Introduction to the Case

The case scenario provided is of a 31year old male whose chief complaint is insomnia that has been worse in the past 6 months. Previously, he reports enjoying restful sleep although for the past 6months he has experienced both difficulties in falling and staying asleep. He even associates the onset of these sleep problems with the loss of his fiancé consequently leading to the loss. During the interview with the clinic, he explains that the problem is a bother because it has interfered with his job where because he experiences sleepiness during the day thus affecting his concentration and productivity at the workplace. He reports recent dependence on alcohol to help him fall asleep. The mental status examination performed on him revealed no abnormality in the orientation appearance, insight, and judgment.

A comprehensive assessment of this case study shows that the patient’s insomnia might be related to his psychological dysfunction resulting from the loss of his fiancé 6months ago. The sudden loss of a dear one triggers a myriad of psychiatric conditions even if the individual has no prior history of psychiatric conditions (Seiler et al., 2020). One of these psychiatric conditions is depression which is especially triggered by

complicated grief. The affected individual would therefore present with low mood, intense sadness, low energy, and loss of interest in activities of pleasure. They may also report sleep disturbances with insomnia being more common than hypersomnolence (Hasin et al., 2018). Managing the depression through medications or psychotherapy would help to relieve the patient’s symptoms such as insomnia that is suspected to arise from depression. The objective of this paper is to discuss how the patient in the case study was managed by describing the therapeutic options at Decision points 1, point 2, and point 3.

Decision Point One

                For the initial management of the patient, I would prescribe 50mg of trazodone to be taken orally at bedtime daily. Trazodone is a drug that acts in the brain by reducing the reuptake of different neurochemicals in the brain such as serotonin but antagonizing the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019). By so doing, the serotonin levels in the brain are increased as well as the intensity of their action. Given depression results from an imbalance of brain neurochemicals such as serotonin and norepinephrine, increased serotonin levels resulting from trazodone use can lead to improved serotonergic actions thus treating depression and its symptoms (Hasin et al., 2018). When trazodone is therefore prescribed, the symptoms of depression including insomnia, appetite changes, and mood changes are corrected (Wang et al., 2020). It would therefore be the first-line medication for this patient.

At decision point one, the foregone options are the 10mg zolpidem taken daily at bedtime or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in the management of insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile which includes drowsiness, complex sleep-related behavior and volition usually limit its use as a first-line medication for insomnia (Edinoff et al., 2021). Hydroxyzine has also been foregone because of its anticholinergic effects such as xerophthalmia and xerostomia (Hasin et al., 2018). Further, neither of these drugs is effective for the management of depression that has been linked with the patient’s insomnia.

The ethical principles require that the health care providers do not harm the patient. At point one, increasing the pill burden by prescribing the antidepressants separately from the drugs addressing insomnia would pose the risk of adverse drug reactions as well as increase the incidence of poor drug compliance (Bipeta, 2019). The ethical principle of non-maleficence would therefore require for prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication to the other provided options.


Decision Point Two

                After 2 weeks of therapy with 50mg of trazodone at bedtime daily, the patient reports experiencing a prolonged erection in the morning that lasts 15 minutes but is undesired and affects his morning preparation for work although his sleeping has improved. At this point, the choice is to be made on how to address the prolonged erection. My decision at this step would be to explain to the patient that this prolonged erection is not priapism and would resolve over time. Thereafter, the current drug dose could be continued for patient care.

One of the undesired side effects of trazodone use is the prolonged erection caused. Through its α-adrenergic antagonism, the drug can lead to dilatation of vessels in the penis thus resulting in prolonged erection (Cuomo et al., 2019). The patient in the case study reports such prolonged undesired erection that lasts for approximately 15 minutes and thus cannot be considered priapism which usually lasts for up to 4hours (Hasin et al., 2018). However, the patient requires reassurance about the side effect profile of the drug, especially with the emphasis that the symptoms would dissipate with time (Cuomo et al., 2019). This would enhance adherence to therapy despite the drug’s side effects.

The other options at decision point 2 were either to discontinue trazodone and initiate 10mg suvorexant daily therapy or to decrease the dose of trazodone to 25mg daily at bedtime. The negative side effect of suvorexant includes daytime drowsiness thus its contraindication for this patient who operates a forklift. On the other hand, decreasing the dose of trazodone to 25mg daily may not be adequate to correct insomnia (Seiler et al., 2020). Patient education on the drug’s side effects, as well as reassurance, would therefore be opted for at this step.

At this decision point 2 where the patient reports the drug’s side effects, it would be ethical to truthfully educate him on the drug’s side effects to anticipate. Medications may be discontinued if necessary to prevent more harm to the patient (Bipeta, 2019). These honor ethical principles of beneficence and non-maleficence.

Decision Point Three

                2 weeks after reassuring and educating the patient on the side effects of trazodone, he now reports that the priapism has resolved although he now experiences increased drowsiness during the next day. His insomnia has also resolved at 50mg of trazodone. At this step, I would continue the patient therapy at 50mg although the dose is split in half, and the patient is reassessed after a month.

As had been alluded to, trazodone is associated with increased drowsiness that may limit its use although the occurrence of such side effects is either rare or mild. However, when such drowsiness occurs, a reduction of the drug dose by 50% may be necessary as this may result in a reduction in drowsiness (Cuomo et al., 2019). The patient should however be adequately educated on how to split the drug dose so that the required drug dose is maintained. Further, patient follow-up within 4weeks would also be indicated to help in reassessing the effectiveness of the drug as well as the persistence of the drowsiness at 50% of the dose (Wang et al., 2020).

The other options provided at decision point 3 included either discontinuing trazodone and initiating sonata at 10mg nightly or replacing trazodone with 50mg of hydroxyzine at bedtime. Both of these options are not appropriate as they involved replacing trazodone that the patient has shown partial response to. Further, both sonata and hydroxyzine have worse side effect profile that limits their administration in this patient (Hasin et al., 2018).

At this decision point, the ethical principle of patient autonomy may affect further care. For instance, the patient may prefer either sonata or hydroxyzine to the in-use trazodone thus they can be prescribed despite their side effect profile (Bipeta, 2019). Such prescription seeks to promote the role of patients in their treatment.


                Individuals presenting with any signs and symptoms at the clinic should be suspected and examined for any underlying conditions responsible for such presentation. For instance, a patient with insomnia may have underlying anxiety or depression. In managing these patients, the drugs prescribed should aim at correcting the underlying psychological disorder instead of addressing the signs and symptoms such as insomnia. specifically for this patient whose insomnia was thought to result from depression due to complicated grief, trazodone which is an antidepressant was prescribed at decision point one because of its effectiveness in managing insomnia (Cuomo et al., 2019). When he returns to the clinic with complaints of prolonged erection, the patient would be reassured with the emphasis that the symptoms would disappear with time. The patient would also be adequately educated on the adverse effects of the drugs to encourage drug compliance as they would be anticipating these side effects (Hasin et al., 2018). Thereafter, when he comes complaining of drowsiness, the drug dose would be reduced by 50% to resolve the symptoms. At either of the steps, the drugs’ side effects profile, as well as effectiveness, are compared before an effective drug with the least side effects is prescribed.




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