What are the primary approaches to managing insomnia as classified under ICD10 (International Classification of Diseases, 10th Revision)?

Management of Insomnia (ICD-10)

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all patients with insomnia disorder due to its sustained benefits without risk of tolerance or adverse effects. 1

Primary Approaches to Managing Insomnia

First-Line Treatment: CBT-I

CBT-I is the most effective non-pharmacological approach and includes five key components:

1. Sleep Consolidation/Restriction (Guideline):

   • Limits time in bed to match actual sleep time
   • Maintains sleep log to determine mean total sleep time
   • Sets strict bedtime and wake-up times
   • Adjusts weekly based on sleep efficiency 2

2. Stimulus Control (Standard):

   • Go to bed only when sleepy
   • Maintain regular schedule
   • Avoid naps
   • Use bed only for sleep
   • Leave bed if unable to fall asleep within 20 minutes 2

3. Cognitive Restructuring:

   • Addresses dysfunctional beliefs about sleep
   • Challenges common cognitive distortions like "I can't sleep without medication" 2, 1

4. Sleep Hygiene Education:

   • Consistent sleep/wake schedule
   • Healthy diet and regular exercise
   • Quiet sleep environment
   • Avoiding caffeine, alcohol, and stimulating activities before bedtime 2, 1

5. Relaxation Techniques (Standard):

   • Progressive muscle relaxation
   • Deep breathing
   • Meditation 2

Second-Line Treatment: Pharmacological Approaches

If CBT-I is unsuccessful after 4-6 weeks or symptoms are severe, consider short-term pharmacological treatment:

1. For Sleep Onset Insomnia:

   • Zolpidem: 10mg (adults), 5mg (elderly)
   • Zaleplon: 10mg
   • Ramelteon: 8mg 1

2. For Sleep Maintenance Insomnia:

   • Doxepin: 3-6mg
   • Eszopiclone: 2-3mg
   • Temazepam: 15mg
   • Suvorexant: 10-20mg 1

3. For Comorbid Conditions:

   • Sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine) when insomnia co-occurs with depression/anxiety 2, 1

Special Considerations

Elderly Patients

• Use lower doses of medications (e.g., zolpidem 5mg instead of 10mg)
• Higher risk of falls and cognitive impairment with sedative-hypnotics 1

Patients with Substance Use History

• Consider non-scheduled options like ramelteon 1
• Avoid benzodiazepines due to abuse potential 2

Patients with Respiratory Conditions

• Exercise caution with sedative medications 1
• Consider CBT-I as safer alternative

Implementation and Delivery Methods

CBT-I can be delivered through:

• Traditional face-to-face therapy
• Digital applications
• Brief behavioral treatment
• Self-help materials 1

Treatment Algorithm

1. Initial Assessment:

   • Evaluate insomnia pattern (onset vs. maintenance)
   • Screen for comorbid conditions (depression, anxiety, sleep apnea)
   • Assess daytime functioning impairment

2. First-Line Treatment:

   • Implement CBT-I for 4-6 weeks
   • Include all five components (sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, relaxation)

3. If Inadequate Response:

   • Add short-term pharmacotherapy based on insomnia type
   • Use lowest effective dose for shortest duration necessary

4. For Persistent Insomnia:

   • Consider combination therapy (CBT-I plus medication)
   • Evaluate for comorbid sleep disorders requiring specialist referral

5. Follow-up and Monitoring:

   • Schedule follow-up within 2-4 weeks after initiating treatment
   • Assess improvement in sleep parameters, daytime functioning, and side effects
   • Consider referral to sleep specialist if insomnia persists 1

Important Caveats

• Over-the-counter antihistamines and herbal supplements (including melatonin and valerian) are not recommended due to lack of efficacy and safety data 2
• Older medications like barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended 2
• FDA labeling indicates pharmacologic treatments for insomnia are intended for short-term use only 1
• Long-term medication use may be indicated for severe or refractory insomnia, but should be accompanied by consistent follow-up and monitoring 2