What is the most appropriate advice for a patient with a 3‑month history of sleep‑maintenance insomnia and an irregular sleep schedule?

Treatment of Sleep-Maintenance Insomnia with Irregular Sleep Schedule

The most appropriate advice is to establish a regular sleep schedule and limit screen time (Option C), combined with Cognitive Behavioral Therapy for Insomnia (CBT-I) as the foundational treatment.

Why Regular Sleep Schedule and Screen Time Limitation Are Essential

• The American Academy of Sleep Medicine (AASM) and NHS recommend that maintaining a consistent bedtime and wake-up time every day is a standard component of sleep hygiene education and forms the foundation of insomnia management 1

• Sleep hygiene education specifically includes avoiding excess screen time before bedtime, as light exposure in the evening disrupts circadian rhythms and worsens sleep maintenance problems 1

• The irregular sleep pattern documented in this patient's diary directly indicates poor sleep-wake scheduling, which perpetuates the insomnia cycle through disrupted circadian timing 1

Why CBT-I Must Be the First-Line Treatment

• The American College of Physicians and AASM strongly recommend that all adults with chronic insomnia (≥3 months) receive CBT-I as initial treatment before any pharmacotherapy, as it demonstrates superior long-term efficacy with sustained benefits after treatment ends 1, 2, 3

• CBT-I includes stimulus control therapy (using the bed only for sleep, leaving bed if unable to sleep within 20 minutes), sleep restriction (limiting time in bed to match actual sleep time), and cognitive restructuring of negative sleep beliefs 1, 2

• For sleep-maintenance insomnia specifically, CBT-I produces moderate-quality evidence showing reduced wake after sleep onset and improved sleep efficiency 3, 4

Why the Other Options Are Incorrect

Option B (Caffeine in Afternoon) – Explicitly Contraindicated

• The AASM explicitly recommends avoiding caffeine for at least 6 hours before bedtime as part of standard sleep hygiene 1

• Encouraging afternoon caffeine would directly worsen sleep-maintenance insomnia by increasing arousal during the sleep period 5

Option A (CBT-I Alone) – Incomplete Without Sleep Hygiene

• While CBT-I is first-line treatment, the AASM states that sleep hygiene education alone is insufficient as monotherapy but must be included as part of comprehensive CBT-I 1, 2

• The patient's documented irregular sleep schedule specifically requires addressing sleep-wake timing as a core intervention 1

Option D (Sedative) – Premature Without Behavioral Intervention

• The American College of Physicians explicitly states that pharmacotherapy should only be added after CBT-I has been attempted, as medications provide inferior long-term outcomes and do not address the underlying behavioral perpetuating factors 2, 3

• For this patient with documented irregular sleep patterns, starting medication without first correcting the sleep schedule would fail to address the root cause 1, 2

Practical Implementation Algorithm

1. Immediate sleep schedule stabilization: Set a fixed wake time every morning (including weekends) and calculate bedtime to allow 7-8 hours in bed 1

2. Screen time restriction: Avoid all screens (phones, tablets, computers, TV) for at least 1 hour before bedtime; if screens are necessary, use blue-light blocking glasses 1, 5

3. Complete 2-week sleep diary: Document sleep quality, bedtime, wake time, napping, caffeine/alcohol intake, and evening activities to guide further CBT-I components 1

4. Initiate full CBT-I program: Add stimulus control (leave bed if awake >20 minutes), sleep restriction (limit time in bed to actual sleep time + 30 minutes), and relaxation techniques 1, 2

5. Reassess after 4-8 weeks: If sleep-maintenance insomnia persists despite optimal CBT-I adherence, consider adding low-dose doxepin 3-6 mg or suvorexant 10 mg as adjunctive therapy 2, 3

Common Pitfalls to Avoid

• Starting medication without addressing the irregular sleep schedule – this perpetuates the underlying circadian misalignment and leads to medication dependence without lasting benefit 1, 2

• Recommending sleep hygiene alone without structured CBT-I – sleep hygiene education is necessary but insufficient; it must be combined with stimulus control and sleep restriction for durable improvement 1

• Allowing continued screen use before bed – even with blue-light filters, screen content is cognitively stimulating and delays sleep onset 1, 5

• Permitting weekend sleep schedule variability – "catching up" on weekends worsens circadian misalignment and perpetuates weekday insomnia 1