What are the appropriate interventions for individuals experiencing sleep disturbances, using sleep scales like PSQI (Pittsburgh Sleep Quality Index) or ESS (Epworth Sleepiness Scale)?

Sleep Scale Assessment and Intervention

For individuals with sleep disturbances identified by scales like PSQI or ESS, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment, followed by FDA-approved medications if needed, with sleep scales serving as screening tools to identify those requiring comprehensive assessment. 1, 2

Screening and Assessment Approach

Initial Two-Step Screening Process

• Begin with two screening questions: (1) Do you have sleep problems ≥3 nights per week? (2) Does this negatively affect daytime functioning? If both are "yes," proceed to comprehensive assessment 1
• Use the Insomnia Severity Index (ISI) for case identification and treatment monitoring, as it specifically measures insomnia symptom severity 1
• The Epworth Sleepiness Scale (ESS) screens for daytime sleepiness and helps rule out comorbid sleep disorders 1
• The Pittsburgh Sleep Quality Index (PSQI) measures global sleep quality; scores >5 indicate clinically significant sleep disturbance 1

Comprehensive Assessment Components

• Complete a 2-week sleep diary tracking sleep quality, timing (bedtime/rise time), sleep latency, wake after sleep onset, total sleep time, napping, medications, caffeine/alcohol use, and stress levels 1
• Obtain patient history including beliefs about sleep, impact on quality of life, daytime functioning (driving ability, employment, relationships, mood), underlying causes, comorbidities, recent stressors, and medication history 1
• Assess for perpetuating factors including sleep-disruptive arousal, maladaptive habits, and conditioning factors 1

Important caveat: PSQI and ESS measure orthogonal (independent) dimensions of sleep-wake symptoms and correlate weakly with each other (r=0.16), so both should be used together for comprehensive evaluation 3

Evidence-Based Treatment Algorithm

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is the primary treatment with sustained effects up to 2 years and should be implemented before pharmacotherapy. 1, 2

• Components include: stimulus control, sleep restriction therapy, cognitive therapy targeting sleep-disruptive thoughts, and sleep hygiene education 1
• Efficacy: CBT significantly improves insomnia severity (p<0.001), sleep efficiency (p=0.002), sleep onset latency (p=0.03), and reduces general fatigue (p=0.001) 1
• Sustained benefits: Sleep efficiency improves from 69% to 84% at 12-month follow-up 1
• Delivery: Typically 5 weekly 50-minute sessions covering multicomponent strategies 1

Second-Line: FDA-Approved Pharmacotherapy

When CBT-I is insufficient, use short/intermediate-acting benzodiazepine receptor agonists or ramelteon as first-line medications. 2

• First-line medications: Zolpidem, eszopiclone, zaleplon (benzodiazepine receptor agonists) or ramelteon (melatonin receptor agonist) 2
• Second-line medications: Low-dose trazodone (25-50mg) or doxepin (3-6mg) for non-responders 2
• Critical warning: Avoid multiple sedating medications simultaneously due to increased daytime sedation risk 2
• Monitoring: Reassess using sleep logs after 2-4 weeks to evaluate sleep efficiency, total sleep time, and daytime functioning 2
• Long-term considerations: Sedative-hypnotics can lose efficacy over time and lead to dependence; use minimum effective doses 1

Adjunctive Interventions

Exercise interventions show significant benefits and can be used alongside CBT-I. 1

• Home-based walking/exercise: Significantly improves PSQI scores (p=0.007), reduces actual wake time (p=0.02), and decreases movement during sleep (p=0.05) 1
• Tai chi/yoga: Reduces PSQI scores from 8.1 to 5.8 (p<0.004), improves sleep latency (p<0.01), and increases sleep duration by ~48 minutes per night (p<0.03) 1
• Physical activity benefits: Both acute bouts and regular physical activity produce small-to-moderate improvements in total sleep time, sleep efficiency, and sleep onset latency 1

Treatment Monitoring

• Use ISI and PSQI scores longitudinally to measure treatment response, with categorical measures of insomnia remission being of primary importance 1
• Sleep diaries provide daily tracking of nighttime symptoms with less recall bias than questionnaires, allowing assessment of both mean-level changes and day-to-day variability 1
• Target outcomes: Both nighttime symptoms (sleep initiation, maintenance, duration) and daytime consequences (fatigue, mood, cognitive function) must improve 1

Common Pitfalls to Avoid

• Do not rely on PSQI/ESS alone for diagnosis: Neither correlates well with objective polysomnographic measures; they screen for subjective complaints requiring further evaluation 3
• Do not start with pharmacotherapy: CBT-I has superior long-term outcomes without dependence risks 1, 2
• Do not ignore comorbidities: Assess for underlying causes (pain, medications, psychiatric conditions) that perpetuate insomnia 1
• Do not use sleep hygiene alone: While recommended as standard practice, sleep hygiene education is insufficient as monotherapy and must be combined with other CBT-I components 1