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Transcript
Management of
Anxiety, Depression
and Insomnia
in Primary Care Settings
NURS 870
Spring 2016
Anxiety, Depression and
Insomnia in Primary Care
Objectives:
Role of mental health treatment in primary
care
2. Review of key neurotransmitters
3. Approach to patient with anxiety
4. Approach to the patient with depression
5. Review of Psychotropic Pharmacology
6. Approach to the patient with insomnia
1.
1. Role of mental health
treatment in primary care
From 2011 AAFP Position Paper
Prevalence and Cost

Psychiatric problems are a major health issue. In the United States,
neuropsychiatric disorders have now surpassed other disorders such
as cardiovascular diseases and malignant neoplasms as the number
one cause of disability as expressed as disability-adjusted life
years.19

According to the most recent data available, mental health
expenditures in the United States, expressed as a percentage of
total health care expenditures, were more than 6%. For the year,
that amounted to a cost approaching $100 billion.20 Analysis of the
sources of payment for those expenditures for the same year
revealed that 10% of Medicaid funding and more than 20% of state
and local funding was spent on mental health care.

Suicide remains a significant cause of death and lost productive
lives, with the most recent U.S. data (from 2007) showing that
almost 35,000 people died that year from all forms of suicide.21
Top 10 Causes of Death
United States - 1916
Prevalence and Cost

Among adults, depression ranks as a significant cause of disease
and disability, with a lifetime prevalence of over 16%. When
analyzed by sex, the 12 month prevalence of depression averages
about 8% to 9% for women and 4% to 5% for men.20

When depression is broken down into various degrees of severity,
more than 30% of U.S. adult cases identified in 2007 are listed as
being in a “severe” category.21 Approximately 52% of those adults
received some form of treatment, with 38% receiving what was
considered adequate treatment.22

Similarly, anxiety disorder represents a significant cause of disease
and disability among adults, with a 12 month prevalence of 18% in
2004. Twenty three percent of those affected patients were
classified as having “severe” disorder.12

Approximately 37% of adults with anxiety disorder receive
treatment in any 12 month period, with only 34% of those patients
receiving adequate treatment.12
Prevalence and Cost

Depressive disorders of all types are found to have a
lifetime prevalence of 11% of 13- to 18-year-olds, with 3%
of those affected having “severe” disorder.23 The
prevalence of depressive disorders at any one time is
thought to be approximately 8%.23

As in adults, the prevalence of depression in girls age 13 to
17 is nearly 3 times as great as that in boys for the same
age group.

Anxiety disorders of all types occur with a lifetime
prevalence of 25% of 13- to 18-year-olds, with
approximately 5% to 6% of those affected classified as
having “severe” disorder.23 Again, statistics for anxiety
disorder in this age category show a significant female
predominance.23
Prevalence and Cost

Two subgroup of adults have a higher-than-average prevalence of
mental health disorder and deserve special mention.

A higher-than-average number of U.S. military veterans of Operation
Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq)
reported mental health problems, (11.3% and 19.1% respectively)
compared with the entire population of post-deployment U.S. military
veterans in the survey period.24 Thirty-five percent of Iraq veterans
were reported to have accessed mental health services during the year
after returning home.25 The suicide rate in this population was not
appreciably higher than in the general population of post-deployment
veterans, although certain subgroups (those veterans with selected
mental health diagnoses) were observed to have a higher than normal
rate.25

The other subgroup of U.S. adults with higher than average occurrence
of mental health disorder is the U.S. inmate population. In data from
surveys of inmates in state, federal and local jails, the 12 month
occurrence of all mental health disorders was found to be 56%, 45% and
64% respectively.26,27 Fewer than 50% of the affected inmates ever
received any treatment for their disorder.26,27
NP Role in Dx & Rx

Another important distinction between psychiatric
practices and family medicine practices is that while
patients who present for psychiatric treatment usually have
severe symptoms that leave little doubt about the
diagnosis,

patients in the family physician's office typically present
with vague somatic complaints such as “fatigue,” “feeling
nervous,” etc., without an established psychiatric
diagnosis.

Unlike the psychiatric professional whose patients accept
the diagnosis and the need for treatment, the family
physician has to identify mental health problems that are
frequently obscured by patient reluctance to acknowledge
the problem or by physical symptoms that mask the
underlying problem.
NP Role in Dx & Rx

The general reluctance of patients to seek care for mental health
problems complicates the diagnosis of mental illness.

