Treatment of Depression with Persistent Severe Insomnia − Interactive Case Study

Family History

Father treated for depression since the age of 40.

Personal History

Normal birth and early development, common childhood illnesses, no attention disorders, and no signs of hyperactivity in childhood. Generally healthy in adulthood, but in recent months has repeatedly recorded high or borderline blood pressure, dyslipidemia currently untreated, has had mild obesity since childhood, and gained an additional 3 kg in the past year. Underwent internal and neurological examinations with negative findings.

He has a high school education with a diploma and works as a programmer. He has been happily married for 5 years and is the father of a healthy 3-year-old daughter. There is no evidence of harmful use of any addictive substances in the past or present, except for zolpidem – previously used irregularly, but in recent months due to worsening insomnia, he takes it regularly at 10–15 mg, and notices a weakening effect. Considers himself a rather closed person, a perfectionist, but this does not complicate his life. Previously tried to exercise regularly but recently lacks the energy and motivation.

Psychiatric History and Current Illness

A year ago, he had his first significant psychological problems, which he attributed to the cumulative effect of several long-term stressful situations – arranging a mortgage, moving the family to a new apartment, and demanding, deadline-driven tasks at work. This period lasted more than 2 years. After successfully managing it, he felt exhausted, slept poorly, and irregularly used zolpidem at doses of 5–10 mg. The general practitioner prescribed paroxetine first at 10 mg daily, increasing to 20 mg daily after 2 weeks. He also used zolpidem for sleep problems. He agreed with the doctor on a 3-week sick leave, and his condition significantly improved, he returned to work, and started functioning normally. However, he developed sexual dysfunction, which he clearly associated with the medication. After 2 months of treatment, he decided to stop the antidepressant. He sought a psychotherapist to learn better stress management. He used zolpidem irregularly at doses of 5–10 mg for sleep issues.

After another 6 months, his sleep worsened; he fell asleep well but started waking up earlier, at first by 1 hour, soon by up to 3 hours. He attributes increasing fatigue to the short sleep, has a sad mood, feels worst in the morning, also feels anxious, has a tight stomach, nothing interests him, feels guilty thinking he is incompetent, has trouble concentrating, experiences a persistent loss of libido, and fears work failure. He has no suicidal thoughts. In the afternoon and evening, he feels better. Despite regular use of zolpidem, which he increased to 15 mg, he takes a long time to fall asleep, sleep is short, interrupted, and wakes up prematurely without feeling refreshed. The therapist recommends considering reintroducing an antidepressant, but the patient fears side effects like sexual dysfunction or weight gain.

Questions

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Conclusion

Depressive disorder is a common illness. Treatment of uncomplicated depression without suicidal thoughts and psychotic symptoms is fully within the competence of the general practitioner. In cases of depression with anxiety and insomnia, as in this patient, treatment with an antidepressant that effectively influences anxiety symptoms and sleep from the start of therapy is indicated. This allows for the gradual withdrawal of hypnotics and prevents the use of benzodiazepines, which carries a risk of dependency.

MUDr. Jaroslava Skopová
Department of Psychiatry, Na Homolce Hospital