From the Guidelines
A comprehensive insomnia workup should begin with a detailed sleep history, including sleep patterns, duration, quality, and daytime symptoms, as well as a physical examination and review of medical conditions, medications, and substance use. This approach is supported by the American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults 1. The workup should also include screening for mental health conditions like depression and anxiety, which frequently coexist with insomnia. Laboratory tests such as thyroid function tests, complete blood count, and basic metabolic panel may be necessary to rule out medical causes of insomnia.
Key Components of Insomnia Workup
- A detailed sleep history, including sleep patterns, duration, quality, and daytime symptoms
- A physical examination and review of medical conditions, medications, and substance use
- Screening for mental health conditions like depression and anxiety
- Laboratory tests to rule out medical causes of insomnia
- Assessment of sleep hygiene practices and environmental factors that may disrupt sleep
Importance of Cognitive Behavioral Therapy for Insomnia (CBT-I)
The American College of Physicians recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder, as stated in their clinical practice guideline for the management of chronic insomnia disorder in adults 1. This approach is supported by moderate-quality evidence and is considered a strong recommendation.
Role of Pharmacological Therapy
Pharmacological therapy may be considered in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful, using a shared decision-making approach that includes a discussion of the benefits, harms, and costs of short-term use of medications 1. However, this recommendation is based on low-quality evidence and is considered weak.
Conclusion is not allowed, so the answer will continue without one.
The evaluation of insomnia should be comprehensive and guided by the latest clinical practice guidelines, prioritizing CBT-I as the initial treatment and considering pharmacological therapy only when necessary. By following this approach, clinicians can provide effective treatment for insomnia, improving patient outcomes and quality of life.
From the Research
Insomnia Workup
Insomnia is a common sleep disorder characterized by difficulty initiating or maintaining sleep, or nonrestorative sleep, leading to daytime impairment 2. The workup for insomnia involves a multi-disciplinary approach, including:
- Behavioral interventions
- Improving sleep hygiene
- Managing psychological stressors
- Hypnotic treatment
- Pharmacological therapy
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is a highly effective treatment for insomnia, with moderate to large effects that can last up to a year after therapy 3. The key components of CBT-I include:
- Sleep consolidation
- Stimulus control
- Cognitive restructuring
- Sleep hygiene
- Relaxation techniques CBT-I is considered a first-line treatment for chronic insomnia, producing results equivalent to sleep medication with no side effects and fewer episodes of relapse 4.
Pharmacological Treatment
Pharmacological treatment, such as zolpidem, can be used as an adjunctive treatment for insomnia, but it is associated with various adverse effects, including an increased risk of falls, hip fractures, and complex behaviors such as sleepwalking and hallucinations 2. The decision to prescribe pharmacological treatment should be made on a case-by-case basis, considering the physical and psychiatric risks posed to the patient.
Online Interventions
Online interventions, such as the Smart CBT-I plus program, can be an effective and convenient way to deliver CBT-I, especially for patients with insomnia combined with anxiety and depression 5. These programs can provide a balance between convenience and efficiency, and can be tailored to individual patient needs.