Survey results show that 40% of patients with major depression do
not want or perceive the need for treatment.11,32

Patients consistently underreport emotional issues to their
physicians. One study found that only 20% to 30% of patients with
emotional/psychologic issues reported these to their primary care
physicians.4

Many patients somatize their psychologic issues. One in three
patients who go to the emergency department with acute chest
pain is suffering from either panic disorder or depression.13

Eighty percent of patients with depression present initially with
physical symptoms such as pain or fatigue or worsening symptoms
of a chronic medical illness.35
Payment

Payment for office visits with a mental health diagnosis code has
traditionally been discounted by Medicare for primary care. Many
managed care plans do not pay family physicians for the provision
of psychiatric care, even though family physicians are frequently in
the position to diagnose and provide the care.

While lack of payment is not the only reason for the documented
failures in mental illness detection, the absence of payment has an
impact on the lack of screening in primary care practices.

This policy is also contradictory to the public's stated preference
for care. A survey conducted for the NMHA indicated that 72% of
diagnosed patients and 61% of symptomatic but undiagnosed people
want greater involvement of their primary care physician in their
treatment.29

This not only reflects the level of rapport between patients and
family physicians, but it is also indicative of the level of
apprehension caused by the potential stigma attached to mental
illness and to accessing the formal mental health system.
2. Neurotransmitter
Review
Neurotransmission Review
Neurotransmission

Like a key inserted into a lock, chemicals fit precisely
into specific receptor cells (made of protein) in axons,
dendrites

Receptor cells open or close doors (ion channels) into
cell; allow interchange of chemicals, ions, e.g.,
sodium (Na+), potassium (K+), calcium (Ca+)

Depolarization changes cell’s electrical charge
Neurotransmitter Roles

Absence or excess can play major role in brain
disease, behavioral disorders

Single neurotransmitter can affect other brain
chemicals and several different subtypes of
receptor cells in different brain regions

Neurotransmitters can have different effects in
different brain parts
Types of Neurotransmitters


Amines

Monoamines (norepinephrine, dopamine,
serotonin, melatonin)

Acetylcholine

Amino acids (glutamate, GABA [gammaaminobutyric acid])
Peptides (endorphins, enkephalins, substance P)
may affect pain transmission
Norepinephrine (NE)

Can be excitatory or inhibitory

Levels fluctuate with sleep and wakefulness

Plays a role in changes in levels of attention and
vigilance

Involved in attributing a rewarding value to a
stimulus

Part of the regulation of mood

Antidepressants block the reuptake of NE into the
presynaptic cell or inhibit monoamine oxidase
from metabolizing it
Dopamine (DA)

Generally excitatory

Involved in the control of complex movements,
motivation, & cognition and in regulation
emotional responses

Many drugs of abuse (e.g. cocaine,
amphetamines) cause DA release, suggest a role in
whatever makes things pleasurable

Involved in movement disorders e.g. PD and in
many deficits seen in schizophrenia

Antipsychotic drugs block DA receptors in the
postsynaptic cell
Serotonin (5-HT)

Mostly Inhibitory

Levels fluctuate with sleep and wakefulness,
suggesting a role in arousal and modulation of general
activity levels of the CNS esp. the onset of sleep

Plays a role in mood and probably in the delusions,
hallucinations, and withdrawal of schizophrenia

Involved in temperature regulations and pain control
system

Plays a role in affective and anxiety disorders

Antidepressants block its reuptake into the presynaptic cell
The Synapse
3. Approach to Anxiety
Anxiety Disorders

Anxiety is a normal human emotion that everyone
experiences occasionally during times of stress

Pathologic “anxiety is the distressing experience of dread,
foreboding, or panic accompanied by a variety of
autonomic—primarily sympathetic—bodily symptoms. The
distress, therefore, is both psychic and physical.” (Goroll
p.1461)

29% estimated life-time prevalence in the general
population

Anxious patients often present to the primary care office
convinced something is very wrong with their body and
need an explanation for how badly they feel

Undiagnosed and untreated anxiety add to the cost of
medical care (2nd opinion for benign CP in ED…)
Anxiety Disorders

Panic Disorder: People with this condition have feelings of terror that strike
suddenly and repeatedly with no warning. Other symptoms of a panic attack include
sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking,
which may make the person feel like he or she is having a heart attack or "going
crazy."

