Patient Management Exercise: Disorders of Sleep

Shirley is a 32-year-old woman who was referred to you by her primary care physician. She had initially sought care there but has been referred for specialty care because she was still symptomatic after many weeks of unsuccessful interventions. Her chief complaint remains “I can't sleep and I'm too tired all the time.”

Shirley is a married mother of two girls (ages 6 and 1.5 years) and is currently staying at home to take care of the children. Before stepping out of the workforce, she had been a mid-level administrator at the local hospital. According to the chart notes you've received, she had been in her usual state of good health until about 4 months ago, when she noted that she was feeling tired all the time and had poor-quality sleep. She had originally reported to her primary care physician (PCP) that she would lie in bed for over an hour when trying to go to sleep, tossing and turning and “with my head full of thoughts.” She felt drowsy during the day and sometimes would nod off in the afternoon when her younger daughter took a nap. She had denied feeling “depressed” but did endorse having an ill-defined, “free-floating anxiety” and irritability that was present much of the time. Her appetite was diminished, but she welcomed this as she was still trying to lose 30 pounds she had gained during her pregnancy. The chart noted that she had some indigestion on review of systems.

In the consultation request and chart notes, her PCP indicates that prior efforts with attention to sleep hygiene (i.e., cool room, no TV/reading/computer use in bed, and so on) and a 2-week trial of lorazepam (0.5 mg) at bedtime had been unsuccessful.

As you collected your own history and examination data, you were struck by how exhausted and depleted Shirley appeared. She reported anxieties and an internal sense of dread but appeared psychomotor slowed. She reported that she drinks two cups of coffee a day, both before 2 p.m.; she denied any recent use of alcohol, drugs of abuse, or herbal/botanical agents. She also endorsed feeling irritable (“short fuse with my kids”), experiencing a loss of interest in playing with her daughters (“they just wear me out”), having a loss of appetite with 7 pounds of weight loss over the past 2 weeks, having insomnia (difficulty falling and staying asleep), being slowed down, having profound fatigue and loss of energy, feeling that she is “failing” in her roles as a mother and as a wife, and having periods of being unable to concentrate long enough to help her 6-year-old with homework assignments. She reported that “life can't go on like this,” but she denied any thoughts of self-harm or suicide. She reported that she does not snore and has no symptoms of heartburn or indigestion.

Because you practice measurement-based care, you had her complete the Quick Inventory of Depressive Symptomatology (Self-report) (QIDS-SR) 16-item questionnaire before you began your evaluation. Her answers confirmed the data you had elicited in the interview, and her score of 14 indicated a moderate level of symptom severity.

She had never before taken psychotropic medications other than the lorazepam prescribed by her PCP. Her mother may have been depressed when the patient was a little girl, but her memories are imprecise. Shirley has a younger sister who is alive and well.

You convince Shirley that a trial of a selective serotonin reuptake inhibitor may help her to feel better, both for her sleep and for other aspects of her current distress. She also wishes to continue lorazepam at a higher dose, because it did help her fall asleep sometimes (partial response). She is willing to keep a sleep diary and bring it back at her next visit.

She returns after 2 weeks and reports that she is feeling somewhat better. Her awakenings in the middle of the night have decreased from every night to only three times in a week. Her daytime irritability has also improved, as has her energy. She had some gastrointestinal side effects in the first week of her new regimen, but followed your guidance about taking the antidepressant after eating breakfast and had been able to tolerate it adequately.

She returns again after 4 weeks of treatment and feels significantly better. Her QIDS-SR score has fallen to 7, nearly into the range of remission. She tells you that keeping the diary has helped her focus on the thoughts attached to her anxieties, and she has seen connections to aspects of her remote history that did not previously seem relevant. When she was 6 years old, her father had an extramarital affair that introduced a great deal of emotional turmoil into her family of origin. Because her older daughter has recently turned 6, she thinks she may have thought more about her own childhood experiences at that age, and acknowledged having fears that her own husband would lose interest in her (because she was irritable, overweight, and intellectually sluggish) that may have been triggered by these recollections. She reports that her husband found her weeping one day and she told him of her fears. They had a long talk and he reassured her that his love for her was strong, that he was not going to behave as her own father had, and that actually he would enjoy spending more “grown-up” time with just the two of them but had not pressed the issue because she had seemed so tired. She reported they let their daughters have a sleepover at a friends' home the previous Saturday night and had been able to enjoy each other's company anew without the pitter-patter of little feet as an interruption.