What is the best course of treatment for a 41-year-old Caucasian male law-enforcement officer with a history of hypertension, presenting with insomnia and fatigue, who recently experienced a divorce and discharged his firearm for the first time, and has no regular exercise routine, while currently managing his hypertension with medication and attending mandatory department psychologist sessions?

Treatment Approach for Law Enforcement Officer with Insomnia, Fatigue, and Recent Critical Incident

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated immediately as first-line treatment, with concurrent screening for obstructive sleep apnea given his hypertension and occupational stress profile. 1

Immediate Priority Actions

Screen for Obstructive Sleep Apnea

• Evaluate for OSA urgently because it is a common, often undiagnosed cause of resistant hypertension and insomnia in law enforcement populations, particularly given his sedentary lifestyle, alcohol use, and hypertension. 1
• OSA causes insomnia and fatigue through chronic sleep deprivation and hypoxia, and is frequently comorbid with hypertension in this demographic. 1
• If clinical suspicion is high (snoring, witnessed apneas, daytime sleepiness), arrange home sleep apnea testing or polysomnography before finalizing insomnia treatment. 1

Assess for Post-Traumatic Stress Disorder

• Screen specifically for PTSD symptoms related to the firearm discharge, as PTSD is highly prevalent in law enforcement after critical incidents and has a 6.3-fold increased association with insomnia. 1
• PTSD commonly presents with insomnia, hypervigilance, and fatigue, and requires specialized trauma-focused therapy beyond standard CBT-I. 1
• The mandatory department psychologist sessions provide an opportunity to coordinate this assessment. 1

Obtain Baseline Sleep Data

• Have him complete a sleep diary for 7-14 days documenting bedtime, sleep latency, number and duration of awakenings, wake after sleep onset, time in bed, total sleep time, and sleep efficiency. 1, 2
• Document his "few beers post-shift" pattern precisely—alcohol disrupts sleep architecture and contributes to both insomnia and resistant hypertension. 1
• Record napping patterns (frequency, duration, timing) as both consequence and contributor to insomnia. 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia

CBT-I is the mandatory first-line treatment with strong evidence supporting its superiority over pharmacotherapy for long-term outcomes. 1, 3, 2

Core CBT-I Components to Implement

Stimulus Control Therapy:

• Go to bed only when sleepy, not at a predetermined time. 3, 2
• Use the bed only for sleep (and sex)—no TV, phone, or worrying. 3, 2
• Leave the bed after 20 minutes if unable to fall asleep; return only when sleepy. 1, 3, 2
• Maintain a consistent wake time every day, including weekends. 1, 3
• Eliminate daytime naps entirely during initial treatment. 1, 3

Sleep Restriction Therapy:

• Calculate his average total sleep time from the sleep diary (e.g., 5 hours). 3, 2
• Restrict time in bed to match actual sleep time plus 30 minutes (e.g., 5.5 hours). 3, 2
• Set a fixed wake time and calculate bedtime backward (if wake time is 6 AM, bedtime becomes 12:30 AM). 3, 2
• Increase time in bed by 15-30 minutes weekly only when sleep efficiency exceeds 85%. 2

Cognitive Restructuring:

• Address catastrophic thinking about sleep consequences ("I can't function without 8 hours"). 3, 2
• Challenge beliefs about needing alcohol to unwind or sleep. 1, 2
• Reframe the firearm discharge and its psychological impact on sleep. 2

Sleep Hygiene Modifications:

• Eliminate alcohol consumption entirely—it fragments sleep, worsens hypertension, and interferes with CBT-I effectiveness. 1
• Avoid caffeine after noon (assess his coffee/energy drink intake during shifts). 1
• Establish a 30-60 minute wind-down routine before bed (not fishing or drinking). 1
• Optimize bedroom environment: dark, quiet, cool temperature. 1
• Note: Sleep hygiene alone is insufficient and should not be used as stand-alone treatment. 1

CBT-I Delivery Options

• Individual therapy with a trained clinician is ideal but group therapy, telephone-based, or web-based CBT-I programs are effective alternatives if access is limited. 2
• Many law enforcement agencies have employee assistance programs that can facilitate CBT-I access. 1

Lifestyle Modifications for Hypertension and Overall Health

Institute a structured exercise program immediately as it addresses multiple problems: hypertension control, stress reduction, sleep quality, and provides a healthier alternative to alcohol for unwinding. 4, 5

Exercise Prescription

• Aerobic exercise: 30 minutes of moderate-intensity activity (brisk walking) at least 3 days per week, ideally 5 days. 4, 5
• Can be broken into 10-minute sessions totaling 30 minutes daily. 4
• Resistance training: 2-3 days per week on non-consecutive days. 4
• Exercise timing: Complete at least 3-4 hours before bedtime to avoid sleep interference. 1
• Expected benefit: 5 mmHg reduction in blood pressure, which decreases coronary mortality by 9%, stroke mortality by 14%, and all-cause mortality by 7%. 4