Obsessive Compulsive Disorder (OCD): People with OCD are plagued by constant
thoughts or fears that cause them to perform certain rituals or routines. The
disturbing thoughts are called obsessions, and the rituals are called compulsions. An
example is a person with an unreasonable fear of germs who constantly washes his
or her hands.

Post-Traumatic Stress Disorder (PTSD): is a condition that can develop following a
traumatic and/or terrifying event, such as a sexual or physical assault, the
unexpected death of a loved one, or a natural disaster. People with PTSD often have
lasting and frightening thoughts and memories of the event, and tend to be
emotionally numb.

Social anxiety disorder: Also called social phobia, social anxiety disorder involves
overwhelming worry and self-consciousness about everyday social situations. The
worry often centers on a fear of being judged by others, or behaving in a way that
might cause embarrassment or lead to ridicule.

Specific Phobias: A specific phobia is an intense fear of a specific object or
situation, such as snakes, heights, or flying. The level of fear usually is
inappropriate to the situation and may cause the person to avoid common, everyday
situations.

Generalized Anxiety Disorder: This disorder involves excessive, unrealistic worry
and tension, even if there is little or nothing to provoke the anxiety.
Anxiety Symptoms

Feelings of panic, fear, and
uneasiness

Shortness of breath

Palpitations

An inability to be still and calm

Uncontrollable, obsessive
thoughts

Repeated thoughts or
flashbacks of traumatic
experiences

Dry mouth

Numbness or tingling in the
hands or feet

Nightmares

Nausea

Ritualistic behaviors, such as
repeated hand washing

Muscle tension

Dizziness

Problems sleeping

Cold or sweaty hands and/or
feet
Symptom Dimension of
Anxiety

Anxiety disorders are co-morbid with:

Other anxiety disorders

Depression

Substance abuse

ADHD

Bipolar Disorder

Pain Disorders

Sleep Disorders
Panic Attack
►
Usually last 5 to 30 minutes
►
Varying degrees of intensity
►
Depression is a common co-morbid
►
Average age of onset is age 22-23
►
An intense discrete episode of anxiety
Predisposing Factors to
Panic & GAD
Biological Aspects

Serotonin
► Some
individuals have hypersensitive 5HT receptors
► SSRI’s
are effective
Predisposing Factors to
Panic & GAD
Medical Conditions

Thyroid Disorders

Acute MI

Substance Abuse

Hypoglycemia

Caffeine Intoxication

Mitral Valve Prolapse

Complex Partial Seizures
Phobias--Background
Assessment
Social Phobias

May be well defined e.g. fear of eating in public or

May involve general social situations

Onset begins in late childhood or early adolescence

Chronic, often lifelong course

Interferes with social & occupational functioning
OCD-Background Assessment
►
Obsessions: the unwanted, intrusive,
persistent ideas, thoughts, impulses, or
images that cause marked anxiety or
distress
►
Compulsions: unwanted repetitive behavior
patterns or mental acts
OCD-Background Assessment
►
Equally common among men & women
►
May begin in childhood, usually adolescence or early
adulthood
►
Usually chronic
►
Often complicated by depression or substance
Behaviors of OCD

Rituals

Aggressive urges

Shouting obscenities

Kleptomania

Binge shopping

Repetitive sexual behaviors
PT Stress Disorder
Background Assessment
Symptoms

Reexperiencing the traumatic event

Sustained high level of anxiety or arousal

A general numbing of responsiveness

Intrusive recollections or nightmares

Depression
PT Stress Disorder
Background Assessment
►
Development of characteristic symptoms following
exposure to an extreme traumatic stressor involving
a personal threat to physical integrity or to physical
integrity of others
PT Stress Disorder
Background Assessment
►
Symptoms must be present for more than 1 month
►
Symptoms must cause significant interference with
social, occupational, & other areas of functioning
►
If the symptoms have not been present for more than
1 month the diagnosis assigned is acute stress
disorder
How does the Primary care
NP diagnose Anxiety?
Anxiety: Beck Anxiety Inventory

0 – 21 indicates very low anxiety

22 – 35 indicates moderate anxiety

> 36 is a potential cause for concern
4. Approach to Depression
Depression
Common symptoms of depression:

Fatigue or loss of energy almost every day

Feelings of worthlessness or guilt almost every day

Impaired concentration, indecisiveness

Insomnia or hypersomnia (excessive sleeping) almost every day

Markedly diminished interest or pleasure in almost all activities nearly every day
(called anhedonia, this symptom can be indicated by reports from significant
others.)

