Insomnia and Alcohol Use After Myocardial Infarction
48-year-old man attends 6 months after myocardial infarction. He is on aspirin 75 mg, atorvastatin 40 mg, bisoprolol 2.5 mg, and ramipril 5 mg. For 3 months he has had poor sleep, low mood, anhedonia, and fatigue. PHQ-9 score is 14. He drinks 2–3 glasses of arak most evenings to help him sleep; AUDIT-C score is 7. He asks for 'the same sleeping tablets' he received in hospital, diazepam 5 mg at night. He denies suicidal ideation but says he is 'tired of everything' and has stopped going to his chess club. BP 132/80, pulse 58/min. He lives with his elderly mother, whom he cares for, and has no other family nearby. He has not told his cardiologist about the drinking.
1. What is your risk assessment, and why is diazepam inappropriate here?
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The main risks are untreated moderate depression, alcohol misuse, and a cardiac history. Diazepam is inappropriate because benzodiazepines worsen sleep architecture, cause dependence, increase fall risk, and can potentiate alcohol-related respiratory depression. In a patient with ischaemic heart disease and a resting pulse of 58 on bisoprolol, added sedation and bradycardia are hazardous. Benzodiazepines also worsen depression and impair driving. Suicide risk should be assessed directly: he denies ideation, but 'tired of everything' and social withdrawal are warning signs. Ask about plan, intent, past attempts, and protective factors. His PHQ-9 of 14 indicates moderate depression. Alcohol is likely a maintaining factor for insomnia and mood.
2. Outline a treatment plan that addresses depression, alcohol, and sleep without benzodiazepines.
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Use a brief intervention for alcohol: give feedback about his AUDIT-C score, advise reduction, assess readiness, and offer referral. Explain that alcohol disrupts sleep and interacts with his cardiac condition. For depression, start an SSRI such as sertraline 25–50 mg daily, which is generally safe post-MI, and review in 1–2 weeks for side-effects and suicidal ideation. Avoid tricyclics because of cardiac conduction effects. For sleep, offer cognitive behavioural therapy for insomnia, sleep hygiene, and a structured wind-down routine; if medication is needed short-term, consider melatonin rather than a benzodiazepine. Monitor BP, pulse, and adherence. Coordinate with his cardiologist with consent.
3. How would you respond to his request and involve his cardiologist?
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Acknowledge his request and explain why you are not prescribing diazepam: risk of dependence, interaction with alcohol, falls, and cardiac sedation. Offer alternatives and a clear follow-up plan. Do not dismiss his insomnia; validate that sleep is important. Ask permission to contact his cardiologist and share the alcohol and depression plan. Document the discussion, including that he was advised about alcohol and benzodiazepine risks. If he becomes angry, remain calm and explore his concerns; maintain the therapeutic relationship. The reasoning is to avoid a prescribing decision that treats the symptom while worsening the underlying mood, alcohol, and cardiac risk.