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LEARNING OBJECTIVES

After completing this case study, the reader should be able to:

  • Identify the psychosocial, disease-related, and drug-induced causes of insomnia.

  • Explain the impact of poor medication adherence on chronic illnesses.

  • Design a therapeutic plan for the treatment of insomnia.

  • Educate a patient regarding nonpharmacologic treatments for insomnia.

PATIENT PRESENTATION

Chief Complaint

“I can’t sleep.”

HPI

Judy Miller is a 55-year-old woman who is referred by her family medicine physician to a pharmacotherapy clinic for medication therapy management for insomnia. She receives help paying for her medications from medication assistance programs. She has been experiencing long-standing insomnia for approximately 9 months. Specifically, she is having difficulty falling and staying asleep at least four to five times during the week, and then sleeps all day on Sunday. Ms Miller is currently taking temazepam 30 mg daily at bedtime that was recently increased from 15 mg. She said that she started taking valerian root 600 mg 6 weeks ago based on a friend’s recommendation but does not feel any benefit. Additionally, she has been experiencing vivid dreams that she attributes to the valerian root. When she had health insurance, she started cognitive behavioral therapy for insomnia (CBT-I); however, when she lost her insurance, she was only able to complete six out of eight sessions, with last session over 4 weeks ago. She endorsed moderate benefit from CBT-I but still complained of residual symptoms. She is also experiencing depression due to not having any employment and a stress of a partner who recently moved in with her because he could not pay his apartment rent. Her most recent Patient Heath Questionnaire-9 (PHQ-9) result was 20. She admits to being intermittently nonadherent and missing doses of scheduled inhaled medications for COPD and sertraline, olanzapine/fluoxetine, and valerian root one to two times per week. She reports that she is no longer able to see her psychiatrist due to cost of the visits.

PMH

Insomnia for many years

COPD

Depression

Migraine headaches

GERD

Allergic rhinitis

FH

Mother is alive and well and lives nearby. Father died of MI at age 65.

SH

She is in a new relationship with her partner who recently moved in due to his own financial difficulties. Unemployed, leading to stress at home to pay bills but receives some money from her mother. She smokes approximately five cigarettes per day now but has smoked up to two ppd in the past. She does not drink alcohol. She sees a deacon at her church for counseling ...

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