Additional Lifestyle Interventions

• Dietary sodium restriction to <2.3 g/day with increased potassium intake (fruits, vegetables). 5
• Weight loss if overweight (not specified but common in sedentary individuals). 5
• Complete alcohol cessation—this is non-negotiable given its effects on sleep, hypertension, and mental health. 1, 5

Pharmacotherapy Algorithm (If CBT-I Insufficient After 4-6 Weeks)

Pharmacotherapy should only supplement, never replace, CBT-I. 1, 3, 2

First-Line Pharmacological Options

If CBT-I alone fails after 4-6 weeks:

• Low-dose doxepin (3-6 mg) for sleep maintenance difficulties—FDA-approved with favorable evidence. 1, 3, 6
• Zolpidem 10 mg (or eszopiclone, zaleplon, temazepam) for combined sleep onset and maintenance insomnia. 1, 3, 2
• Ramelteon if he has substance use concerns (alcohol history) or prefers non-DEA-scheduled medication, particularly effective for sleep initiation. 1, 3

Second-Line Options (If First-Line Fails)

• Trazodone 25-50 mg if depressive symptoms emerge or first-line agents are ineffective. 3, 6
• Switch to alternative agent within same class based on symptom pattern (sleep onset vs. maintenance). 3

Third-Line Options (Refractory Cases)

• Gabapentin or other anti-epileptic medications for severe refractory insomnia. 3
• Avoid benzodiazepines (not approved for insomnia) except in refractory cases due to dependency risk, cognitive impairment, and fall risk. 1, 3, 6

Medications to Avoid

• Do not prescribe over-the-counter antihistamines (diphenhydramine) or melatonin—insufficient evidence for chronic insomnia. 1, 3
• Avoid barbiturates and chloral hydrate entirely. 3
• Do not use immediate-release nifedipine for hypertension management. 7

Hypertension Management Considerations

Medication Review

• Review his current antihypertensive regimen for medications that may worsen insomnia (β-blockers, α-agonists, diuretics taken late in day). 1
• If on β-blockers, consider switching to vasodilating β-blockers (carvedilol, nebivolol) or alternative classes. 1
• Ensure medication compliance—poor adherence is the most common cause of resistant hypertension. 1

Blood Pressure Monitoring

• Obtain ambulatory blood pressure monitoring to characterize true BP elevation versus white coat hypertension and assess nocturnal dipping pattern. 1
• Non-dipping pattern suggests OSA or inadequate BP control. 1

Mental Health Integration

Coordinate with Department Psychologist

• Ensure the mandatory sessions address trauma-specific interventions if PTSD is present, not just general counseling. 1, 8
• Request coordination between the psychologist and whoever delivers CBT-I to ensure integrated care. 1
• Evidence for psychosocial interventions in law enforcement is limited but suggests benefit for anxiety, depression, and PTSD symptoms. 8

Monitor for Depression and Anxiety

• Fatigue and insomnia are common presentations of depression in men, particularly after major life stressors (divorce, critical incident). 1
• Irritability, loss of interest, and cognitive difficulties are common in chronic insomnia but may also indicate mood disorder. 1
• If depression emerges, consider sedating antidepressants (trazodone, mirtazapine) that address both conditions. 3, 6

Follow-Up and Monitoring

Initial Phase (Weeks 1-6)

• Reassess every 2-3 weeks to evaluate CBT-I adherence, sleep diary data, and symptom improvement. 3, 2
• Monitor for adverse effects if pharmacotherapy is added. 3
• Verify alcohol cessation and exercise program initiation. 4, 5

Ongoing Management

• Continue CBT-I throughout any pharmacotherapy trial—the combination is more effective than either alone. 1, 3, 2
• Attempt medication tapering once sleep stabilizes, typically after 3-6 months, facilitated by ongoing CBT-I. 3
• Long-term hypnotic use may be necessary for severe refractory insomnia but requires consistent monitoring. 3
• Reassess hypertension control and adjust medications as needed. 5

Critical Pitfalls to Avoid

• Do not prescribe sleep medication without initiating CBT-I first—this violates evidence-based guidelines and leads to worse long-term outcomes. 1
• Do not overlook OSA screening—it is a common cause of both insomnia and resistant hypertension in this population. 1
• Do not minimize the alcohol use—"a few beers" post-shift is a maladaptive coping mechanism that worsens all his problems. 1
• Do not ignore PTSD risk—discharging a firearm for the first time is a critical incident requiring specific trauma assessment. 1
• Do not accept "mandatory sessions" as sufficient mental health support—he needs voluntary, ongoing care for optimal outcomes. 1, 8