How to manage chronic insomnia in a 40-year-old male with no specified past medical history or substance abuse?

Management of Chronic Insomnia in a 40-Year-Old Male

All adults with chronic insomnia should receive Cognitive Behavioral Therapy for Insomnia (CBT-I) as the initial treatment before any pharmacological intervention. 1, 2, 3

First-Line Treatment: CBT-I

CBT-I is the gold standard and must be initiated first, as it produces clinically meaningful improvements sustained for up to 2 years, unlike medications which show degradation of benefit after discontinuation. 2, 3

Core Components of CBT-I

Sleep Restriction Therapy:

• Calculate the patient's current total sleep time from a 2-week sleep diary 1, 4
• Restrict time in bed to match actual sleep time, with a minimum of 5 hours 1, 2
• Set consistent bedtime and wake time to achieve >85% sleep efficiency 2
• Increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 1

Stimulus Control:

• Go to bed only when sleepy, not at a predetermined time 1, 2
• Use the bed only for sleep and sex—no reading, watching TV, or working in bed 1, 2
• If unable to fall asleep within approximately 20 minutes, leave the bed and engage in relaxing activity until drowsy, then return 1, 2
• Maintain stable bed times and rising times—arise at the same time each morning regardless of sleep obtained 1
• Avoid daytime napping; if necessary, limit to 30 minutes before 2 PM 1

Sleep Hygiene Education (as part of comprehensive CBT-I, not standalone):

• Avoid caffeine, nicotine, and alcohol in the evening 1, 4
• Avoid heavy exercise within 2 hours of bedtime 1
• Ensure the bedroom is quiet, dark, and temperature-regulated 1, 4
• Develop a 30-minute relaxation period before bedtime 1

Relaxation Therapy:

• Progressive muscle relaxation (tensing and relaxing each muscle group) 1
• Guided imagery, diaphragmatic breathing, meditation, or biofeedback 1

Implementation Strategy

• In-person, therapist-led CBT-I is most beneficial; digital CBT-I is effective when in-person is unavailable 2, 3
• Treatment typically requires 4-8 sessions over 6 weeks 2
• Counsel the patient that improvements are gradual but sustained—initial mild sleepiness and fatigue typically resolve quickly 2

Second-Line Treatment: Pharmacotherapy

Pharmacotherapy should only be added after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 1, 2, 3

First-Line Pharmacological Agents

For a 40-year-old male with combined sleep onset and maintenance insomnia:

Preferred Options:

• Eszopiclone 2-3 mg: Addresses both sleep initiation and maintenance with moderate-quality evidence showing improved sleep onset latency, total sleep time, and wake after sleep onset 1, 4
• Zolpidem 10 mg: Effective for both sleep onset and maintenance, with demonstrated efficacy in reducing sleep latency and improving sleep efficiency 1, 5

Alternative First-Line Options:

• Ramelteon 8 mg: Specifically for sleep onset difficulty, with a favorable safety profile and no abuse potential 4, 6
• Suvorexant (orexin antagonist): For sleep maintenance insomnia, with moderate-quality evidence showing reduced wake after sleep onset by 16-28 minutes 1, 4

Second-Line Pharmacological Agents

• Low-dose doxepin 3-6 mg: Specifically for sleep maintenance insomnia, reducing wake after sleep onset by 22-23 minutes with strong evidence 1, 4

Agents to AVOID

• Benzodiazepines (e.g., lorazepam, clonazepam, diazepam): Should be avoided due to dependence, withdrawal, cognitive impairment, fall risk, and associations with dementia 2, 4
• Over-the-counter antihistamines (e.g., diphenhydramine): Not recommended due to lack of efficacy data, anticholinergic effects, daytime sedation, and delirium risk 1, 4
• Trazodone: Explicitly not recommended for sleep onset or maintenance insomnia, as harms outweigh benefits 1, 4
• Herbal supplements (e.g., valerian) and melatonin: Insufficient evidence of efficacy 4

Critical Safety Considerations

• All hypnotics carry risks: driving impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, and cognitive impairment 2, 4
• Pharmacotherapy should be prescribed for short-term use only (typically less than 4 weeks), using the lowest effective dose 1, 4
• Short-term hypnotic treatment must be supplemented with CBT-I, not used as replacement 2, 4
• Monitor patients regularly to assess effectiveness, side effects, and ongoing medication need 4

Assessment Before Treatment

Before initiating treatment, screen for underlying sleep disorders:

• Obstructive sleep apnea: Snoring, witnessed apneas, excessive daytime sleepiness 1, 2
• Restless legs syndrome: Uncomfortable sensations in legs with urge to move, worse at rest 2
• Circadian rhythm disorders: Irregular sleep-wake patterns, shift work 2
• Comorbid psychiatric conditions: Depression, anxiety, PTSD 1
• Substance use: Caffeine, alcohol, nicotine, medications that interfere with sleep 1, 4

Common Pitfalls to Avoid

• Do NOT prescribe medications before attempting CBT-I—this is the most common error and violates guideline recommendations 2, 3
• Do NOT rely on sleep hygiene education alone—it lacks efficacy as a single intervention and should only be part of comprehensive CBT-I 1
• Do NOT let the patient stay in bed "trying to sleep" for hours—this worsens conditioned arousal and perpetuates insomnia 2
• Do NOT use benzodiazepines as first-line treatment—they have significant risks without superior efficacy 2, 4
• Do NOT continue pharmacotherapy long-term without periodic reassessment—hypnotics are intended for short-term use 1, 4

Treatment Algorithm Summary

1. Initiate CBT-I immediately (4-8 sessions over 6 weeks) 2, 3
2. If CBT-I insufficient after 6 weeks, add pharmacotherapy using shared decision-making 1, 2
3. First-line medication: Eszopiclone 2-3 mg or zolpidem 10 mg for combined sleep onset/maintenance insomnia 1, 4
4. If first-line medication fails, try alternative first-line agent (ramelteon, suvorexant) 4
5. If still insufficient, consider second-line agent (low-dose doxepin 3-6 mg) 4
6. Continue CBT-I throughout pharmacotherapy and attempt medication taper after 2-4 weeks 1, 2, 4