Assignment: Malingering and Addiction in the Treatment of Sleep Disorders

According to the National Sleep Foundation (2013), about 30–40% of the general population reports some level of insomnia during their lives, and 10–15% experience significant, chronic insomnia. For these individuals, medications to help induce and sustain sleep may be helpful. On the other hand, sleep aids pose potential concerns, namely abuse.

Some people exceed recommended doses, and some continue taking medications even after symptoms are no longer present. Others obtain medications under false pretenses, which is one form of malingering. Malingering occurs when clients make up or exaggerate symptoms for some personal gain.

Although mental health professionals may not be directly implicated in the client’s deceit, their unique position to receive more accurate and honest information than malingering other medical professionals presents ethical concerns.

What is the mental health professional’s role in these instances? In which instances would it be appropriate to break confidentiality due to a concern of malingering? How could the potentiality be planned for and avoided? 

For this Assignment, conduct an Internet search or a Walden Library search for at least one peer-reviewed journal article that addresses a counseling issue related to malingering and addiction in treating sleep disorders.

BY DAY 7

In a 3- to 5-page, APA-formatted paper, include the following:

• A description and explanation of the major types of drugs prescribed for sleep disorders
• An explanation of the potential for addiction associated with these medicines
• An explanation of the issues related to malingering in the treatment of sleep disorders
• An explanation of the mental health professional’s role in mitigating the potentialities of malingering

Support your explanations with specific references to the Learning Resources and your peer-reviewed journal article

Assessing and Treating Patients with Sleep/Wake Disorders Example

Mental health disorders diagnosis and management are often symptomatic. Care providers use symptoms according to DSM 5 to diagnose and prescribe medications according to their effectiveness and FDA approval. Care providers observe patients’ responses and determine the management interventions depending on their response to the interventions. Psychiatric/mental health nurses play vital roles in assessing patients, and prescribing the correct medication interventions is integral. Insomnia is a mental health issue defined as trouble initiating or maintaining sleep and waking up early.

Insomnia accompanies most conditions, such as Alzheimer’s disease. It also arises from environmental stressors such as depression and medications such as alpha and beta blockers. Insomnia can negatively affect health and productivity and should be promptly addressed while paying attention to the adverse effects and their effects on life quality. This essay reviews management interventions for insomnia patients and explains the reasons behind the decisions.

Decision Point One

The patient presents with insomnia and clarifies that he has trouble falling asleep and maintaining sleep. The patient admitted to having less sleep at night and had an incidence of sleeping at work for not having enough night sleep, which is dangerous given the risky nature of his job. The patient also reports that his symptoms worsened after losing her fiancé. He used diphenhydramine for a while but stopped due to the side effects. The goals of the first decision are to ensure the patient has no problems initiating or maintaining sleep, does not sleep at work or, experiences daytime sleepiness, and reduces risky incidences at work.

The first decision is to initiate Zolpidem 10mg at bedtime. Zolpidem is a sedative-hypnotic in the class of imidazopyridines and a GABA A receptor agonist. It is an FDA-approved medication for short-term insomnia management (Xiang et al., 2020). According to Bouchette et al. (2022), the medication is helpful for patients with problems initiating sleep, improves sleep duration, and reduces night awakenings in transient insomnia. These functions match the requirements of patients who have trouble initiating and maintaining sleep. The approved dose in adults is 10mg and 5mg in the elderly.

Trazodone is an antidepressant medication often used in major depression, mood and anxiety disorders, and sleep disorders. Trazodone is a serotonin antagonist and reuptake inhibitor that is FDA-approved for depression (Stern et al., 2016). According to Madari et al. (2021), The medication is effective at doses between 20-100mg and reduces the risks for tolerance and daytime sleep. It can also be helpful for this patient who admits to being depressed after losing his partner. However, there is insufficient data on its effectiveness in insomnia; thus, the medication is not FDA-approved for insomnia but has off-label uses in managing insomnia. Thus, it is not the decision of choice.

