What is the appropriate management approach for a patient with insomnia?

Management of Insomnia

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

First-Line Treatment: Non-Pharmacological Approaches

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is strongly recommended by the American Academy of Sleep Medicine and American College of Physicians as the primary intervention for chronic insomnia based on moderate-quality evidence 1
• Can be delivered through various methods:
  • Individual or group therapy
  • Telephone or web-based modules
  • Self-help books
• Improves global outcomes including:
  • Increased remission and treatment response
  • Reductions in Insomnia Severity Index scores
  • Improvements in sleep efficiency and quality 1

Sleep Hygiene Recommendations

• 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 bedroom only for sleep and sex
• Leave bedroom if unable to fall asleep within 20 minutes 1

Relaxation Techniques

• Progressive muscle relaxation
• Guided imagery
• Diaphragmatic breathing
• Meditation
• Biofeedback 1

Second-Line Treatment: Pharmacological Approaches

If CBT-I alone is unsuccessful, consider short-term medication through shared decision-making:

Recommended Medications for Short-Term Use (≤4 weeks)

• Non-benzodiazepine hypnotics:
  • Zolpidem (5-10mg) - with caution regarding complex sleep behaviors including sleep-driving 2
  • Eszopiclone - monitor for CNS depressant effects and next-day impairment 3
• Orexin antagonists:
  • Suvorexant - moderate-quality evidence for improved treatment response 1
• Melatonin receptor agonists:
  • Ramelteon (8mg) - may decrease sleep onset latency in older adults 1, 4
• Low-dose doxepin - for sleep maintenance insomnia with fewer side effects than other antidepressants 1

Important Medication Warnings

• All sleep medications carry risks of:
  • CNS depression and next-day impairment 3, 2, 4
  • Complex sleep behaviors (sleep-walking, sleep-driving) 2
  • Abnormal thinking and behavioral changes 3, 2, 4
  • Severe anaphylactic reactions (rare) 3, 2, 4
• Patients should avoid:
  • Driving or hazardous activities after taking sleep medication
  • Combining sleep medications with alcohol or other CNS depressants
  • Taking medication with less than 7-8 hours of sleep time remaining 3, 2, 4

Melatonin Considerations

• The American Academy of Sleep Medicine suggests against using melatonin for sleep onset or maintenance insomnia in adults (weak recommendation) 1
• May be considered for:
  • Older patients with Alzheimer's disease
  • Children with sleep disorders (3mg of immediate-release melatonin 30-60 minutes before bedtime, can be titrated up to 5mg if needed) 1

Special Populations

Older Adults/Dementia Patients

• Implement multicomponent approach:
  • Increased daytime physical activity
  • Sunlight exposure
  • Decreased time in bed during the day
  • Consistent bedtime routine 1

Children

• Implement developmentally appropriate bedtime and consistent routine
• Use visual schedules, especially for children with Autism Spectrum Disorder
• Behavioral interventions are first-line treatment as recommended by the American Academy of Pediatrics 1

Monitoring and Follow-Up

• Follow-up within 2-4 weeks of any intervention
• Use standardized sleep assessment tools (Insomnia Severity Index or Pittsburgh Sleep Quality Index)
• Assess:
  • Frequency and severity of episodes
  • Daytime functioning and behavior
  • Medication side effects
  • Need for treatment plan adjustment 1

When to Refer

• If symptoms persist despite appropriate treatment
• If concerning symptoms are present
• If severe anxiety or panic attacks are not responding to first-line treatment 1
• If comorbid sleep disorders are suspected (sleep apnea, restless legs syndrome, etc.) 1

Common Pitfalls to Avoid

• Failing to screen for underlying medical or psychiatric conditions causing insomnia 3, 2, 4
• Long-term use of hypnotic medications (should be limited to 4 weeks or less) 1
• Inadequate patient education about sleep hygiene
• Not allowing adequate time (7-10 days) to evaluate treatment response 3, 2, 4
• Overlooking potential drug interactions with CNS depressants 3, 2