What is the initial management approach for a patient presenting with insomnia?

Initial Management of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be recommended as the first-line treatment for all adult patients presenting with chronic insomnia. 1, 2

Assessment and Diagnosis

Before initiating treatment, evaluate for:

• Duration and pattern of sleep disturbance
• Daytime symptoms and impairment
• Sleep habits and environment
• Comorbid medical or psychiatric conditions
• Current medications that may affect sleep
• Use of standardized tools like Insomnia Severity Index or Pittsburgh Sleep Quality Index 2

First-Line Treatment: CBT-I

CBT-I is strongly recommended by the American College of Physicians with moderate-quality evidence supporting its efficacy 1. It consists of several components:

1. Cognitive therapy: Identifying and challenging dysfunctional beliefs about sleep
2. Sleep restriction: Limiting time in bed to increase sleep efficiency
3. Stimulus control: Using the bedroom only for sleep and sex
4. Sleep hygiene education: Teaching good sleep habits
5. Relaxation techniques: Progressive muscle relaxation, guided imagery, diaphragmatic breathing

Implementation of CBT-I

• Can be delivered through various methods: individual/group therapy, telephone/web-based modules, or self-help books 1
• Typically involves 4-8 weekly sessions of 60-90 minutes 3
• Produces reliable and durable improvements in sleep parameters with 70-80% of patients benefiting from treatment 4

Benefits of CBT-I

• Improves global outcomes including increased remission and treatment response
• Reduces Insomnia Severity Index and Pittsburgh Sleep Quality Index scores
• Decreases sleep onset latency and wake time after sleep onset
• Improves sleep efficiency and quality 1
• Provides sustained benefits for at least 6 months after treatment completion 4

Sleep Hygiene Recommendations

As part of CBT-I, advise patients to:

• Maintain stable bed and wake times
• Avoid daytime napping (limit to 30 minutes if needed, not after 2pm)
• Avoid caffeine, nicotine, and alcohol
• Avoid heavy exercise within 2 hours of bedtime
• Use the bedroom only for sleep and sex
• Leave the bedroom if unable to fall asleep within 20 minutes 2

Second-Line Treatment: Pharmacological Options

If CBT-I alone is unsuccessful, the American College of Physicians recommends a shared decision-making approach to consider adding short-term medication 1:

Medication options to consider:

• Non-benzodiazepine hypnotics: Zolpidem (5-10mg), limited to short-term use (≤4 weeks) 2
• Doxepin: Low-dose for sleep maintenance insomnia 2
• Suvorexant: Orexin antagonist with moderate-quality evidence for improved treatment response 1
• Ramelteon: May decrease sleep onset latency in older adults 1

Important considerations:

• Discuss benefits, harms, and costs of short-term medication use
• Evidence on harms from RCTs is limited, but observational studies show hypnotics may be associated with serious adverse effects including dementia, injury, and fractures 1
• FDA labels warn of daytime impairment, "sleep driving," behavioral abnormalities
• Commonly used medications like diphenhydramine and trazodone have not been well-studied 1

Special Populations

Older Adults

• CBT-I is still first-line and shows benefits in this population 1, 2
• If medications are needed, use lower doses and shorter durations
• The American Geriatrics Society recommends using pharmacologic treatments with caution due to risks of tolerance and dependence 2

Patients with Comorbidities

• For patients with anxiety, short-acting benzodiazepines or lower-dose zolpidem may be considered 2
• For patients with depression, sedating antidepressants like trazodone or mirtazapine may be effective 2

Follow-Up and Monitoring

• Schedule follow-up within 2-4 weeks of any intervention 2
• Assess treatment response using standardized tools
• Evaluate for side effects if medications were prescribed
• Consider referral to sleep specialist if symptoms persist despite appropriate treatment 2

Common Pitfalls to Avoid

1. Jumping to pharmacological treatment before trying CBT-I
2. Prolonged use of sleep medications beyond recommended durations
3. Failing to address underlying medical or psychiatric conditions
4. Overlooking the importance of consistent sleep schedules
5. Not providing adequate time for CBT-I to demonstrate effectiveness