You must be signed in to participate in this activity. New to WebBasedCME.com? Click here to register.


Patient Case Study (APL) - Redefining Insomnia: State-of-the-Science in Insomnia Management

Please select a patient from YOUR clinical practice that is most similar to the patient described below. Please reflect on his/her history and course of treatment when providing case-related details and answering case-related questions.

Patient Profile
  • 49-year-old Caucasian female who works as an executive assistant
  • Complains of both sleep-onset and sleep-maintenance insomnia, which has been persistent for greater than 4 nights per week for the past 6 months. Degree of sleep-onset and sleep-maintenance symptoms vary from month to month
  • Patient lies 8 hours in the bed (11 pm to 7 am ) to sleep, but gets 3 hours or less per night of actual sleep
  • Patient dreads going to bed and lies in bed “watching the clock” off-and-on for most of the night
  • Insomnia is causing irritability, including fights with family and co-workers, which have resulted in reprimands
  • Past medical history is significant for hypertension, diabetes, migraine headaches, and depression, all well-controlled on medications
  • Patient states that depression is worsening due to her conflicts with family and coworkers
  • Social history:
    • Cigarette smoker (30 packs per year)
    • Occasional alcohol use
    • No history of illicit drug abuse
  • Review of systems and complete physical examination is negative for any other medical, neurologic, psychiatric, or sleep disorder
  • Current medications:
    • Lisinopril 40 mg orally once daily
    • Metformin 850 mg orally twice daily
    • Sertraline 100 mg orally once daily
    • Acetaminophen as needed
0. Have you created an account on WebBasedCME.com? You must register and be signed in to participate and receive CME credit for this activity.



1.What is your initial treatment strategy for this patient?
 
Aggressively treat the depression, follow up with a later visit to see if the insomnia resolves once the depression has resolved
Treat the insomnia, follow up to see if the depression improves once the insomnia has resolved
Treat both simultaneously
Other

2.Which of the following cognitive behavioral therapies (CBTs) would you consider conducting or prescribing for this patient’s insomnia? Check all that apply.
 
Sleep hygiene education (including no smoking before bed, get the clock out of the bedroom, etc)
Stimulus control therapy
Sleep restriction therapy
Paradoxical intention therapy
Progressive muscle relaxation therapy
Cognitive restructuring therapy
I would not recommend CBT at this time

3.How likely is this patient to be adherent to CBT?
 
Very likely
Moderately likely
Somewhat likely
Moderately unlikely
Very unlikely

4.Which of the following factors may decrease the likelihood that this patient will be compliant with CBT? Check all that apply.
 
Time
Distance and travel
Expense
Personal preference

5.If the patient refused or failed on a trial of cognitive behavioral therapy, would you recommend pharmacotherapy for this patient?
 
Yes
No

6.If you would recommend pharmacotherapy to treat this patient’s sleep-onset and sleep-maintenance insomnia, which of the following FDA-approved agents for insomnia would you recommend?
 
Zolpidem CR
Eszopiclone
Temazepam
Estazolam
I would not recommend pharmacotherapy

7.Which of the following factors would influence your treatment decision? Check all that apply.
 
Efficacy
Cost to patient
Durability of effect
Potential side effects
Potential beneficial effect of restfulness on comorbid conditions (depression)
Potential adverse effects of tolerance, dependence, abuse, or residual sedation

8.Assuming the patient’s insomnia stays chronic, possibly needing long-term therapy, which of the following FDA-approved therapies for chronic sleep-onset and sleep-maintenance insomnia would you recommend for this patient?
 
Zolpidem CR
Eszopiclone
I would not recommend pharmacotherapy

9.Which of the following factors would influence your treatment decision? Check all that apply.
 
Efficacy
Cost to patient
Durability of effect
Potential side effects
Potential beneficial effect of restfulness on comorbid conditions (depression)
Potential adverse effects of tolerance, dependence, abuse, or residual sedation

10.Which of the following factors would decrease the likelihood that this patient will adhere to treatment with benzodiazepines (temazepam and estazolam)?
 
Efficacy
Cost to patient
Durability of effect
Potential side effects
Potential beneficial effect of restfulness on comorbid conditions (depression)
Potential adverse effects of tolerance, dependence, abuse, or residual sedation

11.Which of the following factors would decrease the likelihood that this patient will adhere to treatment with NBBRAs (zolpidem CR and eszopiclone)?
 
Efficacy
Cost to patient
Durability of effect
Potential side effects
Potential beneficial effect of restfulness on comorbid conditions (depression)
Potential adverse effects of tolerance, dependence, abuse, or residual sedation

12.Which of the following factors would decrease the likelihood that this patient will adhere to treatment with melatonin-receptor agonists (ramelteon)?
 
Efficacy
Cost to patient
Durability of effect
Potential side effects
Potential beneficial effect of restfulness on comorbid conditions (depression)
Potential adverse effects of tolerance, dependence, abuse, or residual sedation

13.Which of the following factors would make insomnia pharmacotherapy more attractive to you as a clinician? Check all that apply.
 
Improved efficacy over existing therapies
More durable treatment effects
Improvements in comorbid conditions and quality of life (no daytime consequences)
Better safety profile

14.Which of the following factors would make insomnia pharmacotherapy more attractive to your patients? Check all that apply.
 
Improved efficacy over existing therapies
More durable treatment effects
Improvements in comorbid conditions and quality of life (no daytime consequences)
Better safety profile

15.When would you schedule a follow-up visit for this patient?
 
1 month
2 months
3 months
6 months

16.Would you recommend a polysomnogram and/or a referral to a sleep specialist for this patient if treatment with pharmacotherapy was ineffective?
 
Yes
No

You must be signed in to participate in this activity. New to WebBasedCME.com? Click here to register.