Hydroxyzine is an antihistamine often used for allergic reactions. The medications’ drowsy effects take 4-6 hours, hence their limited use in managing sleep. The medication is FDA-approved for providing sedation (hence used as premedication in procedures), relieving anxiety symptoms, and relieving skin itchiness in atopic dermatitis (Krzystanek et al., 2020). The medication helps relieve insomnia resulting from anxiety. However, the medication is not approved for FDA-approved for insomnia. In addition, the patients admit to developing severe side effects that affect his uptake of antihistamines; thus, this medication is not the medication of choice. Therapy changes using drugs in the same class are done with caution due to the possibility of severe side effects.

It is also essential to consider the safety and effectiveness of the medication before medication. In addition, it is essential to consider the side effects of medications that could interfere with intake. For example, medications with low efficacy or late onset of action may not help manage acute symptoms. It is vital to avoid medication with a short maximum use period. Trazodone is licensed for use for a maximum of 2 weeks. Patient safety is essential, and for initiating therapy, the FDA recommends that healthcare providers prescribe FDA-approved medications and only use off-label mediations in rare occasions such as resistance, known greater efficacy, and unavailability of FDA-approved medications (Bouchette et al., 2021).

Decision Point #2

Once care providers make a medical management decision, they observe the patient’s reaction and make medical decisions depending on side effects and effectiveness in managing the symptoms. The patient had a night wakening, does not recall the incident, and says he sleeps well. He claims the medication knocked him out. The desired outcomes of this decision are the maintenance of effectiveness in sleep management and the reduction of complex sleep behaviors.

Harbout et al. (2020) note that zolpidem and other medications, such as zaleplon, have an FDA-black box warning indicating their risk for injury due to complex sleep behaviors that they do not remember later. The medication has led to symptom relief, but the side effects may warrant dose adjustment; reducing the doses when side effects arise is a recommended intervention by the FDA. Thus, reducing the drug dose to 5mg from 10mg is the intervention of choice.

Eszopiclone is an FDA-approved medication for insomnia. The symptoms of interest in this patient are complex sleep behaviors, such as waking up and doing roles that he has no memory of in the morning. Eszopiclone, zaleplon, and zolpidem are medications with increased risk for complex sleep behaviors and are thus not a drug of choice (Harbout et al., 2020). Its side effect profile also rules out its use in insomnia. Its typical side effects include daytime drowsiness, lightheadedness, and loss of coordination, which present symptoms similar to those the patient presented on the first visit, ruling out the decision.

Trazodone, as discussed earlier, is a non-FDA-approved medication. The dose is within the minimum and maximum licensed doses. However, the patient is already responding to the medication prescribed, and thus, there is no need for a therapy change. However, the drug can be considered if selected insomnia medications are ineffective or cause undesirable side effects (Maradani et al., 2021). The patient reports reduced sleep awakening and trouble initiating sleep and reports sleeping well. The side effects that arose do not require a therapy change but a dose reduction and subsequent observation. However, their persistence may warrant therapy changes.

In this decision, the principle of non-maleficence applies. The intention is to ensure that the decision made relays the least harm and maximum benefits to the patient. The medication given, zolpidem, is effective in managing insomnia symptoms but has led to undesirable effects. A reduction in the dose of the medication is the intervention of choice to help reduce the side effects while maintaining clinical effectiveness. The drug’s lowest licensed dose is 5mg before bedtime; thus, reducing the dose will maintain the drug’s efficacy and reduce the side effects.

Decision Point Three

The third decision depends on the current patient presentations. The patient returns to the hospital after reducing the dose to 5mg before bedtime. The symptoms have significantly reduced, and the patient likes the drug due to its ability to help him maintain sleep. However, the complex behaviors have not ceased and have persisted. This decision aims to eliminate the side effects while maintaining insomnia management. Despite Zolpidem FDA-approval, the medication has a horde of side effects preventing its first-line use (Mittal et al., 2021).

Choice decides to discontinue zolpidem and start the patient on trazodone 50mg. Mittal et al. (2021) note that the medication is highly effective in insomnia but is a double-edged sword due to its severe side effects, especially on complex sleep behaviors. These complex behaviors, such as waking up and preparing to go to work, can lead to activities that can cause harm, such as leaving the house at night. The medication should be stopped to prevent the patient from any harm.

