Please review the complete instructions. Use at least 2 of the resources, see complete list and attached document. 

Assignment 1: Short Answer Assessment

As a psychiatric nurse practitioner, you will likely encounter patients who suffer from various mental health disorders. Not surprisingly, ensuring that your patients have the appropriate psychopharmacologic treatments will be essential for their overall health and well-being. The psychopharmacologic treatments you might recommend for patients may have potential impacts on other mental health conditions and, therefore, require additional consideration for positive patient outcomes. For this Assignment, you will review and apply your understanding of psychopharmacologic treatments for patients with multiple mental health disorders.

To complete:

Address the following Short Answer prompts for your Assignment. Be sure to include at least 2 references to the Learning Resources for this week. (See below Resources) and attached documents

1. In 3 or 4 sentences, explain the appropriate drug therapy for a patient who presents with MDD and a history of alcohol abuse. Which drugs are contraindicated, if any, and why? Be specific. What is the timeframe that the patient should see resolution of symptoms?

2. List 4 predictors of late onset generalized anxiety disorder.

3. List 4 potential neurobiology causes of psychotic major depression.

4. An episode of major depression is defined as a period of time lasting at least 2 weeks. List at least 5 symptoms required for the episode to occur. Be specific.

5. List 3 classes of drugs, with a corresponding example for each class, that precipitate insomnia. Be specific. 

6. APA 7

7. At least 5 references.



Insomnia and its Impact on Physical and Mental Health

Julio Fernandez-Mendoza & Alexandros N. Vgontzas

Published online: 5 November 2013
# Springer Science+Business Media New York 2013

Abstract In contrast to the association of insomnia with
mental health, its association with physical health has
remained largely unexplored until recently. Based on findings
that insomnia with objective short sleep duration is associated
with activation of both limbs of the stress system and other
indices of physiological hyperarousal, which should adversely
affect physical and mental health, we have recently
demonstrated that this insomnia phenotype is associated with
a significant risk of cardiometabolic and neurocognitive
morbidity and mortality. In contrast, insomnia with normal
sleep duration is associated with sleep misperception and
cognitive-emotional arousal, but not with signs of physiological
hyperarousal or cardiometabolic or neurocognitive morbidity.
Interestingly, both insomnia phenotypes are associated with
mental health, although most likely through different
pathophysiological mechanisms. We propose that objective
measures of sleep duration may become part of the routine
evaluation and diagnosis of insomnia, and that these two
insomnia phenotypes may respond differentially to biological
versus psychological treatments.

Keywords Cardiometabolic morbidity . Insomnia .

Mortality . Neurocognitive impairment . Physiological
hyperarousal . Polysomnography . Poor sleep . Psychiatric
morbidity . Short sleep duration . Sleep disorders . Psychiatry


The prevalence of insomnia in the general population ranges
between 8 % and 40 %, depending on the definition used.
While 20–30 % of the general population has poor sleep (i.e.,
insomnia, symptoms of difficulty initiating or maintaining
sleep, early morning awakening, or non-restorative sleep at
any given time), another 8–10 % of the population suffers
from chronic insomnia [1, 2]. Also, about 4 % of the
population uses sleeping pills on a regular basis [3]. However,
the connection of insomnia with significant medical morbidity
has not been examined until very recently. This has led to
the view of insomnia and its associated mental and
physical health complaints as a minor problem from a
public health perspective.

A factor that may have contributed to this lack of firm
association between insomnia and significant medical
morbidity is the definitions used for this disorder and the lack
of validated objective/biological markers. Sleep disorders
were included for the first time in the Diagnostic and
Statistical Manual of Mental Disorders (DSM)-III-R [4] in
1987, and provided overall diagnostic criteria for “insomnia
disorders” based on the subjective complaints of difficulty
initiating or maintaining sleep or of non-restorative sleep,

SLEEP, Vol. 30, No. 12, 2007 1705


thus adversely affecting quality of life. Sleepiness is an important
public health issue among individuals who work in fields where
the lack of attention can result in injury to self or others such as
transportation and healthcare. Hypersomnia of central origin is a
category of disorders in which daytime sleepiness is the primary
complaint, but the cause of this symptom is not due to “disturbed
nocturnal sleep or misaligned circadian rhythms.”1

