What is the initial approach to managing a patient with insomnia?

Initial Approach to Managing Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for patients with insomnia due to its proven efficacy and long-term benefits with minimal side effects. 1

Initial Assessment and Diagnosis

• Evaluate for co-morbid conditions as sleep disturbances may be a manifestation of underlying physical or psychiatric disorders 1, 2, 3, 4
• If insomnia doesn't improve after 7-10 days of treatment, consider unrecognized primary medical or psychiatric illness 2, 3, 4
• Assess for:
  • Sleep patterns (onset, maintenance, early morning awakening)
  • Duration of symptoms
  • Daytime functioning impairment
  • Current sleep habits and environment
  • Medication use (including OTC and supplements)
  • Substance use (caffeine, alcohol, tobacco)

First-Line Treatment: CBT-I

CBT-I includes several evidence-based components:

1. Stimulus Control Therapy 1

   • Go to bed only when sleepy
   • Use bed only for sleep and sex
   • Leave bed if unable to sleep within 15-20 minutes
   • Maintain regular wake-up time regardless of sleep duration

2. Sleep Restriction Therapy 1

   • Limit time in bed to match actual sleep time
   • Gradually increase time in bed as sleep efficiency improves
   • Target sleep efficiency >85%

3. Relaxation Training 1

   • Progressive muscle relaxation
   • Deep breathing exercises
   • Meditation techniques

4. Cognitive Restructuring 1, 5

   • Identify and challenge unhelpful beliefs about sleep
   • Address excessive worry about consequences of poor sleep

5. Sleep Hygiene Education 1

   • Regular sleep schedule
   • Limit caffeine and alcohol
   • Create comfortable sleep environment
   • Note: Sleep hygiene alone is insufficient and should be used as an adjunct to other CBT-I components 5

Pharmacological Interventions (Second-Line)

If CBT-I is not immediately available or for short-term use while initiating CBT-I:

For Sleep Onset Insomnia:

• Ramelteon 8mg 1, 4

  • Targets melatonin receptors
  • Lower risk of next-day impairment
  • Caution: May affect reproductive hormones 4

• Zolpidem 10mg (5mg in elderly) 1, 3

  • Caution: Risk of complex sleep behaviors, next-day impairment 3

• Zaleplon 10mg 1

For Sleep Maintenance Insomnia:

• Low-dose doxepin 3-6mg 1
• Eszopiclone 2-3mg 1, 2
  • Caution: CNS depressant effects, next-day impairment 2
• Suvorexant 10-20mg 1

Important Precautions with Medications

• Avoid benzodiazepines due to high risk of falls, cognitive impairment, and dependency 1
• Start with lower doses in elderly patients or those with liver impairment 1
• Monitor for complex sleep behaviors (sleep-walking, sleep-driving) with sedative-hypnotics 2, 3
• Avoid concomitant use of multiple CNS depressants 2, 3, 4
• Discontinue medication if angioedema or abnormal thinking/behavioral changes occur 2, 3, 4

Follow-up and Monitoring

• Schedule follow-up within 2-4 weeks to assess effectiveness and side effects 1
• For CBT-I, typical treatment duration is 6-8 sessions 6
• Treatment goals include: 1
  • Sleep onset latency <30 minutes
  • Wake after sleep onset <30 minutes
  • Total sleep time >6 hours or sleep efficiency >80-85%
  • Improvement in daytime functioning and quality of life

Special Considerations

• CBT-I is effective for insomnia comorbid with psychiatric and medical conditions 1, 7
• For elderly patients, use lower medication doses and prioritize non-pharmacological approaches 1
• CBT-I has been shown effective for 70-80% of patients with sustained benefits 8
• When using medications, administer 30-60 minutes before desired sleep time 1