Psychomotor agitation or retardation (restlessness or being slowed down)

Recurring thoughts of death or suicide (not just fearing death)

Significant weight loss or gain (a change of more than 5% of body weight in a month)

Symptoms must be present every day or nearly every day for at least two weeks.
Who is at risk for major depression?

Major depression affects about 6.7% of the U.S. population over age 18, according
to the National Institute of Mental Health. Overall, between 20% and 25% may suffer
an episode of major depression at some point during their lifetime.
Differences
Anxiety
Depression

Psychomotor
hyperactivity
►
Slowed speech &
thought process

Tremors & palpitations
►
Loss of interest in usual
activities

Rapid pulse, breathing
disturbances, dizziness
►
Inability to experience
pleasure
►
Thoughts of
death/suicide
Differences
Anxiety
►
Does not regard defects
or mistakes as
irrevocable
►
►
Depression
►
Regards mistakes as
beyond redemption
Uncertain in negative
evaluations
►
Absolute in negative
evaluations
Predicts that only
certain events may go
badly
►
Global view that nothing
will turn out right
Differences
Anxiety
►
Predominately fear or
apprehension
►
DFA
►
Phobia
►
Depersonalizations
►
Derealizations
Depression
►
Predominately sad or
hopeless with feelings of
despair
►
Diurnal variation (feels
worse in the morning)
How does the Primary care
NP diagnose depression?
Depression: Beck Depression Inventory
http://www.apa.org/pi/about/publications/caregivers/pra
ctice-settings/assessment/tools/beck-depression.aspx
Interpretation

Score <15: Mild Depression

Score 15-30: Moderate Depression

Score >30: Severe Depression
Always ask depressed patients
something like, Has it ever gotten
so bad that….
You thought the world would be better off without you?
Delineate extent of suicidal ideation

When did you begin to have suicidal thoughts?

Did any event (stressor) precipitate the suicidal thoughts?

How often do you think about suicide? Do you feel as if you're a burden? Or that life isn't worth living?

What makes you feel better (e.g., contact with family, use of substances)?

What makes you feel worse (e.g., being alone)?

Do you have a plan to end your life?

How much control of your suicidal ideas do you have? Can you suppress them or call someone for help?

What stops you from killing yourself (e.g., family, religious beliefs)?
Ascertain plans for furtherance and lethality

Do you own a gun or have access to firearms?

Do you have access to potentially harmful medications?

Have you imagined your funeral and how people will react to your death?

Have you “practiced” your suicide? (e.g., put the gun to your head or held the medications in your
hand)?

Have you changed your will or life insurance policy or given away your possessions?
AFP - 1999
Risk factors associated with
completed suicide
Epidemiologic factors
Male, white, age greater than 65 years
Widowed or divorced
Living alone; no children under the age of 18 in the household
Presence of stressful life events
Access to firearms
Psychiatric disorders
Major depression
Substance abuse (particularly alcohol)
Schizophrenia
Panic disorder
Borderline personality disorder
Additionally, in adolescents: impulsive, aggressive and antisocial
behavior;
presence of family violence and disruption
Past history
History of previous suicide attempt
Family history of suicide attempt
Symptoms associated with suicide
Hopelessness
Anhedonia
Insomnia
AFP - 1999
Suicidal Ideation
Contract for safety

Sample:

I, Jane Doe, promise not to harm myself in any way. If I have such thoughts I
pledge to first call my primary care provider [insert your name and emergency
on-call or contact number] or Crisis intervention.

Signed: __________________ (patient signs here)

Witnessed: _______________ (you sign here)
Crisis Intervention for your county:
Cumberland: 717-763-2222
Dauphin : 717-232-7511
AFP - 1999
When is patient
confidentiality gone?
 1.
Suicidal intent
 2. Homicidal intent
Psychotherapy

Patients with anxiety, depression benefit greatly from
talk therapy such as CBT (cognitive behavioral therapy).
For patients with mild-moderate symptoms, try
psychotherapy first!
5. Psychopharmacology
Depression/Anxiety Meds: SSRIs
Selective serotonin reuptake inhibitors (SSRIs) approved
to treat depression and anxiety:

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac, Prozac Weekly, Sarafem)

Paroxetine (Paxil, Paxil CR, Pexeva)

Sertraline (Zoloft)
SSRIs: Common side-effects
All SSRIs work in a similar way and generally cause similar side effects.
However, each SSRI has a different chemical makeup, so one may affect
you a little differently from another.

