What adjustments can be made to a 61-year-old female patient's medication regimen, currently consisting of sertraline (selective serotonin reuptake inhibitor) 150 mg (milligrams) orally every morning, depakote (divalproex sodium) dr (delayed release) 250 mg po (by mouth) twice daily, melatonin 10 mg po qhs (every bedtime), and trazodone 50 mg po qhs, to address her complaint of sleep onset insomnia?

Managing Sleep Onset Insomnia in a 61-Year-Old Female Patient with MDD and Impulse Disorder

For your patient with sleep onset insomnia, you should discontinue trazodone and melatonin, and consider adding zaleplon 10 mg, eszopiclone 2 mg, or ramelteon 8 mg at bedtime to specifically target sleep onset difficulties. 1

Current Medication Analysis

Your patient is currently taking:

• Sertraline 150 mg PO QAM (for MDD)
• Depakote DR 250 mg PO BID (for impulse disorder)
• Melatonin 10 mg PO QHS (for sleep)
• Trazodone 50 mg PO QHS (for sleep)

Problems with Current Sleep Medications

1. Trazodone:

   • The American Academy of Sleep Medicine (AASM) specifically recommends against using trazodone for sleep onset insomnia 1
   • Current evidence shows that harms may outweigh benefits for insomnia treatment 1
   • The 50 mg dose your patient is taking matches exactly the dose that clinical trials found ineffective 1

2. Melatonin:

   • AASM guidelines recommend against using melatonin for sleep onset insomnia 1
   • Clinical trials with 2 mg doses showed insufficient evidence of benefit 1
   • Your patient is taking 10 mg, which is a high dose without proven additional benefit

Recommended Medication Changes

First-Line Options (in order of preference):

1. Zaleplon 10 mg PO QHS:

   • Specifically recommended for sleep onset insomnia 1
   • Short half-life minimizes morning grogginess
   • Low risk of drug interactions with her current medications

2. Eszopiclone 2 mg PO QHS:

   • Effective for both sleep onset and maintenance insomnia 1
   • 2 mg dose is appropriate for elderly patients 2
   • Clinical trials show significant decrease in sleep latency 2

3. Ramelteon 8 mg PO QHS:

   • Specifically indicated for sleep onset insomnia 1
   • Melatonin receptor agonist with better evidence than melatonin itself
   • Favorable safety profile in older adults 3

Implementation Plan

1. Discontinue both trazodone 50 mg and melatonin 10 mg
2. Start one of the recommended medications above
3. Maintain sertraline 150 mg PO QAM and Depakote DR 250 mg PO BID
4. Implement sleep hygiene measures:
   • Consistent sleep-wake schedule
   • Limit screen time before bed
   • Create a calm, quiet, dark sleep environment

Monitoring and Follow-up

• Assess effectiveness for sleep onset within 1-2 weeks
• Monitor for adverse effects:
  • Morning grogginess (especially with eszopiclone)
  • Dizziness
  • Unpleasant taste (common with eszopiclone)
  • Potential for falls (especially important in nursing home setting)

Important Considerations

• Avoid benzodiazepines in this 61-year-old nursing home patient due to increased risk of falls, cognitive impairment, and dependence
• Be cautious with zolpidem in elderly females due to slower metabolism and increased risk of next-day impairment
• Consider drug interactions with sertraline and Depakote when selecting a sleep medication

Recent evidence shows that trazodone, despite being commonly prescribed for insomnia, has a moderate level of evidence suggesting harms outweigh benefits for sleep onset insomnia 1, making it a poor choice for this patient's specific complaint of difficulty falling asleep.