What are the treatment options for a 23-year-old with insomnia (sleep issues)?

Treatment of Insomnia in a 23-Year-Old

Cognitive behavioral therapy for insomnia (CBT-I) should be the initial treatment for this patient, as it is the standard of care with strong evidence for efficacy and durable benefits lasting up to 2 years. 1

First-Line Treatment: CBT-I

The American College of Physicians provides a strong recommendation that all patients with chronic insomnia receive CBT-I as the initial treatment intervention, and the American Academy of Sleep Medicine designates it as the standard of care for chronic insomnia in adults of all ages. 1 This recommendation applies equally to younger adults like this 23-year-old patient. 2

Why CBT-I is Superior

• CBT-I produces clinically meaningful improvements that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation. 1
• Treatment typically requires 4-8 sessions over 6 weeks. 1
• In-person, therapist-led programs are most beneficial, though digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable. 1

Components of CBT-I

CBT-I is a multicomponent therapy that includes: 2

Sleep Restriction Therapy:

• Limits time in bed to consolidate actual sleep time, based on sleep logs kept for 2 weeks. 2
• For example, if spending 8.5 hours in bed but sleeping only 5.5 hours, time in bed is reduced to 5.5-6 hours. 2
• Time in bed is gradually increased by 15-20 minute increments every 5 days as sleep efficiency improves. 2

Stimulus Control:

• Strengthens the association between the bed/bedroom and sleep only. 2
• Key instructions include: 2
  • Go to bed only when sleepy
  • Use the bedroom only for sleep and sex (no TV, work, or other activities)
  • Leave the bedroom if unable to fall asleep within 20 minutes
  • Maintain consistent sleep and wake times daily
  • Avoid daytime napping, or limit to 30 minutes before 2 PM

Cognitive Therapy:

• Identifies and modifies unhelpful beliefs about sleep that may raise performance anxiety. 2
• Uses structured psychoeducation, Socratic questioning, and behavioral experiments. 2

Relaxation Techniques:

• Progressive muscle relaxation, guided imagery, diaphragmatic breathing, and meditation. 2
• Helps achieve a calm state conducive to sleep onset. 2

Sleep Hygiene Education

While sleep hygiene should not be used as a single-component therapy due to lack of efficacy evidence, certain principles are helpful when incorporated into comprehensive treatment: 2, 1

Behaviors to avoid: 2

• Excessive caffeine intake
• Evening alcohol consumption
• Smoking in the evening
• Late heavy meals
• Late evening exercise (avoid within 2 hours of bedtime)
• Stimulating activities at night (TV in bed, vigorous discussions)
• Clock watching and anxiety about sleep

Environmental optimization: 2

• Ensure bedroom is comfortable temperature, quiet, and dark
• Develop a 30-minute relaxation ritual before bedtime

When to Consider Pharmacotherapy

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 1, 3

Medication Options (if needed)

For a 23-year-old, if pharmacotherapy becomes necessary: 4, 5

Non-benzodiazepine hypnotics (Z-drugs):

• Zolpidem is indicated for short-term treatment of insomnia characterized by sleep onset difficulties, with efficacy demonstrated for up to 35 days. 5
• Eszopiclone can be used for both sleep onset and maintenance issues. 4
• Critical warning: Take only when able to stay in bed for 7-8 hours, right before getting into bed. 4
• Common side effects include unpleasant taste, drowsiness, dizziness, and next-day impairment. 4

Important medication caveats: 4

• Do not take with alcohol or other sedating medications
• Risk of complex sleep behaviors (sleep-walking, sleep-driving, sleep-eating)
• May cause abnormal thoughts, memory loss, and anxiety
• Should be used short-term only

Critical Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment, as this violates guideline recommendations and deprives patients of more effective, durable therapy. 1
• Do not rely on sleep hygiene education alone, as it lacks efficacy as a single intervention. 2, 1
• Do not expect immediate results with CBT-I—patients need counseling that improvements are gradual but sustained, unlike the immediate effects of medications. 2, 1
• Avoid benzodiazepines due to risks of dependence, cognitive impairment, and adverse effects. 3
• Avoid antihistamines (diphenhydramine) due to lack of systematic evidence for primary insomnia. 3

Practical Implementation Algorithm

1. Initiate CBT-I as first-line treatment 1
2. If CBT-I unavailable or patient declines: Consider brief behavioral therapy for insomnia or single-component therapies (sleep restriction, stimulus control, relaxation) 2
3. If inadequate response to behavioral interventions after 4-8 weeks: Consider short-term pharmacotherapy through shared decision-making 1, 3
4. If pharmacotherapy needed: Start with lowest effective dose, use intermittently rather than nightly when possible, and reassess regularly 3