Insomnia Insomnia

Insomnia in Psychiatric Disorders 131
depression showed greater improvement in their psychiatric symptoms when taking
Clonazepam concomitantly (12). In a double-blind study by Rosenberg et al.,
Zolpidem was found to improve the quantity and quality of sleep without worsening
depression when co-administered with antidepressants (12). Patient’s individual
susceptibility to certain side effects, personal and family history of previous response
to specific antidepressants, history of alcohol or drug abuse, patient’s age, and possible
other concomitant underlying medical problems should all be factored in when
an antidepressant and/or benzodiazepine are to be selected.
Case 1
A 45-year-old married male was referred to the sleep center by his primary
care physician.
The patient presented with symptoms of frequent awakening and poor night’s
sleep.
He went to bed at 10:30 PM and was able to fall asleep within 15 to 20
minutes. Two to three hours later, he would wake up for a brief period of time
and would fall asleep again for several minutes. He would repeat the pattern
a few times before waking up between 3:30 and 4:00 AM, at which time he
would be unable to fall asleep for the rest of the night. He would stay in bed
tossing and turning and then get out of bed at 6 AM. He reported that his
symptoms started 3 months previously. He complained of feeling tired, yet
denied any symptoms of excessive daytime sleepiness.
He reported that his job as a banker started to become more stressful 6
months previously.
He did not drink alcohol and smoked 15 cigarettes a day. He has been a
smoker since age 18. He reported that he would smoke one or two cigarettes
at night when he could not sleep. He was unaware of any positive family
history of sleep disorders. He had a history of arthritic low back pain and high
cholesterol. He denied any past psychiatric history.
On physical exam, chest exam showed scattered rhonchi bilaterally and
the patient had some productive cough. Otherwise, physical exam was essentially
normal.
At the end of this visit, the patient was given educational material on sleep
hygiene and insomnia. Behavioral techniques like stimulus control therapy
and relaxation were discussed.
He was started on 1 mg of Lorazepam orally at bedtime. The patient did not
call between visits to report his progress although he was advised to do so.
On the second visit, 4 weeks later, the patient was apologetic. He admitted
to feeling guilty for not complying with the behavioral treatment recommendations.
He reported that he was not waking up as much during the night on
Lorazepam, yet he complained of ongoing difficulties waking up early in the
morning and feeling more tired during the day.