What is the first-line treatment for a patient with insomnia, fatigue, and poor concentration, but a negative depression screening?

First-Line Treatment for Insomnia with Fatigue and Poor Concentration

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the definitive first-line treatment for this patient, delivered over 4-8 sessions with a trained specialist, and should be initiated before considering any pharmacological intervention. 1, 2

Why CBT-I is the Clear Choice

The evidence is unequivocal across multiple major guidelines:

• The American Academy of Sleep Medicine, American College of Physicians, and VA/DoD all recommend CBT-I as first-line treatment due to superior long-term efficacy compared to medications, with sustained benefits lasting up to 2 years without risk of tolerance or adverse effects 2, 3

• CBT-I produces clinically meaningful improvements in sleep parameters including reduced sleep onset latency, decreased wake after sleep onset, improved sleep efficiency, and enhanced sleep quality 2

• Compared to pharmacotherapy, CBT-I shows equivalent short-term results (2-4 weeks) but superior long-term outcomes, with fewer adverse effects and no concerns about dependency 1

Core Components of Effective CBT-I

The treatment must include these evidence-based elements:

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 2, 4

• Stimulus control: Strengthens the association between bed/bedroom and sleep by going to bed only when sleepy, using bed only for sleep and sex, and leaving bed if unable to sleep within 15-20 minutes 1, 2

• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 2

• Sleep hygiene education: Addresses caffeine, alcohol, nicotine use, exercise timing, sleep environment, and sleep-wake regularity, though this should never be used as standalone treatment 1

Treatment Structure and Monitoring

• Standard CBT-I is delivered over 4-8 sessions with a trained CBT-I specialist, with in-person one-on-one delivery being most effective 2, 4

• Brief Behavioral Therapy for Insomnia (BBT-I) can be offered when resources are limited or patients prefer shorter treatment (1-4 sessions), focusing on behavioral components only 2, 4

• Sleep diary data must be collected before and during treatment to monitor progress and guide adjustments 2, 4

Expected Timeline and Side Effects

• Improvements are gradual, not immediate like with medications, which is critical to communicate upfront to set realistic expectations 1

• Temporary side effects during early treatment include daytime fatigue, sleepiness, mood impairment, and cognitive difficulties, but these typically resolve quickly as treatment continues and by the end of treatment 1, 4

• These initial symptoms are particularly relevant given this patient's existing fatigue and poor concentration, but they are mild and transient 1, 4

Critical Contraindications to Consider

Sleep restriction therapy may be contraindicated in:

• Patients working in high-risk occupations (due to temporary increased sleepiness) 2, 4
• Those predisposed to mania/hypomania 2, 4
• Those with poorly controlled seizure disorders 2, 4

What NOT to Do: Common Pitfalls

• Do not offer sleep hygiene education alone as standalone treatment—it is ineffectual and potentially harmful if patients believe effective treatments like CBT-I will also fail 1, 2

• Do not start with medications as first-line treatment—this undermines long-term outcomes, creates dependency risk, and lacks clear long-term safety data 1, 2, 3

• Do not use over-the-counter antihistamines, melatonin, or herbal supplements—these lack efficacy data and carry safety concerns, especially daytime sedation and delirium in older patients 2, 3

• Do not use antipsychotics as first-line treatment due to problematic metabolic side effects 3

When to Consider Pharmacotherapy (Second-Line Only)

Medications should only be considered when: 3

• Patients are unable to participate in CBT-I
• Symptoms persist despite completing CBT-I
• As a temporary adjunct to CBT-I during initial treatment

If medications become necessary, FDA-approved options include benzodiazepine receptor agonists (eszopiclone, zolpidem, zaleplon, triazolam, temazepam) for sleep onset and maintenance, ramelteon for sleep onset, or low-dose doxepin for sleep maintenance, but only with short-term use and careful monitoring 3

Follow-Up Protocol

• Regular follow-up should occur until insomnia stabilizes or resolves, then every 6 months to ensure CBT-I effectiveness and address any emerging concerns 2