Narcolepsy, a disorder characterized by excessive daytime
sleepiness and intermittent manifestations of REM sleep during
wakefulness, is the best characterized and studied central hyper-

somnia. The use of stimulants for treatment of narcolepsy was
the subject of an American Academy of Sleep Medicine (AASM)
review paper in 1994, and formed the basis for practice param-
eters published by the Standards of Practice Committee (SPC) of
the AASM on therapy of narcolepsy with stimulants.2,3 In 2000,
the SPC published a combined review and updated practice pa-
rameters on treatment of narcolepsy that included therapies other
than stimulants.4

Since the publication of the 2000 paper, there have been signif-
icant advances concerning the treatment of hypersomnia to justify
a practice parameters update. In addition, since the publication of
the previous practice parameters, the AASM published a revised
coding manual, the International Classification of Sleep Disor-
ders, Second Edition (ICSD-2).1 The ISCD-2 includes 12 disor-
ders under the category of hypersomnia of central origin. This
updated parameter paper and the accompanying review expanded
the scope of the review and practice parameters to a subset of
disorders in which the primary pathophysiology of hypersomnia
is not related to sleep restriction, medication use or psychiatric
disorder. For these disorders, the use of alerting medications of-
ten represent the primary mode of therapy. The specific disorders
included in these practice parameters are narcolepsy (with cata-
plexy, without cataplexy, due to medical condition and unspeci-
fied) idiopathic hypersomnia (with long sleep time and without
long sleep time), recurrent hypersomnia, and hypersomnia due to
a medical condition. For the remainder of this manuscript, use of

Practice Parameters for the Treatment of Narcolepsy and other Hypersomnias of
Central Origin
An American Academy of Sleep Medicine Report

Timothy I. Morgenthaler, MD1; Vishesh K. Kapur, MD, MPH2; Terry M. Brown, DO3; Todd J. Swick, MD4; Cathy Alessi, MD5; R. Nisha Aurora, MD6; Brian Boehlecke,
MD7; Andrew L. Chesson Jr., MD8; Leah Friedman, MA, PhD9; Rama Maganti, MD10; Judith Owens, MD11; Jeffrey Pancer, DDS12; Rochelle Zak, MD6; S

307 Journal of Clinical Sleep Medicine, Vol. 13, No. 2, 2017

Introduction: The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults,
when such treatment is clinically indicated. Unlike previous meta-analyses, which focused on broad classes of drugs, this guideline focuses on individual
drugs commonly used to treat insomnia. It includes drugs that are FDA-approved for the treatment of insomnia, as well as several drugs commonly used to
treat insomnia without an FDA indication for this condition. This guideline should be used in conjunction with other AASM guidelines on the evaluation and
treatment of chronic insomnia in adults.
Methods: The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine. A systematic review was conducted
to identify randomized controlled trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to
assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and
harms, and patient values and preferences. Literature reviews are provided for those pharmacologic agents for which sufficient evidence was available to
establish recommendations. The AASM Board of Directors approved the final recommendations.
Recommendations: The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment
of chronic insomnia in adults, when such treatment is indicated. Under GRADE, a STRONG recommendation is one that clinicians should, under most
circumstances, follow. A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for
all patients, but should not be construed as an indication of ineffectiveness. GRADE recommendation strengths do not refer to the magnitude of treatment
effects in a particular patient, but rather, to the strength of evidence in published data. Downgrading the quality of evidence for these treatments is predictable
in GRADE, due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias; the relatively small number of eligible
trials for each individual agent; and the observed heterogeneity in the data. The ultimate judgment regarding propriety of any specific care must be made by
the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources.

1. We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
2. We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK)
3. We suggest th

SLEEP, Vol. 29, No. 10, 2006 1277


RING IN APPROXIMATELY 20% TO 30% of infants, toddlers,
and preschoolers. Bedtime problems include bedtime struggles
and bedtime refusal (e.g., verbal protests, crying, getting out of
bed, attention-seeking behaviors). These sleep behaviors usually
fall within the clinical diagnostic category of behavioral insom-
nia of childhood, limit-setting type, in which parents demonstrate
difficulties in adequately enforcing bedtime limits. Night wak-
ings are nocturnal awakenings that are viewed as problematic by
caregivers, generally because they are frequent and/or prolonged
and/or require parental intervention. In general, night wakings fall
within the diagnostic category of behavioral insomnia of child-
hood, sleep onset association type, in which children become
dependent upon specific sleep onset associations (e.g., rocking,
feeding, parental presence) to fall asleep at bedtime and to return

Practice Parameters for Behavioral Treatment of Bedtime Problems and Night
Wakings in Infants and Young Children
An American Academy of Sleep Medicine Report

Timothy I. Morgenthaler, MD1; Judith Owens, MD2; Cathy Alessi, MD3; Brian Boehlecke, MD, MSPH4; Terry M. Brown, DO5; Jack Coleman, Jr., MD6; Leah Friedman,
MA, PhD7; Vishesh K. Kapur, MD, MPH8; Teofilo Lee-Chiong, MD9; Jeffrey Pancer, DDS10; Todd J. Swick, MD11

1Mayo Clinic, Rochester, MN; 2Rhode Island Hospital, Providence, RI; 3VA Greater Los Angeles Healthcare System and University of California,
Los Angeles, Sepulveda, CA; 4University of North Carolina, Chapel Hill, NC; 5St. Joseph Memorial Hospital, Murphysboro, IL; 6Murfreesboro, TN;
7Stanford University, Stanford, CA; 8University of Washington, Seattle, WA; 9National Jewish Medical and Research Center, Denver, CO; 10Toronto,
Ontario, Canada; 11Houston Sleep Center, Houston, TX

Review of Bedtime Problems in Children—Morgenthaler et al

Disclosure Statment
This was not an industry supported study. Dr. Morgenthaler has received re-
search support from Itamar Medical Ltd. and ResMed Research Foundation;
and has received research equipment from Olympus. Dr. Owens is a consul-
tant for Eli Lilly, Sanofi-Aventis, Cephalon, and Shire; has received research
support from Eli Lilly, Cephalon, and Sepracor; and is a speaker for Eli Lilly,
Cephalon, Sanofi-Aventis, and Johnson & Johnson. Dr. Alessi is a consul-
tant for Prescription Solutions, Inc. Dr. Kapur has received research support
from the Washington Technology Center and Pro-tech Services, Inc.; and
has received research equipment from Respironics. Dr. Swick has received
research support from Sanofi-Aventis, Takeda Pharmaceuticals, Merck, Jazz
Pharmaceuticals, Pfizer, Somaxon, Astellas-Pharmaceuticals, and Cepha-
lon; and is on the speakers’

Th e Pathophysiology of Insomnia

Jessica C. Levenson , PhD ; Daniel B. Kay , PhD ; and Daniel J. Buysse , MD

Insomnia disorder is characterized by chronic dissatisfaction with sleep quantity or quality

that is associated with diffi culty falling asleep, frequent nighttime awakenings with diffi culty

returning to sleep, and/or awakening earlier in the morning than desired. Although progress

has been made in our understanding of the nature, etiology, and pathophysiology of insomnia,

there is still no universally accepted model. Greater understanding of the pathophysiology of

insomnia may provide important information regarding how, and under what conditions, the

disorder develops and is maintained as well as potential targets for prevention and treatment.

The aims of this report are (1) to summarize current knowledge on the pathophysiology of

insomnia and (2) to present a model of the pathophysiology of insomnia that considers evi-

dence from various domains of research. Working within several models of insomnia, evidence

for the pathophysiology of the disorder is presented across levels of analysis, from genetic to

molecular and cellular mechanisms, neural circuitry, physiologic mechanisms, sleep behavior, and

self-report. We discuss the role of hyperarousal as an overarching theme that guides our concep-

tualization of insomnia. Finally, we propose a model of the pathophysiology of insomnia that

integrates the various types of evidence presented. CHEST 2015; 147� ( 4 ): 1179 – 1192

ABBREVIATIONS: GABA 5 g -aminobutyric acid ; MnPO 5 median preoptic area ; NREM 5 non-rapid eye
movement ; PEP 5 pre-ejection period ; PSG 5 polysomnography ; REM 5 rapid eye movement ; SNP 5
single-nucleotide polymorphism ; TMN 5 tuberomammillary nucleus of the posterior hypothalamus ; VLPO 5
ventrolateral preoptic area

[ Contemporary Reviews in Sleep Medicine ]

Manuscript received July 3 , 2014 ; revision accepted October 28 , 2014 .

AFFILIATIONS: From the Department of Psychiatry, University of
Pittsburgh School of Medicine, Pittsburgh, PA.

FUNDING/SUPPORT: Dr Buysse is supported by the National Institutes
of Health [Grants MH024652, MH102412, AG020677, and HL125103].
Drs Levenson and Kay are supported by the National Institutes of
Health [Grant HL082610, T32, PI Buysse].

CORRESPONDENCE TO: Daniel J. Buysse, MD, University of Pittsburgh,
3811 O’Hara St, WPIC E-1127, Pittsburgh, PA 15213; e-mail: buyssedj@