Running head: MENTAL HEALTH PROBLEMS

Mental Health Problems

Insomnia/Anxiety

Alexander Warren
Albany State University
NURS 6211 Primary Care of Adults

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Insomnia
Insomnia is commonly considered as the inability to sleep, but it is more specifically the
name for a chronic condition which leaves the patient with an inadequate amount of sleep as to
affect their daily lives. If a patient has difficulty sleeping for a couple of nights, it does not mean
they suffer from insomnia. This is a life altering illness that extends beyond the inability to
initiate sleep. It also includes the inability to maintain sleep and the patient waking early.
Patients who suffer from insomnia have difficulty carrying out daily functions due to increased
fatigue.
The diagnosis of insomnia is made through ruling out other causes for the lack of sleep.
The patient may be suffering from a psychiatric condition or other medical issues. The patient
may be depressed, anxious, use excessive caffeine/tobacco, or have poor sleep hygiene. Once all
other causes can be ruled out you must consider the actual problems the patient is experiencing
and if they are severe enough to be considered insomnia.

Does the patient have daytime

sleepiness, mood changes, social dysfunction, memory issues, or headaches due to lack of sleep?
If the patient suffers from any of these symptoms along with the chronic inability to sleep, a
diagnosis of insomnia can be made.
The diagnosis of insomnia can be split into two categories. Primary insomnia is when all
other medical reasons for insomnia have been ruled out and we are left with a sleep disturbance
only. Secondary insomnia is when the patient is suffering from a medical or psychiatric
condition that is also causing an inability to sleep. Usually when the cause of secondary
insomnia is found, the patient can be treated for the psychiatric/medical condition and the

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insomnia will also resolve. Insomnia is very prevalent in our society with, One third of the
adult population reporting insomnia, 9 to 12% experience day time consequences and
approximately 6% meet formal criteria for an insomnia diagnosis (Vyas, 2013).
The goal of treating primary insomnia is to decrease daytime symptoms and to improve
sleep quality/quantity. The current Journal of Clinical Sleep Medicine (JCSM) guidelines state
that a least one behavioral intervention should be used in conjunction with pharmacological
treatment. These interventions include relaxation therapy, stimulus control therapy, and
cognitive behavioral therapy (Shutte-Rodin, 2008). The first line treatment of insomnia is
benzodiazepines such as zolpidem. This is commonly known as Ambien and is a sedating
hypnotic which helps the patient to fall asleep and stay asleep. Second line treatment is sedating
antidepressants such as trazodone. Trazodone is an antidepressant but it is effective in its off
label use for insomnia. Third line treatment is the combination of benzodiazepines and sedating
antidepressants. The patient can also try anti-seizure medications such as gabapentin due to its
sedating ability. Some over the counter drugs are beneficial in the treatment of insomnia. Some
antihistamines such as Benadryl are known to cause drowsiness and will help with sleep patterns.
Insomnia is a chronic condition, so patients will need to be on these medications long
term. Some of the medications are harmful if taking for extended periods of time. Hypnotics
can become habit forming and cause rebound insomnia if the patient begins to taper off the
medication. Non-pharmacological therapy is an important consideration when discussing
treatment options for insomnia. These options are time consuming and can be expensive as a
therapist is usually needed. Options such as stimulus control therapy, relaxation training, sleep
restriction, and sleep hygiene can be beneficial but do not take effect immediately. This can
cause the patient to lose interest and resort to taking medications.

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Anxiety
Generalized Anxiety Disorder (GAD) is characterized by an irrational fear of disastrous
events that have little chance of occurring. Many patients worry over their jobs, family, health,
and finances. They feel that some horrible event will cause harm to themselves or their loved
ones. The fears are so consuming that they patients are usually discouraged to leave the home or
put themselves in any situation that could increase the chances of these events occurring.
Epidemiological surveys of the general population have shown that GAD has a lifetime
prevalence of 4.3% to 5.9% (Bandelow, 2013). The diagnosis and treatment of GAD are
difficult due to the causes of this disorder being unknown.

When diagnosing a patient with GAD a few criteria must be made. The patient must
have fears about everyday events for a time span of at least 6 months with some of the following
signs; increased heart rate, diaphoresis, chest pain/tightness, fear of dying, paresthesiae, muscle
tension, irritability, etc. These patients usually worry about the fact that they are always
worrying (Bandelow, 2013). Patients that present to the office with these symptoms are often
misdiagnosed and are treated for depression, sleep disturbances, and other types of psychiatric
issues. The underlying GAD often goes untreated and the patient continues to have the
symptoms.

Treatment for anxiety begins with counseling. The patient may have some type of
underlying problem that is the cause of the GAD. Having a conversation with the patient about
their life is an important step in the history of present illness of these patients. The patients will
need extensive education on the disorder including information on their treatment options as they

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may be afraid of medications and physicians. Counseling will include discussing the fears and
having the patient attempt to rationalize them. The patient should be able to discuss how
someone without GAD would handle various situations and be able to recognize the difference in
their behavior. These patients should also attempt to gain a support system for their day to day
lives. Relaxation techniques can also be invaluable. The patients anxiety feeds upon itself and
they become more anxious as their worries increase.

The first line drug of choice in the pharmacotherapy management of GAD are SSRIs and
SNRIs such as Lexapro, Paxil, or Cymbalta. These drugs are beneficial as they cause no
dependence but they can take up to 6 weeks before the patient feels their effects. Tricyclic
antidepressants are one of the drugs for second line treatment of GAD but there is no data
available on the long term effects of this drug in relation to anxiety disorder. As with insomnia,
the patient may be started on benzodiazepines but these can be habit forming. These medications
are a good adjunct to care but counseling and relaxation are the best long term solutions for
GAD.

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References

Bandelow, B., Boerner, R. J., Kasper, S., Linden, M., Wittchen, H., & Mller, H. (2013). The

Diagnosis and Treatment of Generalized Anxiety Disorder. Deutsches Aerzteblatt

International, 110(17), 300-310. doi:10.3238/arztebl.2013.0300

Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical Guideline for

the Evaluation and Management of Chronic Insomnia in Adults. Journal of Clinical Sleep

Medicine. Retrieved November 12, 2014, from

http://www.aasmnet.org/Resources/clinicalguidelines/040515.pdf

Vyas, U. K. (2013). Non-Pharmacological Management of Insomnia. British Journal Of Medical

Practitioners, 6(2), 1-5.