We apologize for the length of this newsletter. We are presenting a real case which serves to illustrate the type of information that can be provided in an eConsult, at a time when psychiatry resources are under some pressure.
As we all know, the Hamilton FHT centralized psychiatry service is now closed to new referrals. As staff works to accommodate the backlog of new referrals, it is worth noting that OTN’s eConsult service can be utilized to obtain advice on managing patients with psychiatric issues.
After being accredited with eConsult (see below), there is access to four province-wide psychiatry specialty groups: general, paediatric, perinatal and geriatric, and also 56 psychiatrists who are accredited and set up to do eConsults. One does not have to use a local psychiatrist. Some of the psychiatrists listed have certain limitations which are easily reviewed in their listing on the OTN directory.
For more information about eConsult, including help, general information and technical requirements, please visit our "Quick Links" section in this email. To read about this week's case, scroll down!
If you have specific questions or would like to have OTN setup at your practice, please contact Tsalka Bennett, an OTN representative, at:
REFERRAL: INSOMNIA IN AN ADOLESCENT PATIENT
Adolescent patient with poor sleep, for months, has symptoms of anxiety but not significant enough that I was planning to start pharmacotherapy. Have set up with counselling for CBT. She has been taking Melatonin 10mg qhs with no effect. Was thinking of nortriptyline 10mg qhs or trazadone 25mg qhs as would in adults, however can't find any info on whether this is appropriate in an adolescent. She also recently had a concussion but most of those symptoms have resolved. Teacher is complaining that patient is falling asleep at school because of fatigue. My locum had given lorazepam, but I wasn't keen on that.
Question: What is your recommendation for next steps?
Thank you for this referral. As you may know, medications for insomnia in children and adolescents are all off-label and youth/families should be advised of this. I will provide some options below, from clinical experience and common usage, though the girl and her parents should know that this is the quality of the recommendation and this discussion should be documented in the chart.
No doubt there has already been some conversation about sleep hygiene, as this would be the most important starting place. I have attached a handout I use for youth, with clear guidelines.
I generally begin by taking a clear history with respect to the kind of sleep problems the youth is experiencing, to assist in identifying possible etiologies and optimal strategies. This should include: bedtime and activities before bed, time to sleep onset, middle insomnia, wake up time and any difficulty getting up, daytime sleepiness, naps, substance/ caffeine use, timing of food intake and exercise, bedroom environment, stressors in the evening, possible past traumas in the evening or night-time (e.g. parental conflict or domestic violence), any anxiety symptoms or ruminations before bed, nightmares, restless legs, snoring, parasomnias, etc.
See this link to a reference (Canadian Position Paper on Paediatric Sleep) that provides further details
It would be important to rule out any primary sleep disorders, such as sleep-related breathing disorders and parasomnias. I would advise the youth to keep a sleep log. This can be done via Apps, in smart-phone notes sections, in a diary or on a calendar. Bedtime, time to sleep onset, wake up time and any naps should be recorded.
I would also go over the sleep hygiene guidelines carefully to get a sense of where the trouble spots may lie. Some of these may be habitual and hard to shift, particularly if they are anxiety-related. Parent support and structure can help. It is usually wise to begin with the ‘lowest hanging fruit’ and to move forward step-wise from there, with incentives and encouragement along the way.
Anxiety symptoms, especially anxious ruminations, can be addressed with more specific approaches. I often encourage a step-wise routine, tailored to the individual youth:
- About one hour before bed, turn off electronics and take some time to jot down any worries or ruminations in a separate “worry book” (journal). Beside each, try to reframe the content of the worry with evidence (e.g. “I’m going to fail the test tomorrow and mess up my entire future” can become “I studied the material, I’m as prepared as I can be and I’ll do the best I can – it’s only one test after all”). Talking to a parent can also be helpful for some youth. Once this has been done, the book should be put away. If the worries return, remind yourself that you have written them down and can check them again in the morning.
- If medications will be used, they should be taken at this stage. This can be accompanied by a calming drink, such as ‘sleepy-time tea’ or warm milk with honey. Medication options should be considered shorter term approaches. Giving medications in conjunction with non-pharmacological strategies from the beginning (so that the two become associated in the brain) can boost the efficacy of these strategies once the medication has been tapered down.
- The remaining time before bed should include calming activities with low stimulation, such as quiet reading, stretching, listening to calm music, taking a bath, etc.
- Once in bed, the youth should practice about ten minutes of diaphragmatic breathing (check instructions on YouTube, if needed, or in Apps, such as Calm or Mindshift). This can be accompanied by progressive muscle relaxation (try YouTube again), visualization or other sensory experiences (some youth like certain calming smells or soft things to touch). A mental distraction, such as a detailed visualization, mindful listening to music or rehearsal of lists of mundane objects, can help counter ruminations.
Medication options can include the following:
- Melatonin – this does not seem to be helpful for this girl in the way she has been using it. If it does not work as a sedative and she describes a clear sleep wake cycle shift, it may still be helpful to try good quality melatonin given in somewhat lower doses about 3 hours prior to desired sleep onset.
- Mirtazapine – this sedating antidepressant can be used in very low doses, often with good effect. It is not addictive. In someone with an existing anxiety or mood disorder, its use can be somewhat rationalized by the additional therapeutic benefit for the associated mental health condition.
I tend to start at 3.75mg (1/4 of a 15mg pill) and some youth need only 1.875mg (1/8 of a pill). The dose can be increased to 7.5mg but anything higher tends to lead to weight gain. Even 7.5mg can have this side effect. Keep in mind that any antidepressant can have a slight risk of inducing suicidal thoughts and the youth/parents should be advised of this. It should not be used if there is any risk of bipolar disorder in the girl or a strong family history of this in first degree relatives, because of the risk of a switch to hypomania or mania.
- Trazadone – this is also often used in adolescents and should be seen as similar to mirtazapine with respect to rationale. The starting dose is 25mg, increasing to 50mg or even 75mg in some youth, if needed. Weight gain is not a concern, though the other adverse effects outlined above do apply (e.g. suicidal ideation and risk of hypomania/mania).
- Zopiclone – this is the only one in the group that is specifically designed as a hypnotic. It can work well in low doses (e.g. 5mg) for shorter periods (several weeks), though can lead to some dependence over time and should be avoided if longer term use is anticipated. It can have a bitter aftertaste that leads to discontinuation in some youth.
Please feel free to contact me again for further recommendations, if needed.
We look forward to providing more examples of potential uses for eConsult in the coming weeks and look for dedicated space on the HFHT website for useful eConsult resources!
Choosing Wisely Committee: