Do psychiatrists treat insomnia?

Do Psychiatrists Treat Insomnia?

Yes, psychiatrists absolutely treat insomnia, particularly when it co-occurs with psychiatric disorders, and they are specifically trained to manage both the behavioral and pharmacological aspects of insomnia treatment. 1, 2

Psychiatrists' Role in Insomnia Management

Psychiatrists are well-positioned to treat insomnia for several key reasons:

• Insomnia is a cardinal symptom of psychiatric disorders, especially depression and anxiety, occurring in 30-90% of psychiatric conditions. 2, 3
• The ATN Sleep Committee for autism spectrum disorders explicitly includes psychiatrists alongside sleep medicine specialists, developmental pediatricians, and neurologists in developing insomnia treatment pathways. 1
• Psychiatrists can address both the underlying psychiatric condition and the insomnia simultaneously, which is critical since anxiety and depressive disorders account for 40-50% of all chronic insomnia cases. 3

Treatment Approach Psychiatrists Use

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

Psychiatrists should initiate CBT-I as the first-line treatment for all adults with chronic insomnia before considering medications. 1, 4

• CBT-I can be delivered by trained clinicians or mental health professionals (including psychiatrists) through individual therapy, group sessions, telephone-based programs, or web-based modules. 1, 4
• CBT-I includes cognitive therapy, behavioral interventions (sleep restriction, stimulus control), and sleep hygiene education. 1
• This approach shows superior long-term efficacy compared to medications and has minimal adverse effects. 4, 5

Pharmacological Management

When CBT-I alone is insufficient, psychiatrists have specific medication algorithms:

For patients with comorbid depression/anxiety, sedating antidepressants are the preferred initial pharmacological choice since they simultaneously address both the mood disorder and sleep disturbance. 4

• Options include low-dose doxepin (3-6 mg) for sleep maintenance, trazodone (25-50 mg), or mirtazapine. 4, 6
• If sedating antidepressants are insufficient or contraindicated, first-line hypnotics include short-intermediate acting benzodiazepine receptor agonists (eszopiclone 2-3 mg, zolpidem 5-10 mg, zaleplon 10 mg, temazepam 15 mg) or ramelteon 8 mg. 4

Critical Distinctions in Psychiatric Populations

Psychiatrists must determine whether sleep deprivation causes mood disturbance or whether the psychiatric disorder is the primary reason for sleep dysfunction. 3

• Treatment of the underlying psychiatric disorder may be sufficient to relieve accompanying insomnia. 2
• If insomnia persists despite adequate psychiatric treatment, consider inadequate treatment of the primary disorder, medication-induced insomnia, medical causes, or learned/habit insomnia. 2
• Persistent insomnia should be aggressively pursued in psychiatric patients, as it has been associated with adverse outcomes in depressed patients. 2

Special Considerations for Psychiatric Patients

• CBT-I protocols may need adaptation for specific psychiatric populations (depression, substance abuse, schizophrenia spectrum disorders) to optimize therapeutic outcomes. 5
• For PTSD patients with trauma-related nightmares, specialized techniques like Exposure, Relaxation, and Rescripting Therapy (ERRT) and image rehearsal therapy should be added to standard CBT-I. 7
• Avoid benzodiazepines as first-line therapy in psychiatric patients due to dependence risk, abuse potential, and cognitive impairment. 7

Common Pitfalls to Avoid

• Never rely solely on pharmacological management without addressing behavioral factors through CBT-I. 6
• Do not prescribe over-the-counter antihistamines (diphenhydramine) due to lack of efficacy data, daytime sedation, and delirium risk, especially in elderly patients. 4
• Avoid combining multiple sedating medications simultaneously, which significantly increases risks of daytime sedation, falls, and cognitive impairment. 6
• Do not continue pharmacotherapy long-term without periodic reassessment, as sedative-hypnotics can lose efficacy over time and lead to dependence. 4, 6