Intermezzo is a brand for zolpidem, and these medications have similar structure and effectiveness and thus carry a high risk for recurrence or worsening of these symptoms. Thus, intermezzo 5mg sublingually before bedtime is not the decision of choice. Trazodone is a well-tolerated medication with fewer side effects compared to the medication (Madari et al.., 2021). The drug is administered in small doses, reducing the side effects severity.

Titrating the medication between 50 and 100 mg on the upper limit will allow the care providers to study the drug’s efficacy, tolerability, and side effects (Madari et al., 2021). The medication will help address the symptoms because studies show that trazodone is not associated with complex sleep behaviors and is, thus, a choice drug. Continuous patient observation and review of the medications will help with management and prevent complications.

The most critical ethical consideration is non-maleficence. Despite the effectiveness of the medication, the patient is experiencing marked complex sleep behaviors that potentially affect his life. Patients who perceive a medication as a threat can fear poor drug adherence affecting remission. Thus, changing the therapy to help manage the side effects is vital to maintaining the patient’s adherence and confidence in the mediation.

Conclusion

Insomnia can affect various aspects of life, and its management should be well-evaluated to ensure it does not affect other aspects. Zolpidem is an effective medication for insomnia but carries a significant risk for complex sleep behaviors, which could negatively impact patient safety. Thus, the medication is often avoided as the first-line treatment despite its FDA approval. Assessing the patient and collecting relevant data during every visit helps care providers determine patient needs and intervene accordingly.

Zolpidem achieves the therapeutic targets but leads to the development of undesirable side effects that do not cease with drug reduction. A change of therapy to trazodone, an effective off-label drug, is the intervention of choice due to its high efficacy and fewer side effects. Healthcare providers should assess therapeutic interventions regularly to ensure they produce the desired effects and their benefits outdo any harm they relay to the patients.

Assignment: Malingering and Addiction in the Treatment of Sleep Disorders References

Bouchette, D., Akhondi, H., & Quick, J. (2022). Zolpidem. In StatPearls [Internet]. StatPearls Publishing.

Harbourt, K., Nevo, O. N., Zhang, R., Chan, V., & Croteau, D. (2020). Association of eszopiclone, zaleplon, or zolpidem with complex sleep behaviors resulting in serious injuries, including death. Pharmacoepidemiology and drug safety, 29(6), 684–691. https://doi.org/10.1002/pds.5004

Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in the treatment of insomnia–superstitions and evidence. Pharmacotherapy in Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33-40.

Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological management of insomnia. Neurotherapeutics, 18(1), 44-52. https://doi.org/10.1007/s13311-021-01010-z

Mittal, N., Mittal, R., & Gupta, M. C. (2021). Zolpidem for insomnia: a Double-edged Sword. a Systematic Literature Review on Zolpidem-induced Complex Sleep behaviors. Indian Journal of Psychological Medicine, 43(5), 373–381. https://doi.org/10.1177/0253717621992372

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of zolpidem in the treatment of insomnia disorder for one month: a meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250-256. https://doi.org/10.1016/j.sleep.2021.09.005

REQUIRED READINGS for Assignment: Malingering and Addiction in the Treatment of Sleep Disorders

Lichtblau, L. (2011). Psychopharmacology demystified. Clifton Park, NY: Delmar, Cengage Learning.

• Chapter 6, “Anxiolytic-Sedative-Hypnotic Drug Pharmacotherapy” (previously read in Week 5)

Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2017). Handbook of clinical psychopharmacology for therapists (8th ed.). Oakland, CA: New Harbinger.

• Chapter 15, “Other Miscellaneous Disorders” (pp. 161-174)
• Assignment: Malingering and Addiction in the Treatment of Sleep Disorders

Murdach, A. D. (2006). Social work and malingering. Health & Social Work, 31(2), 155-8.

National Institute of Neurological Disorders and Stroke. (2014). Brain basics: Understanding sleep. Retrieved from http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm#sleep_disorders
As you review this website, consider the types of sleep disorders associated with mental health treatment.