formal mental status
exam, Folstein Mini-Mental State Examination, would be appropriate to perform on the patient
because of her age and to rule out any underlying cognitive impairment such as dementia
(Gatchel et al., 2016).  Depression and insomnia are often co-occurring conditions in a patient
with dementia.  Because the patient is taking Zoloft, the prescriber would need to monitor the
patient for SIADH which is a risk for elderly patients taking an SSRI (Stahl. 2013). A CMP
would be necessary to check for hyponatremia which is a symptom of SIADH (Smedegaard et
al., 2019). The CMP would give indications of any hepatic or renal issues which would help
determine if the patient can tolerate medications that are metabolized by the liver and kidneys. A
hemoglobin A1c would be another test to confirm the patient’s compliance level with her
diabetes management and her medications.


The diagnosis of complicated grief would be appropriate for this patient because she is
having persistent and impaired grief with the inability to adapt to the loss of her spouse that has
been going on for more than 6 months (Szuhany et al., 2020). Studies have shown that there is a
high prevalence of sleep disorders with complicated grief (Lancel et al., 2020).  Major depressive
disorder would be a differential diagnosis and the patient meets the criteria to have this diagnosis
according to the DSM-5. It does state to carefully consider that the response to a significant loss
may be appropriate but inevitably the decision requires clinical judgment based on the patient’s
history and cultural norms (American Psychiatric Association, 2013).
Pharmacologic Agents

At this time, the provider may want to continue to prescribe the Zoloft but make some
adjustments to the dose and start her with Zoloft 75mg. The Zoloft could be attributed to her
insomnia and decreasing the dose by 25mg may help to eliminate her sleep disruptions.  Also,
the prescriber needs to dose the Zoloft in the morning which can also help to reduce insomnia
(Stahl, 2013).
Trazodone and Remeron are two medications recommended to augment with Zoloft and
both of these medications can help to decrease her depression and insomnia.  Remeron is an

antidepressant that is a dual serotonin and norepinephrine agent (Stahl, 2013). If starting
Remeron to augment with Zoloft for helping with insomnia, the initial dose of 7.5mg at bedtime
would be appropriate because this dose has shown to have a more sedating effect. Ethical
consideration needs to be taken with this medication because this medication can also be
associated with weight gain. Given the patient is already overweight and diagnosed with
diabetes, monitoring of her weight and BMI need to take place. Consideration of switching the
patient off this medication needs to be taken if she gains more than 5% of her starting weight
(Stahl, 2013).
Because of the possibility of significant weight gain with Remeron, Trazodone would be
the first choice as an augmenting agent with Zoloft.  Plus, Trazodone is a serotonin 2
antagonist/reuptake inhibitor and is effective for improving insomnia and for boosting the actions
of antidepressants when used in combination.  In elderly patients, it is recommended to dose low
because of the potential for an increase in sensitivity to adverse effects. The recommended
starting dose for insomnia is 25mg to 50mg therefore, for this patient, Trazodone would be
started at 25mg at bedtime (Stahl, 2013). For both Trazodone and Remeron, ethical consideration
needs to be taken with regards to antidepressants having the potential to trigger suicidal thoughts
and close monitoring for symptoms needs to take place.
Check Points

After initiating the changes with the patient’s Zoloft dose and starting her on Trazodone,
the provider will need to follow up with the patient in four weeks to observe how the
medications are working or sooner if there are any adverse effects.  If the patient has a decrease
in her insomnia and is still having somewhat of a response to the Zoloft with her depression
symptoms, the provider can consider increasing her Zoloft back to 100mg.  If the patient has a
minimal response to the Trazodone at the low dose, the option is to increase it to 50mg with the
potential to continue to increase it by 50mg every 3-4 days (Stahl, 2013). The next step would be
to see the patient back in another 4 weeks and if the medications continue to have little effects on
sleep and depression, the option would be to switch the medications.  If the patient initially
responds to the medications, the provider would continue the current dosages and follow up with
the patient in another 4 weeks to monitor for any adverse effects and continued efficacy which

can take up to 12 weeks to reach full potential with antidepressants (Rosenthal & Burchum,


When treating patients, the provider needs to consider all patient factors and risks that
may influence treatment options.  Physical exams and diagnostic tests can assist providers to
determine the proper course of treatment based on the results. When prescribing medications, the
provider needs to carefully consider the best option for the patient and monitor the patient
closely for efficacy and any potential adverse effects.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5 th  ed.).
Lancel, M., Stroebe, M., & Eisma, M. C. (2020). Sleep disturbances in bereavement: A
systematic review. Sleep Medicine Reviews, 53.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced
practice nurses and physician assistants (2 nd  ed.) St. Louis, MO: Elsevier.
Gatchel, J., Wright, C., Falk, W. & Trinh, N. (2016). Dementia. In T. A. Stern, M. Favo, T. E.
Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital
psychopharmacology and neurotherapeutics (pp. 149–162). Elsevier.
Smedegaard, S. B., Jørgensen, J. O., & Rittig, N. (2019). Syndrome of Inappropriate Antidiuretic
Hormone Secretion (SIADH) and Subsequent Central Diabetes Insipidus: A Rare
Presentation of Pituitary Apoplexy. Case Reports in Endocrinology, 1–4.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and
practical application (4 th  ed.) Cambridge University Press.

Szuhany, K. L., Young, A., Mauro, C., Garcia de la Garza, A., Spandorfer, J., Lubin, R.,
Skritskaya, N. A., Hoeppner, S. S., Li, M., Pace, S. E., Zisook, S., Reynolds, C. F., Shear,
M. K., Simon, N. M., & Pace-Schott, E. (2020). Impact of sleep on complicated grief
severity and outcomes. Depression & Anxiety (1091-4269), 37(1), 73–80.

Important information for writing discussion questions and participation

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

  • Your response needs to be a minimum of 150 words (not including your list of references)
  • There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
  • Include in-text citations in your response
  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
  • Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

  • A minimum of 6 responses per week, on at least 3 days of the week.
  • Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
  • Each response needs to be at least 75 words in length (does not include your list of references)
  • Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
  • Follow APA 7th edition
  • Points will be deducted if the above is not followed

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to.

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

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