What treatment options are available for a 17-year-old with insomnia who has tried many different medications?

Treatment Options for Insomnia in a 17-Year-Old Who Has Tried Multiple Medications

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for this 17-year-old with insomnia, even if they have already tried multiple medications. 1

First-Line Approach: Non-Pharmacological Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is strongly recommended as the initial treatment for chronic insomnia disorder based on moderate-quality evidence 1. It consists of:

• Cognitive therapy: Addressing unhelpful beliefs and thoughts about sleep
• Behavioral interventions:
  • Sleep restriction: Limiting time in bed to match actual sleep time
  • Stimulus control: Using the bed only for sleep and sex
• Educational components: Sleep hygiene education

CBT-I can be delivered through:

• Individual or group therapy
• Telephone or web-based modules
• Self-help books 1

This approach is particularly valuable for adolescents as it avoids medication-related risks and provides long-term skills for managing sleep.

Sleep Hygiene Practices

While not effective as a standalone treatment 2, sleep hygiene should be incorporated as part of the comprehensive approach:

1. Maintain stable bed and wake times 1
2. Avoid daytime napping (limit to 30 minutes if needed, not after 2pm) 1, 3
3. Avoid caffeine, nicotine, and alcohol 1
4. Avoid heavy exercise within 2 hours of bedtime 1
5. Create a sleep-conducive environment (quiet, dark, comfortable) 3
6. Limit screen time before bed 3
7. Use the bedroom only for sleep and sex 1
8. Leave the bedroom if unable to fall asleep within 20 minutes 1

Relaxation Techniques

Relaxation therapy can be effective for reducing physiological and cognitive arousal 1:

• Progressive muscle relaxation
• Guided imagery
• Diaphragmatic breathing
• Meditation
• Biofeedback

Second-Line Approach: Pharmacological Options

If CBT-I alone is unsuccessful, a shared decision-making approach should be used to consider adding pharmacological therapy 1. This discussion should include the benefits, harms, and costs of short-term medication use.

Medication Considerations for Adolescents

For a 17-year-old who has tried multiple medications, consider:

1. Melatonin: A safer option for adolescents, starting with 3mg immediate-release 30-60 minutes before bedtime, titrating up to 5mg if needed 3

2. Non-benzodiazepine hypnotics: For short-term use only, with caution:

   • Eszopiclone: Low-quality evidence shows improved global and sleep outcomes 1
   • Zolpidem: Low-quality evidence shows improved sleep outcomes, but should be used at lower doses (5mg immediate-release or 6.25mg extended-release) 1, 3

3. Doxepin: Low-dose doxepin has shown improvements in sleep outcomes with fewer side effects than other antidepressants 1

Important Cautions

• FDA has approved pharmacologic therapy for short-term use only (4-5 weeks) 1
• Medication should be used at the lowest effective dose 1
• Benzodiazepines should be avoided or used with extreme caution in adolescents due to risk of dependence 3, 4
• Consultation with a pediatric sleep specialist is recommended before using sedative-hypnotics in adolescents 3

Monitoring and Follow-up

1. Follow up within 2-4 weeks of any intervention to assess:

   • Frequency and severity of insomnia
   • Daytime functioning and behavior
   • Side effects of medications
   • Need for treatment adjustments 3

2. Use standardized sleep assessment tools to track progress:

   • Insomnia Severity Index
   • Pittsburgh Sleep Quality Index 3

Common Pitfalls to Avoid

1. Relying solely on medications: Many clinicians jump to medications without trying CBT-I, despite evidence showing CBT-I produces results equivalent to sleep medication with no side effects and fewer episodes of relapse 5

2. Using sleep hygiene alone: Sleep hygiene education as a primary intervention is insufficient and should only be used as an adjunct to other evidence-based treatments 2

3. Overlooking underlying conditions: Screen for medical contributors that can affect sleep, such as:

   • Obstructive sleep apnea
   • Restless legs syndrome
   • Seizure disorders
   • Psychiatric conditions 3

4. Failing to address medication timing: Consistency in medication timing helps maintain steady blood levels and establish a routine 3

By implementing this structured approach prioritizing CBT-I and addressing both behavioral and physiological aspects of insomnia, this 17-year-old has the best chance of achieving long-term improvement in sleep quality and overall health.