What is the management of stress-induced insomnia?

Management of Stress-Induced Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for stress-induced insomnia, as it provides superior long-term outcomes compared to pharmacotherapy and directly addresses the maladaptive thoughts and behaviors that perpetuate insomnia. 1

First-Line Treatment: CBT-I

All patients with stress-induced insomnia should receive CBT-I as initial therapy based on strong recommendation from the American College of Physicians and American Academy of Sleep Medicine. 1, 2, 3 This recommendation is supported by moderate-quality evidence showing sustained benefits for up to 2 years without the risks of tolerance, dependence, or adverse effects associated with medications. 1, 2

Core Components of CBT-I

CBT-I is a multimodal intervention delivered over 4-8 sessions that combines behavioral and cognitive strategies: 1, 2

Behavioral Components:

• Sleep restriction therapy: Limit time in bed to match actual sleep duration (minimum 5 hours), then gradually increase by 15-20 minutes weekly when sleep efficiency exceeds 85-90%. 1, 2 This creates mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 2
• Stimulus control: Go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 20 minutes, maintain consistent wake times, and avoid daytime napping. 1, 2
• Relaxation therapy: Progressive muscle relaxation or other counterarousal strategies to reduce physiological and mental hyperarousal. 1

Cognitive Components:

• Cognitive restructuring: Target maladaptive beliefs about sleep such as "I can't sleep without medication," "If I can't sleep I should stay in bed and rest," or catastrophic thinking about consequences of poor sleep. 1, 2 This is particularly relevant for stress-induced insomnia where worry and rumination perpetuate the disorder. 4

Educational Component:

• Sleep hygiene education: Information about caffeine, alcohol, nicotine use, exercise timing, sleep environment optimization, and stress management. 1 However, sleep hygiene alone is insufficient as monotherapy and should only be incorporated as part of comprehensive CBT-I. 1, 3

Evidence Supporting CBT-I

CBT-I demonstrates clinically meaningful improvements in multiple sleep parameters including reduced sleep onset latency, decreased wake time after sleep onset, improved sleep efficiency (>85%), and enhanced sleep quality. 1, 2 The American College of Physicians systematic review of 59 trials showed consistent benefits favoring CBT-I over passive controls. 1

Critically, CBT-I is superior to pharmacotherapy in long-term outcomes (beyond 2-4 weeks), though medications may show equivalent short-term results. 1 This is especially important for stress-induced insomnia, as the cognitive and behavioral skills learned in CBT-I provide lasting tools for managing stress-related sleep disruption. 4, 5

Delivery Methods

CBT-I can be delivered through multiple modalities: 1

• In-person individual or group therapy
• Telephone-based sessions
• Internet-based self-directed programs
• Self-help books or modules

Internet-based CBT-I shows clinically significant improvements and increases access to care, though evidence is insufficient to definitively recommend it over face-to-face treatment. 1, 6

Second-Line Treatment: Pharmacotherapy

Medications should only be considered when CBT-I alone is unsuccessful, the patient cannot participate in CBT-I, or as a temporary adjunct during CBT-I. 1, 3 This decision requires shared decision-making with discussion of benefits, harms, and costs. 1

FDA-Approved Medications

For sleep onset insomnia:

• Ramelteon (melatonin receptor agonist): Preferred option with minimal side effects and no abuse potential. 6
• Zolpidem, zaleplon, triazolam: Nonbenzodiazepine and benzodiazepine hypnotics. 1, 7

For sleep maintenance insomnia:

• Low-dose doxepin (3-6 mg): Most effective with minimal side effects. 1, 6
• Eszopiclone, temazepam, estazolam: Longer-acting agents. 1, 8

Suvorexant (orexin receptor antagonist): Recently approved option. 1

Critical Warnings About Pharmacotherapy

Benzodiazepine receptor agonists carry significant risks:

• Complex sleep behaviors including sleep-driving, sleep-walking, and engaging in activities while not fully awake may occur after first or subsequent doses. 8, 7 These behaviors can result in serious injury or death and require immediate discontinuation. 7
• Next-day psychomotor impairment and decreased driving ability, especially with doses ≥2 mg eszopiclone or when taken with <7-8 hours sleep time remaining. 8, 7
• CNS depression is increased when combined with alcohol or other CNS depressants. 8, 7
• Risk of falls, cognitive impairment, and dependence, particularly in older adults. 3, 6
• Abnormal thinking, behavioral changes, worsening depression, and suicidal thoughts have been reported. 8, 7

Short-term use is strongly preferred due to concerns about tolerance, dependence, and lack of long-term safety data beyond brief treatment periods. 1, 3 When discontinuing after more than a few days, taper gradually to minimize rebound insomnia and withdrawal effects. 6

Treatments to Avoid

Do NOT use as first-line therapy:

• Sleep hygiene education alone: Ineffectual as monotherapy and potentially harmful if patients believe effective behavioral treatments will also be ineffectual. 1, 3
• Over-the-counter antihistamines: Lack efficacy data and carry risk of anticholinergic side effects, especially daytime sedation and delirium in older patients. 3, 6
• Melatonin: Insufficient evidence for chronic insomnia treatment. 1
• Antipsychotics: Should not be used as first-line due to problematic metabolic side effects. 3
• Traditional benzodiazepines (lorazepam, clonazepam): Higher risk profile than alternatives. 6

Treatment Algorithm for Stress-Induced Insomnia

Step 1: Initiate CBT-I (4-8 sessions with trained clinician or mental health professional). 1, 2, 3

• Collect sleep diary data before and throughout treatment to monitor progress. 2, 6
• Implement sleep restriction, stimulus control, relaxation training, and cognitive restructuring targeting stress-related thoughts. 1, 2

Step 2: Assess response after 4-8 weeks. 6

• Evaluate sleep efficiency, total sleep time, and daytime functioning rather than just subjective sleep quality. 6
• If insomnia persists despite adequate CBT-I trial, proceed to Step 3. 6

Step 3: Consider adding short-term pharmacotherapy using shared decision-making. 1, 3

• For sleep onset difficulty: Ramelteon preferred, or short-acting agents (zolpidem, zaleplon, triazolam). 6
• For sleep maintenance difficulty: Low-dose doxepin 3-6 mg, or longer-acting agents (eszopiclone, temazepam). 6
• Reassess every 2-4 weeks until insomnia stabilizes, then every 6 months. 6
• Plan for medication taper with continued CBT-I support to prevent relapse. 4

Important Considerations

Screen for comorbid conditions that may contribute to insomnia:

• Depression, anxiety, or other psychiatric disorders that may require concurrent treatment. 6, 5, 9
• Obstructive sleep apnea or restless legs syndrome. 6
• Review medications that disrupt sleep (β-blockers, corticosteroids, decongestants, diuretics, SSRIs, SNRIs). 6

Contraindications to sleep restriction therapy:

• High-risk occupations requiring alertness
• Predisposition to mania/hypomania
• Poorly controlled seizure disorders 2

For stress-induced insomnia specifically, the cognitive components of CBT-I are particularly valuable as they directly address worry, rumination, and catastrophic thinking about sleep that perpetuate the disorder. 4, 10 The behavioral components help break the conditioned association between the sleep environment and wakefulness that develops when stress interferes with sleep. 1, 2