What adjustments can be made to a patient's treatment plan, currently including duloxetine and buspirone, to improve sleep quality in a patient with a history of depression and anxiety?

Treatment Optimization for Sleep in Depression and Anxiety

Primary Recommendation: Add Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I should be initiated as first-line treatment for this patient's insomnia, as it is the only intervention with standard-level evidence for chronic insomnia and demonstrates superior long-term outcomes compared to pharmacological approaches. 1

Rationale for CBT-I Priority

• CBT-I improves both global outcomes (remission, treatment response, reduced ISI and PSQI scores) and specific sleep outcomes (reduced sleep onset latency, wake after sleep onset, improved sleep efficiency) with moderate-quality evidence in the general population 1
• The American College of Physicians designates CBT-I as first-line treatment before considering pharmacological sleep aids, even when patients are already on antidepressants 1
• CBT-I combines cognitive therapy (addressing beliefs like "I can't sleep without medication") with behavioral treatments including stimulus control, sleep restriction, and relaxation therapy 1
• Various delivery methods are effective: individual therapy, group therapy, telephone-based, web-based modules, or self-help books 1

Specific CBT-I Components to Implement

• Sleep restriction therapy: Limit time in bed to actual total sleep time from baseline sleep logs, maintaining >85% sleep efficiency, with weekly 15-20 minute adjustments based on sleep efficiency calculations 1
• Stimulus control: Establish consistent sleep-wake schedule and use bed only for sleep 1
• Progressive muscle relaxation: Methodical tensing and relaxing of muscle groups to reduce somatic arousal 1

Secondary Recommendation: Pharmacological Augmentation Only After CBT-I Trial

If CBT-I alone is unsuccessful after 8-12 weeks, add low-dose sedating antidepressant using shared decision-making regarding benefits, harms, and short-term duration (4-5 weeks maximum). 1

Preferred Pharmacological Options

• Trazodone 25-100 mg at bedtime: First choice for sleep augmentation in patients already on duloxetine, as it has little anticholinergic activity and can be used as adjunct to full-dose antidepressants 1
• Mirtazapine 7.5-15 mg at bedtime: Alternative option with 5-HT2 blocking properties that improves sleep architecture, shortens sleep-onset latency, increases total sleep time, and improves sleep efficiency 2, 3
• Low-dose doxepin 3-6 mg: Moderate-quality evidence shows improved ISI scores and sleep outcomes in older adults, though anticholinergic effects are a consideration 1

Medications to Consider With Caution

• Eszopiclone or zolpidem: Low-to-moderate quality evidence for improved sleep onset latency and total sleep time, but observational studies show associations with dementia, serious injury, and fractures 1
• Suvorexant: Moderate-quality evidence for improved treatment response and sleep outcomes, but limited long-term safety data 1
• Benzodiazepines (lorazepam, clonazepam): May be considered if duration of action matches patient's presentation, but insufficient evidence from guidelines and concerns about dependence 1

Critical Medications to Avoid

• Diphenhydramine: Not studied in guideline-quality trials and carries anticholinergic burden 1
• Ramelteon: Low-quality evidence showed no statistically significant difference from placebo for sleep outcomes 1

Optimization of Current Antidepressant Regimen

Duloxetine Assessment

• Duloxetine 60-120 mg once daily is effective for generalized anxiety disorder and demonstrates efficacy in preventing relapse 4
• If depression symptoms remain "potentially insufficient," consider increasing duloxetine to 90-120 mg once daily before adding sleep medication 4
• SSRIs and SNRIs (including duloxetine) stimulate 5-HT2 receptors, which underlies insomnia and disrupted sleep architecture—this is why hypnotics or low-dose trazodone are commonly co-prescribed 2

Buspirone Continuation

• Buspirone 5-30 mg/day (mean dose 18 mg/day) is well-tolerated and effective for anxiety in patients receiving concomitant medications for chronic conditions 5
• Continue buspirone as it provides anxiety management without sedating properties that could complicate sleep assessment 5

Monitoring Protocol

• Assess sleep quality at 4 weeks and 8 weeks using standardized measures (ISI, PSQI) 1
• Monitor for treatment-emergent adverse effects, particularly with any new sleep medication 1
• If insomnia does not remit within 7-10 days of pharmacological treatment, further evaluation is warranted per FDA recommendations 1

Critical Pitfalls to Avoid

• Do not start with pharmacological sleep aids before attempting CBT-I, as this contradicts guideline recommendations and may lead to long-term medication dependence 1
• Do not continue pharmacological sleep aids beyond 4-5 weeks without reassessment, as FDA approval is for short-term use only 1
• Do not use sleep hygiene education alone, as it has no recommendation level in guidelines and is insufficient as monotherapy 1
• Avoid abrupt discontinuation of any sleep medication due to rebound insomnia risk 3
• Do not prescribe benzodiazepines long-term due to dependence risk, cognitive impairment, and fall risk, particularly in older adults 1

Treatment Algorithm Summary

1. Weeks 0-8: Initiate CBT-I (any delivery method) while continuing duloxetine and buspirone 1
2. Week 4: Assess sleep improvement; if inadequate, optimize duloxetine dose to 90-120 mg if depression symptoms insufficient 4
3. Week 8: If CBT-I unsuccessful, add trazodone 25-50 mg at bedtime or mirtazapine 7.5-15 mg at bedtime using shared decision-making 1
4. Week 12: If sleep medication added, reassess for efficacy and plan taper if successful, or switch to alternative if unsuccessful 1