1. PSYCHOPHARMACOLOGY. Respond to this discussion post
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 kgCurrent height: 64 inchesTemp: 98.6 degrees FBP: 132/86 By
Day 3 of Week 7Post 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 the client’s ethnicity. Discuss
why the contraindication/alteration you identify exists. That is, what would be problematic
with the use of this drug in individuals of other ethnicities?• 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. Respond to the these discussions. All questions need to be addressed. Discussion 2
MeTreatment of a Patient with Insomnia The case presented this week, is that of a
75-year-old widow who just lost her spouse 10-months ago. Th patient presents with chief
complaints of insomnia. Past medical history of DM, HTN, and MDD is reported. Since the
passing of her husband, she states her depression has gotten worse as well as her sleep

2. 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, and Sertraline 100mg daily. Current weight: 88 kg.
Current height: 64 inches. Temp: 98.6 degrees F. BP: 132/86 (Walden
University). Question number one, what brings you in today? By asking an open-ended
question, the patient is more willing to share information with the provider (Stern, 2016).
Another question that would be of beneficial knowledge during the interview is, do you
consume caffeine? If so, how much caffeine do you consume in a day? Caffeine consumption
close to bedtime contributes greatly to insomnia (Farazdaq et al., 2018). Lastly, the third
question that should be asked is, do you suffer from Gastro Esophageal Reflux Disease
(GERD). According to Farazdaq, Andrades, and Nanji, (2018) GERD is a contributing factor
to insomnia in elderly patients. By asking the above questions, the provider can rule out
environmental factors while assessing the patients concerns with open-ended
questions. People in the patient’s life that could provide further information is children
or caretakers. Questions that would be appropriate to ask the patient’s children or
caretaker would be if there is a recent decrease in her appetite, energy, mood, or interests.
By asking about these areas of the patient’s life will provide external information that the
patient might be withholding or may be unaware of. Insomnia relies heavily on self-report
for a diagnosis (Levenson et al., 2015). Also, a physical exam could be performed with the
order of blood testing to rule out thyroid problems. According to Dr. Abhinav Singh (2021),
hyperthyroidism results in nervousness from overactivity of this hormone, and insomnia is
often a symptom. Administering the Hamilton Anxiety Rating Scale (HAM-A) would assess
the severity of the patient’s anxiety. The HAM-A results would aid with further treatment of
the patient’s insomnia, if related to anxiety (Psychiatry & Behavioral Health Learning
Network, 2021). Another appropriate scale to administer to this patient is the Hamilton
Depression Rating Scale (HDRS). HDRS is an assessment that focuses on feelings of guilt,
mood, suicidal ideation, activities, weight, various stages of insomnia, and many more
important areas (Hamilton, 1960). The patient presents with a previous diagnosis of
depression. The differential diagnosis for this patient is Generalized Anxiety Disorder
(GAD), secondary to husband’s death. There are many possible changes within the living
dynamics, such as financial burdens, fear of her own death, and suddenly sleeping
alone. Changes within this patient’s routine may be a cause of reported
insomnia. Temazepam is FDA approved for insomnia, and used off-label for anxiety
disorders, acute mania, psychosis, and catatonia (Puzantian & Carlat, 2020). Temazepam is
generally effective in the treatment of insomnia, by enhancing widespread inhibitory
activity of GABA (Levenson et al., 2015). Temazepam is metabolized through the liver
without CYP450 (Puzantian & Carlat, 2020). Another good sleep aid choice is Trazodone.
Trazodone is widely used for insomnia (Levenson et al., 2015). Trazodone is FDA approved
for the treatment of major depression and used off-label for insomnia and anxiety
(Puzantian & Carlat, 2020). Trazodone inhibits serotonin reuptake, alpha-1 adrenergic
receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist (Puzantian &

3. Carlat, 2020). And Trazodone is metabolized primarily through CYP3A4 to active metabolite
mCPP, that is metabolized by 2D6, inducing P-glycoprotein (Puzantian & Carlat, 2020).
Trazodone, however, carries the side effect of daytime somnolence and dizziness (Puzantian
& Carlat, 2020). The favorable medication for this patient, is Temazepam. Temazepam
is a safer medication to use in elderly patients because of the lack of active metabolites, its
short half-life and absence of drug interactions (Puzantian & Carlat, 2020). The patient is
currently taking Metformin, Januvia, Losartan, HCTZ, and Sertraline. Based on the current
medications, the patient is being treated for diabetes mellitus, hypertension, and
depression. Adding Temazepam to the patient’s medication regimen would not result in
toxicity of other medications. Sleep is heritable and regulated by numerous genes. A
genome wide association study found numerous single-nucleotide polymorphisms (SNPs)
significantly associated with insomnia symptoms. The most significant SNPs occurred
within genes involved in neuroplasticity, stress reactivity neuronal excitability, and mental
health (Rajib, 2020). The starting dose of Temazepam is lower in the elderly
population (Puzantian & Carlat, 2020). The proper dose to begin with this patient, is
Temazepam 7.5mg tab PO QHS. At the 4-week checkup, the expected outcome would be an
increased ability to sleep, and reduced anxiety. If these results have not been achieved,
Temazepam 15mg tab PO Q HS would be ordered. Temazepam does have the risk of
weakness and dizziness, so great care and caution would need to be taken when increasing
the dose. There needs to be an evaluation of the effects at week 8, or sooner if needed. The
maximum dose of Temazepam is 30mg PO Q HS, and even lower in the elderly (Puzantian &
Carlat, 2020).ReferencesFarazdaq, H., Andrades, M., & Nanji, K. (2018, December 31).
Insomnia and its correlates among elderly patients presenting to family medicine clinics at
an academic center. Malaysian family physician: the official journal of the Academy of
Family Physicians of Malaysia.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/.Hamilton, M. (1960). Hamilton
Rating Scale for Depression. PsycTESTS Dataset, 23, 56–62.
https://doi.org/10.1037/t04100-000Levenson, 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-
1617Puzantian, T., & Carlat, D. J. (2020). Medication fact book for psychiatric practice. Carlat
Publishing, LLC.Rajib, D. (2020). Do genes matter in sleep? -A comprehensive update.
Journal of Neuroscience and Neurological Disorders, 4(1), 014–023.
https://doi.org/10.29328/journal.jnnd.1001029Singh, A. (2021, March 8). Could Your
Thyroid be Causing Sleep Problems? Sleep Foundation.
https://www.sleepfoundation.org/physical-health/thyroid-issues-and-sleep.Stern, T. A.
(2016). Massachusetts General Hospital: psychopharmacology and neurotherapeutics (1st
ed.). Elsevier.Walden University. (n.d.). Treatment for a Patient with a Common Condition.
https://class.content.laureate.net/14884e77402afe219224c67c4f0463b3.html.