What is recommended for a 73-year-old male with insomnia, currently on escitalopram (Selective Serotonin Reuptake Inhibitor), who did not respond to trazodone (triazolopyridine)?

From the Guidelines

For a 73-year-old male on escitalopram experiencing sleep difficulties where trazodone was ineffective, I recommend trying cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment. CBT-I has been shown to improve global outcomes, including increased remission and treatment response, and reduced insomnia severity index (ISI) and Pittsburgh Sleep Quality Index (PSQI) scores compared with controls 1. This approach is particularly beneficial for older adults, as it can be performed in primary care and has minimal side effects.

Some key components of CBT-I include:

• Cognitive therapy around sleep
• Behavioral interventions, such as sleep restriction and stimulus control
• Education on sleep hygiene

If CBT-I is not effective, consider adding a low-dose sedating medication, such as eszopiclone or zolpidem, under the guidance of a healthcare provider. These medications have been shown to improve sleep outcomes, such as sleep onset latency and total sleep time, in adults with chronic insomnia disorder 1. However, it is essential to weigh the benefits and harms of pharmacologic treatment and use the lowest effective dose for the shortest possible duration.

Additionally, maintaining consistent sleep-wake times, avoiding caffeine after noon, limiting evening screen time, and creating a cool, dark sleeping environment can also help improve sleep quality. If these options do not help, discuss with your doctor about switching from escitalopram to another antidepressant with less sleep disruption potential. Sleep problems are common with escitalopram, and finding the right solution often requires trying different approaches under medical supervision.

From the FDA Drug Label

1. 1 Controlled Clinical Trials Chronic Insomnia Three randomized, doubleblind trials in subjects with chronic insomnia employing polysomnography (PSG) were provided as objective support of ramelteon's effectiveness in sleep initiation The second study employing PSG was a three-period crossover trial performed in subjects aged 65 years and older with a history of chronic insomnia Subjects received ramelteon (4 mg or 8 mg) or placebo and underwent PSG assessment in a sleep laboratory for two consecutive nights in each of the three study periods. Both doses of ramelteon reduced latency to persistent sleep when compared to placebo.

The patient is a 73-year-old male who is having trouble sleeping and has not responded to trazodone. Ramelteon may be a suitable alternative for treating insomnia in this patient, as it has been shown to be effective in reducing sleep latency in older adults with chronic insomnia 2.

• The recommended dose for older adults is 4 mg or 8 mg per night.
• It is essential to note that the patient is currently taking escitalopram, and there is no direct information in the provided drug label about potential interactions between ramelteon and escitalopram.

From the Research

Sleep Disturbances in Patients Taking Escitalopram

• Patients taking escitalopram, such as the 73-year-old male in question, may experience sleep disturbances, including insomnia 3, 4.
• Trazodone is sometimes prescribed to help with sleep, but in this case, it was not effective.

Alternative Treatments for Sleep Disturbances

• Melatonin has been shown to be effective in improving sleep quality and reducing daytime drowsiness, with fewer adverse effects compared to trazodone and doxepin 5.
• Doxepin is also an effective treatment for sleep disturbances, but it may have more adverse effects than melatonin, such as dry mouth 5.
• Ramelteon, a melatonin receptor agonist, has been shown to be effective in treating insomnia and has a favorable safety profile 6, 7.

Considerations for Treatment

• When evaluating treatment options for sleep disturbances in patients taking escitalopram, it is essential to consider the potential benefits and risks of each medication, including their effects on sleep quality, daytime drowsiness, and adverse effects 5, 6, 7.
• The choice of treatment should be based on the individual patient's needs and medical history, as well as the potential for interactions with other medications, such as escitalopram 3, 4.