Nausea

Dry mouth

Headache

Diarrhea

Nervousness, agitation or restlessness

Reduced sexual desire or difficulty reaching orgasm

Inability to maintain an erection (erectile dysfunction)

Rash

Increased sweating

Weight gain

Drowsiness

Insomnia
2nd Line Depression Meds: SNRIs
Serotonin and norepinephrine reuptake inhibitors
approved to treat depression

Duloxetine (Cymbalta)

Venlafaxine (Effexor, Effexor XR)

Desvenlafaxine (Pristiq)
2nd Line Depression Meds: SNRIs
Other antidepressants:

Wellbutrin (bupropion) – no sexual dysfunction

Remeron (mirtazipine) – good for sleep/appetitie

Oleptro (trazodone) – good for sleep

Elavil (amitriptyline) – good for sleep/pain
Others for anxiety:
Others for depression:
Starting Dose
Bupropion:
Mirtazpine:
Trazodone:
Amitryline:
Usual Daily
Dose
Extreme
“Psychiatrist”
Range
no sexual dysfunction BUT lowers seizure threshold
good for sleep and poor appetite; + weight gain
good for sleep; + constipation
good for sleep & pain; + weight gain
FDA Suicidality “Black Box”
warning for all antidepressants:

Anyone who starts being treated with antidepressant
medicines, particularly those being treated for depression,
should be watched closely for worsening of depression and for
increased suicidal thinking or behavior.

Close observation of adults may be especially important when
antidepressant medications are started for the first time or
when doses for their antidepressant medications have been
changed.

Adults whose symptoms worsen while being treated with
antidepressants, including an increase in suicidal thinking or
behavior, should be evaluated by their health care professional.
Benzodiazepines

Treatment should be brief and for specific symptoms

Target Symptoms for Benzodiazepines
Psychological

Irritability

Uneasiness

Worry

Fear

Insomnia
Benzodiazepines
Benzodiazepines

No clinical advantage over each other BUT

Clients with persistent anxiety should take one with a long
half-life; with fluctuating anxiety a shorter half life

Lipid solubility determines the rapidity of onset and the
intensity of effect

e.g. Diazepam (Valium) is more lipid than Lorazepam
(Ativan) thus moves more readily into and then out of
CNS and is more extensively distributed to peripheral
sites particularly to fat cells
Benzodiazepines

Elderly Clients

More vulnerable to side effects

Aging brain

Dose from one half to one third of the usual daily
dose used for adults

Select BZ with no active metabolites since they are
less affected by liver disease, the age of the
patient or drug interactions e.g. Klonopin, Ativan,
Serax

Avoid use in the elderly – often makes them worse.
Consider Haldol – then geriatric psychiatry consult
Nonbenzodiazepine Antianxiety
Agents

BuSpar (Buspirone)

No addictive potential

Does not exhibit muscle –relaxant or anticonvulsant activity, interaction with
CNS depressants, or sedative-hypnotic properties

Not effective in management of drug or alcohol withdrawal or panic disorder

Generally takes several weeks to take effect
Nonbenzodiazepine Antianxiety
Agents

Inderal (Propranolol) (beta-blocker)

Catapress (Clonidine) (an alpha 2 receptor agonist)

Both used for off-label treatment of anxiety

Act by blocking peripheral or central noradrenergic
(norepinephrine) activity and many of the manifestations
of anxiety (e.g. tremor, palpitations, tachycardia,
sweating)
Nonbenzodiazepine
Antianxiety Agents

Propranolol-Used in treatment of performance
anxiety

Clonidine-also used to block physiological symptoms
of opioid symptoms of opioid withdrawal and the
tachycardia and excessive salivation seen with
atypical antipsychotic clozapine
Prescribing Pearls

Start with an SSRI; plan to treat for 6-12 months

If first SSRI not effective due to intolerable side effects,
or no benefit after ~4-6 weeks at max dose, try a
second SSRI.

If 2nd SSRI not effective, try a second line agent (i.e.
Bupropion or Duloxetine)

Once you fine a med that is effective, but patient still
has symptoms, choose add-on therapy to address those
remaining symptoms.

