What treatment approach should be taken for a 21-year-old female with major depressive disorder and adjustment disorder with mixed anxiety and depressed mood who stopped her medications, including selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft) or fluoxetine (Prozac), and is now experiencing insomnia?

Treatment for Insomnia in a Young Adult with Major Depressive Disorder and Adjustment Disorder

For a 21-year-old female with major depressive disorder and adjustment disorder who discontinued her medications and is now experiencing insomnia, cognitive behavioral therapy for insomnia (CBT-I) should be initiated as first-line treatment, with consideration of restarting an SSRI such as sertraline, which has a favorable profile for both depression and anxiety while causing less insomnia than other SSRIs. 1

Assessment of Current Situation

The patient's presentation suggests:

• History of major depressive disorder and adjustment disorder with mixed anxiety and depressed mood
• Recent discontinuation of psychiatric medications (likely SSRIs)
• Development of insomnia (difficulty falling asleep and staying asleep)

Treatment Approach

First-Line Treatment: Non-Pharmacological

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

   • Strongly recommended as first-line treatment for insomnia 1
   • Components include:
     • Sleep hygiene education
     • Stimulus control
     • Sleep restriction
     • Cognitive restructuring
     • Relaxation techniques

2. Sleep Hygiene Measures

   • Maintain regular sleep-wake schedule
   • Create a sleep-conducive environment
   • Avoid heavy meals, caffeine, and alcohol before bedtime
   • Regular exercise (but not close to bedtime)

Pharmacological Management

1. Restart SSRI Treatment

   • Sertraline (Zoloft) would be a preferred option because:
     • Extensively studied and appears to have lower risk of QTc prolongation 2
     • Effective for both depression and anxiety symptoms 3
     • Less likely to cause insomnia compared to other SSRIs like fluoxetine 4
     • Start at low dose (25-50mg) and titrate gradually

2. Short-term Management of Insomnia

   • While CBT-I is being implemented and SSRI is taking effect (which may take 4-6 weeks):
     • Low-dose doxepin (3-6mg) for sleep maintenance insomnia 1
     • Ramelteon (8mg) for sleep onset difficulties 1
     • Both have better safety profiles than benzodiazepines or Z-drugs

Important Considerations

Medication Discontinuation Issues

• Abrupt discontinuation of SSRIs can lead to withdrawal symptoms including insomnia 2
• Symptoms may include dizziness, fatigue, headaches, nausea, and sleep disturbances 2
• These symptoms can persist for weeks after discontinuation

Relationship Between Depression, Anxiety and Insomnia

• Insomnia is both a symptom and risk factor for depression 2
• Untreated insomnia increases risk of recurrent or new-onset depression 2
• SSRIs may initially cause or exacerbate insomnia as a side effect 2, 5

Monitoring and Follow-up

• Schedule follow-up within 7-10 days to assess treatment response 1
• Monitor for side effects and symptom improvement
• Use standardized measures like the Insomnia Severity Index (ISI) to track progress

Pitfalls to Avoid

1. Avoiding benzodiazepines or Z-drugs as first-line treatment

   • Risk of dependence, tolerance, and cognitive impairment
   • Not recommended for long-term use

2. Not addressing the underlying psychiatric conditions

   • Treating insomnia without addressing depression and anxiety will likely lead to treatment failure
   • Insomnia is often comorbid with psychiatric disorders 2

3. Relying solely on medications

   • Combining pharmacological and non-pharmacological approaches is more effective
   • CBT-I has demonstrated long-term benefits beyond medication alone 1

4. Using sedating antihistamines

   • Poor efficacy profile and potential side effects including daytime sedation and anticholinergic effects 1

By implementing this comprehensive approach that addresses both the insomnia and underlying psychiatric conditions, this young patient has the best chance of achieving symptom relief and preventing recurrence of both insomnia and mood symptoms.