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4 Case study: Nick
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This case illustrates the diagnosis and management of insomnia
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-:Z associated u.,ith clinical depression. lt serves to highlight the
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,-i close relationsl-rip between sleep disturbances and psychiatric
disorders and emphasises the importance of actively treating
ti
both conditions to achieve positive patient outcomes'
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A{ter completing this case participants should be able to:
--
Differentiate betrnreen primary and secondary
-= (co-morbid) insomnia

z Discuss the link bet$/een insomnia and depression

I * Describe the sleep disturbances seen in patients
',"-A vvith depression Module 2
tl- Rhythm and blues:
"14 s Detail the pharmacologlcal management of insomnia

b 6
associated \ /ith depresslon
Understand the different aspects of non-pharmacological
The management of
insomnia in Patients
b therapy that might be used with depression vvith depression

i> * Evaluale the need for specialist care

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 C

€
C

Nick, a 22 year old C

university student comes to
your clinic and mmplains of: C
o Pmblems wi$r his sleep - he
can't get up in the rnoming and C
neverfuels like he has a good
nights sleep and always feels C
exhausted
o He has exams approaching and C
wants you to prescribe
something to help him sleep C

Presentation C
Nick visits your clinic and reports that he is having problems
with his sleep. He never feels like he gets a good nights sleep C
and it is beginning to impact on his study. Mid-year exams are
approaching and he asks for a prescription for sleeping pills to e
get him through the next fevrr weeks.
e
On questioning he reports that he " just can'1 get up in the
t--*'
-**-^-*,---;
morning" and is constantly exhausted. f
, c
e
e
I vlodute 2
Rhythm and blues: e
The management of
a
insomnia in patients
with depression a
a
a
..,-..a=.*

"-_*_"_-*.-.
a
a
a
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 22 yer oH university sfudent living away from
horne
He describes his sleep pmHems as:
o Unable to full a$eap till afier Zam, or
o l{lfak* boea*yin the moming
q Feels like he has never had enorgh sleep
Yol ask him about hb generalwellbeing and he
responds thaf
o llb uni$ersity grades are falling as he cen"t mncentsate
o At a r*sdt he b thinkirq of giying up unirrersity at the end
af the year - 'Y\lhat is the point if 1 just fail my exams?F and,
o "l'm not lnteested in smidising wih my friends anywat'

History
Nick is in his second year of an economics degree at the local
university. He is from out of town and lives in shared student
accommodation.
You ask him to describe his problems rnzith sleep. He reports that
he is unable to fall asleep iill after 2ar*, or on the nights that
he does manage to fall asleep "l vvake up any\ ray at about 4 or
5am". Consequently, he feels like he has never had enough sleep
and is constantly tired and lethargic.
You ask him about his general wellbeing and horru university life
is going. He admits that over the past fernr months his university
grades are falling as he can't concentrate. As a result he is
thinking of giving up university at the end of the year. He believes
he jusl needs some help to get through the next fe\A/ rnreeks and Module 2
then he is "out oJ here". Rhffthm and blues:
You ask him rnrhy he rnrants to give up university and he responds The managernent of
"What is the poir:t if I just fail my exams?". His mocd changes insomnia in patients
and he gets very low, and mentions that he n/on'l miss university urith depression
life and he isn't interested in the social side of university li{e and
he has lost contact with many of his friends. He admits to feeling
verv'lornr'.
 Physical
o BP, haart, pulse, Bill all nmnal
o Frsious bhod iests were all normd

MedicalHistory:
s f*opsy&iatrichtslory

Social History:
a &inks atmhol socidly and rp to 6 or 7 cups of
offie a day; no illicit drugs
o Reports tds rypefite has decreased and las*s
ene|Is
o lSe h*no girlFierd, a wide drch of ti$ds (ftat he
has wi8rdrawn fun), he talks to his parents on he---

History
This slide outlines the results from a complete physical exam,
including blood pressure and heart rate measurement urhich are
necessary to exclude other medical conditions. Nick had blood
tests done 6 months previously and they returned normal. Nick
has no previous psychiatric historv.
On questioning him on his social history you elicit the follornring
response:
Nick reports that he drinks alcohol socially, but usually on the
weekends. He has never been a "big drinker" and probably has 3
or 4 beers on a Friday or Saturday night. Hornrever, he hasn't been
out with his friends in the past couple of months, so has not had
many drlnks. Module 2
He proudly reports he is a "caffeine addict" and calculates he Rhythm and blues:
drinks 6 or 7 cups of ccffee a day. His intake increased rnrhen
he started having sleep problems. The management of
insomnia in patients
He does not take illicit drugs. with depression
You ask him to describe his appetite and he reports "l survive on
caffeine!". He used to share cooking rruith his flatmates. but now
"can't be bothered". He has no girlfriend and although he has
many friends from the previous year rruhen he raras in university
halls of residence, he has lost contact with many of them. His
mother calls him every Sunday night on the phone.
 Markedly diqrinished intercst or pleasure in
activities f
o Signifteant*eight loss
s Insmnia or hypersomnia El
o Psychomobr agitation or rctardation
o Faligue 0rloss otenergy d
o Feelings of trfloilhleseness or exessirre or
in*ppropriate guilt
Diminished ability tq$ink or mncenfate,
or indecisirreness ff
Recurnnt thougfrb of death orsuicide" or
atbmpled sui'ei&

Discussion points
Nick is suffering from insomnia secondary to depression.
Differentiate bet\ /een primary insomnia and insomnia secondarv
to another problem. Psychiatric, medical, behavioural.
psychosocial and pharmacological factors that could underlie the
complaint of insomnia may be explored.
Discuss the factors that may cause insomnia (e.g. mood \".
disorders, such as depression; drugs, such as selective serotonin n
reuptake inhibitors [sSRls]) or contribute to it (e.g. coffee intake. \
illicit drugs, alcohol) in this case.

Discuss the DSM-IV definition of depression, relating these

issues to Nick's case. Module 2 1
1

The diagnostic criteria for major depressive disorder are listed in Rhythm and blues:
this slide. The management of
insomnia in patients
Minor depressive disorder requires at least two, but feurer than rruith depression
five depressive symptoms during the same Z-week period.
Five {or more) of the symptoms have to have been present during
the same 2-ureek period and represent a change from previous
functioning; at least o,ne of the symptoms is either: 1) depressed
mood; or 2i loss of interest or Dleasure.
symptoms that are clearly due to a general medical condition.
or mood-incongruent delusions or hallucinations, should not il****---o
be included.
E

E lilanagement plan
E
I You diss.rss the follovring
1 appmaches with Nick:
o Treshnenthrdepesslon
E' o Referral for penana$cogrdtive {ll*rqy
o Cutting &ruvn on cafieine

I c Flecsnrirend eleep hlgiene ard

highlighl tt€ importance of exsrise
o Sbephlqiene
o Gdngio bed ard gei$rE uF etlhs
= sr€ lime e\,ery day- encdrr€e Nid(
€ to sel an alarrn
o D*ehping a bdinc ritual {herbal tea
and utarm shower)
--t a lf he cen't Elesp lmu |€csrnnHld h6
- geb up end doe$ somelhLq quiel out
of tha be*oan far 15 mirubs

Managernent plan
Behavioural changes, which may take longer to become effective.
provide results that are unde:'the patients control.
Behavioural approaches include:
r Counselling I psychotherapy fo:, depression
i
. Encouraging use of relaxation techniques (e.g. progressive
muscle relaxation)
r ?romoting sleep hygiene (including exercise and alcohol,/
caffeine intake modification)

Module 2
Rhythm and blues:
The management of
insomnia in patients
vvith depression

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