Anxiety – Clonidine, Guanfacine or Klonopin

Sleep – Trazodone, Mirtazapine

Pain – amitriptyline, gabapentin
Prescribing Pearls

Always counsel about the black box warning, and
instruct patients to call if they have new or worsening
thoughts about self-harm.

Monitor for symptoms of mania/hypomania incase
patient has undiagnosed bipolar disorder.

Counsel patients to expect side effects the first week as
neurotransmitter levels are rising. Side effects become
markedly improved after the first week.

Follow patients monthly until symptoms improve

Cognitive Behavior Therapy is highly beneficial when
patients have access.
6. Insomnia
Insomnia
Insomnia is a sleep disorder that is characterized by
difficulty falling and/or staying asleep. People with
insomnia have one or more of the following symptoms:

Difficulty falling asleep

Waking up often during the night and having trouble
going back to sleep

Waking up too early in the morning

Feeling tired upon waking
Insomnia causes & symptoms
Causes of acute insomnia can include: Causes of chronic insomnia include:
Significant life stress (job loss or
change, death of a loved one,
divorce, moving).

Depression and/or anxiety.

Chronic stress.

Illness.

Pain or discomfort at night.

Emotional or physical discomfort.

Symptoms of Insomnia:

Environmental factors like noise,
light, or extreme temperatures (hot
or cold) that interfere with sleep.

Sleepiness during the day.

General tiredness.

Irritability.

Problems with concentration or
memory.


Some medications (for example
those used to treat colds, allergies,
depression, high blood pressure and
asthma) may interfere with sleep.

Interferences in normal sleep
schedule (jet lag or switching from a
day to night shift, for example).
Sleep Hygiene

Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness.

Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well
known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to
metabolize the alcohol, causing arousal.

Exercise can promote good sleep. Vigorous exercise should be taken in the morning or late afternoon.
A relaxing exercise, like yoga, can be done before bed to help initiate a restful night's sleep.

Food can be disruptive right before sleep. Stay away from large meals close to bedtime. Also dietary
changes can cause sleep problems, if someone is struggling with a sleep problem, it's not a good time
to start experimenting with spicy dishes. And, remember, chocolate has caffeine.

Ensure adequate exposure to natural light. This is particularly important for older people who may
not venture outside as frequently as children and adults. Light exposure helps maintain a healthy
sleep-wake cycle.

Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and
activities before trying to go to sleep. Don't dwell on, or bring your problems to bed.

Associate your bed with sleep. It's not a good idea to use your bed to watch TV, listen to the radio, or
read.

Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the
room should not be too hot or cold, or too bright.
Retrieved April 7, 2015
http://sleepfoundation.org/ask-the-expert/sleep-hygiene?page=0%2C0
Sleep Hygiene

regularize sleep and wake times,

avoid caffeine,

create dark and quiet sleep environment, and

limit napping;

effective for 40% of patients with chronic insomnia
Feb 2015 Audio Digest Family Practice
Stimulus control

avoid looking at clock at night,

do not remain in bed when awake and not drowsy,

avoid screen time (eg, television, computer), and

read, do craft, or do crossword puzzle until drowsy,

then return to bed;

associated with highest level of evidence for effectiveness
Feb 2015 Audio Digest Family Practice
Meds used to treat Insomnia:
1.
2.
Consider treating
underlying
depression/anxiety first
Sleep Meds:
Hypnotics
Ambien
Lunesta
Sonata
Antihistamines
diphenhydramine
Melatonin
Rozerem
Tricyclics
Trazodone
amitriptyline
Benzos
Restoril
Concerns with treatment of insomnia:
1.
Any medication, including over-the-counter meds, used to treat
insomnia are potentially habit-forming and addicting.
2.
Prescription sleep aids are controlled substances.
3.
Should be taken when the patient has a full 8-hours to sleep.
Ambien Zombie Nation

http://video.foxnews.com/v/1843051633001/whats-allthe-commotion-about-ambien/?#sp=show-clips

https://www.youtube.com/watch?v=amAjJ_tgcsQ
Online Resources

NIH – Mental Health
https://www.nimh.nih.gov/health/index.shtml

DSM 5 Manual – Free on Google Docs!

https://docs.google.com/file/d/0BwDYtZFWfxMbWs2UC1WdWJzZTQ/edit?pli=1