What are the primary goals and recommended therapies for insomnia according to Canadian guidelines?

Goals of Therapy in Insomnia

The primary goals of insomnia treatment are to improve both sleep quality and quantity while simultaneously addressing insomnia-related daytime impairments, with cognitive behavioral therapy for insomnia (CBT-I) as the first-line intervention. 1

Primary Treatment Goals

Regardless of whether behavioral or pharmacological therapy is used, treatment must target two fundamental outcomes: 1

• Improve sleep quality and quantity - This addresses the nighttime symptoms that patients experience 1
• Improve insomnia-related daytime impairments - This addresses functional consequences including fatigue, irritability, decreased concentration, and impaired quality of life 1

Specific Sleep Outcome Measures

Beyond the primary goals, treatment success should be evaluated using objective sleep parameters: 1

• Wake time after sleep onset (WASO) - Reduction indicates improved sleep maintenance 1
• Sleep onset latency (SOL) - Shorter latency demonstrates improved ability to fall asleep 1
• Number of awakenings - Fewer awakenings reflect better sleep continuity 1
• Sleep time and sleep efficiency - Increased total sleep time and higher efficiency percentages indicate treatment success 1
• Psychological factors - Formation of positive associations between bed and sleeping, plus reduction in sleep-related psychological distress 1

Monitoring and Follow-Up Strategy

Sleep diary data must be collected before and during active treatment, with reassessment at relapse or every 6 months long-term. 1

The monitoring approach should follow this timeline: 1

• Initial phase: Clinical reassessment every few weeks to monthly until insomnia stabilizes or resolves 1
• Maintenance phase: Reassessment every 6 months due to high relapse rates 1
• Ongoing assessment: Repeated administration of questionnaires and survey instruments to guide treatment adjustments 1

Treatment Algorithm When Goals Are Not Met

When single or combination treatments fail to achieve these goals, clinicians should consider alternative behavioral therapies, different pharmacological options, combined therapies, or reevaluation for occult comorbid disorders. 1

The escalation strategy includes: 1

• Try alternative behavioral interventions if initial CBT-I components were ineffective 1
• Consider pharmacological augmentation if behavioral therapy alone is insufficient 1
• Reassess for undiagnosed comorbid conditions (sleep apnea, restless legs syndrome, psychiatric disorders) that may be perpetuating insomnia 1

Common Pitfalls to Avoid

• Focusing solely on sleep parameters without addressing daytime function - Both nighttime and daytime outcomes must improve for treatment success 1, 2
• Failing to collect sleep diary data - Without objective tracking, treatment adjustments cannot be properly guided 1
• Inadequate follow-up frequency - Given high relapse rates, the every-6-month reassessment schedule is critical and often neglected 1
• Not recognizing treatment failure early - If goals are not being met after adequate trial periods, prompt escalation or reevaluation is necessary rather than continuing ineffective therapy 1