How should I manage insomnia in a patient with a mood disorder, a history of seizures, and non‑restorative light sleep?

Managing Insomnia in a Patient with Mood Disorder, Seizure History, and Non-Restorative Sleep

Start Cognitive Behavioral Therapy for Insomnia (CBT-I) immediately as first-line treatment, then add low-dose doxepin 3–6 mg at bedtime if behavioral therapy alone is insufficient after 4–8 weeks.

Critical Safety Consideration: Seizure Risk

• Avoid sleep restriction therapy—a core CBT-I component—in patients with seizure disorders because sleep deprivation can lower seizure threshold and trigger breakthrough seizures. 1
• Modify CBT-I to emphasize stimulus control, relaxation techniques, cognitive restructuring, and sleep hygiene education while omitting or carefully limiting sleep restriction. 1

Why CBT-I Must Come First

• The American Academy of Sleep Medicine and American College of Physicians issue a strong recommendation that all adults with chronic insomnia receive CBT-I as initial treatment before any medication, because it provides superior long-term efficacy with sustained benefits after discontinuation. 1, 2
• Mood disorders and insomnia have a bidirectional relationship—insomnia exacerbates depression/anxiety, and untreated mood symptoms perpetuate sleep disturbance. 3, 4, 5
• In patients with epilepsy, more than 55% suffer from insomnia and over 70% report poor sleep quality; depressive and anxiety symptoms are the strongest predictors of sleep impairment, even more than seizure-related factors. 6, 7

Modified CBT-I Components for This Patient

• Stimulus control: Use the bed only for sleep; leave the bed if unable to fall asleep within 20 minutes; return only when drowsy. 1, 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or breathing exercises to reduce hyperarousal. 1, 2
• Cognitive restructuring: Address catastrophic thoughts about sleep loss triggering seizures or worsening mood. 1, 2
• Sleep hygiene: Fixed wake time daily (including weekends), avoid caffeine ≥6 hours before bed, eliminate screens 1 hour before bedtime, optimize bedroom environment. 1, 2
• Omit or carefully limit sleep restriction due to seizure risk; if used, maintain minimum 6–7 hours time-in-bed to avoid dangerous sleep deprivation. 1

First-Line Pharmacotherapy (After CBT-I Initiation)

• Low-dose doxepin 3 mg at bedtime is the preferred medication because it reduces wake after sleep onset by 22–23 minutes, has minimal anticholinergic effects at hypnotic doses, carries no abuse potential, and does not lower seizure threshold. 1, 2
• If 3 mg is insufficient after 1–2 weeks, increase to 6 mg. 1, 2
• Doxepin does not interact with most antiepileptic drugs and is safer than benzodiazepines or Z-drugs in patients with seizure disorders. 1

Alternative Second-Line Options (If Doxepin Fails)

• Suvorexant 10 mg (orexin-receptor antagonist) reduces wake after sleep onset by 16–28 minutes with lower cognitive/psychomotor impairment risk than benzodiazepine-type agents. 1
• Ramelteon 8 mg (melatonin-receptor agonist) for sleep-onset insomnia; no abuse potential, no DEA scheduling, no withdrawal symptoms. 1
• Eszopiclone 2 mg (1 mg if age ≥65 years) for combined sleep-onset and maintenance insomnia; increases total sleep time by 28–57 minutes but carries higher fall/cognitive impairment risk. 1

Medications to Absolutely Avoid

• Benzodiazepines (lorazepam, clonazepam, diazepam) are contraindicated because they increase fall risk, cause cognitive impairment, produce dependence, and can worsen mood instability in bipolar disorder. 1, 3
• Trazodone yields only ~10 minutes reduction in sleep latency with no improvement in subjective sleep quality; harms outweigh minimal benefits. 1, 2
• Over-the-counter antihistamines (diphenhydramine, doxylamine) lack efficacy, cause strong anticholinergic effects (confusion, falls, daytime sedation), and develop tolerance within 3–4 days. 1
• Antipsychotics (quetiapine, olanzapine) have weak evidence for insomnia benefit and significant risks including weight gain, metabolic disturbance, and extrapyramidal symptoms. 1

Addressing the Mood Disorder Component

• Ensure the patient is on adequate mood-stabilizing medication (SSRI, SNRI, or mood stabilizer) before adding sleep-specific pharmacotherapy, as untreated mood symptoms are the strongest predictor of persistent insomnia. 3, 7, 5
• SSRIs and TCAs were associated with lower mania scores in hospitalized bipolar patients, though these medications can cause or exacerbate insomnia in some individuals. 3
• If the patient has bipolar disorder, sedating antidepressants (including doxepin, mirtazapine, trazodone) should only be used when the patient is concurrently receiving at least one mood stabilizer to prevent triggering manic episodes. 3
• Insomnia can precipitate manic episodes in bipolar disorder, and mania itself causes marked decrease in sleep need—creating a self-reinforcing cycle. 3

Monitoring and Reassessment

• Reassess sleep parameters using a sleep log after 2–4 weeks to evaluate sleep latency, wake after sleep onset, total sleep time, and daytime functioning. 1, 2
• Monitor for adverse effects: morning sedation, cognitive impairment, complex sleep behaviors (sleep-walking, sleep-driving). 1
• If insomnia persists despite CBT-I plus doxepin after 4–6 weeks, refer to a sleep specialist to evaluate for comorbid sleep disorders (sleep apnea, restless legs syndrome, periodic limb movements). 1, 2
• Screen for worsening mood symptoms at every visit, as depression/anxiety are the most powerful predictors of treatment-resistant insomnia in patients with epilepsy. 6, 7

Common Pitfalls to Avoid

• Starting medication without implementing modified CBT-I leads to less durable benefit and contravenes guideline recommendations. 1, 2
• Using standard sleep restriction therapy in a patient with seizures can trigger breakthrough seizures through sleep deprivation. 1
• Prescribing benzodiazepines creates dependence risk, worsens mood instability, and increases fall/cognitive impairment risk. 1, 3
• Adding multiple sedating medications simultaneously (e.g., combining doxepin with a benzodiazepine) markedly increases respiratory depression, fall, and cognitive impairment risk. 1
• Failing to address underlying mood symptoms perpetuates insomnia, as affective symptoms explain more variance in sleep quality than seizure-related factors. 6, 7
• Ignoring trauma-related fear of sleep—post-seizure trauma is a significant contributor to insomnia in patients with epilepsy and should be addressed in therapy. 8