What first‑line non‑pharmacologic treatments are recommended for persistent insomnia in an otherwise healthy adult taking escitalopram 10 mg daily for depression and anxiety and using clonazepam 0.25 mg only as needed for occasional anxiety or insomnia?

Non-Pharmacologic Interventions for Insomnia

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated immediately as the standard of care for all adults with chronic insomnia, either alone or alongside any medication, because it provides superior long-term efficacy with sustained benefits after treatment ends—unlike pharmacotherapy, whose effects cease when stopped. 1, 2, 3

Core Components of CBT-I

• Stimulus control therapy – Use the bed only for sleep and sex; leave the bedroom if unable to fall asleep within 15–20 minutes and return only when sleepy; maintain a consistent wake time every morning including weekends. 1, 2

• Sleep restriction therapy – Limit time in bed to match actual sleep time plus a 30-minute buffer (e.g., if sleeping 5.5 hours, allow 6 hours in bed); gradually increase as sleep efficiency improves to ≥85%. This creates mild sleep deprivation that consolidates sleep. 1, 2

• Cognitive restructuring – Challenge catastrophic beliefs about sleep (e.g., "I must get 8 hours or I'll be dysfunctional"); replace with realistic expectations and reduce performance anxiety around sleep. 1, 2

• Relaxation techniques – Progressive muscle relaxation, diaphragmatic breathing, guided imagery, or mindfulness meditation performed 30–60 minutes before bedtime to reduce physiological arousal. 1, 2

Sleep Hygiene Education (Adjunctive Component)

Sleep hygiene alone is insufficient as monotherapy but must supplement the behavioral components above. 1, 2, 3 Key elements include:

• Maintain a fixed wake time every day (including weekends) to stabilize circadian rhythm. 1, 3
• Avoid caffeine for at least 6 hours before bedtime. 1, 3
• Eliminate alcohol in the evening, as it fragments sleep in the second half of the night. 1, 3
• Stop all screen use (phones, tablets, computers) at least 1 hour before bed; blue light suppresses melatonin and delays sleep onset. 1, 3
• Keep the bedroom dark, quiet, and cool (60–67°F / 16–19°C). 1, 3
• Avoid daytime naps or limit to ≤30 minutes before 2 PM. 1, 3
• Exercise regularly but complete vigorous activity at least 3–4 hours before bedtime. 1, 3

Delivery Formats for CBT-I

CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats demonstrate comparable effectiveness, making treatment accessible even in resource-limited settings. 1, 2

Timeline and Monitoring

• Improvements from CBT-I are gradual, typically emerging over 4–8 weeks, but benefits are durable and persist long after treatment ends. 1, 2

• Initial side effects such as mild daytime sleepiness and fatigue from sleep restriction typically resolve within 1–2 weeks as sleep consolidates. 1

• Maintain a 2-week sleep diary before and during treatment to document bedtime, wake time, sleep latency, number of awakenings, total sleep time, and daytime functioning; this data guides dose adjustments in sleep restriction. 1, 3

Special Population Considerations

• In patients with seizure disorder or bipolar disorder, use sleep restriction cautiously because sleep deprivation can trigger seizures or manic episodes; consider lower restriction ratios and closer monitoring. 1

• In elderly patients (≥65 years), CBT-I is equally effective and safer than pharmacotherapy, with no fall risk, cognitive impairment, or drug interactions. 1, 2

Integration with Pharmacotherapy

If pharmacotherapy is added (e.g., for patients already on escitalopram 10 mg and using clonazepam 0.25 mg as needed), CBT-I must continue concurrently because behavioral therapy provides the foundation for eventual medication tapering and prevents relapse when drugs are stopped. 1, 2, 4, 5

• Short-term hypnotic treatment should always supplement—not replace—CBT-I. 1, 2

• For patients on escitalopram with comorbid depression/anxiety and insomnia, CBT-I addresses the insomnia directly while escitalopram treats the underlying mood disorder; this dual approach is more effective than either alone. 4, 5

Common Pitfalls to Avoid

• Initiating pharmacotherapy without first implementing CBT-I leads to less durable benefit and higher relapse rates when medication is stopped. 1, 2

• Relying on sleep hygiene education alone without structured stimulus control and sleep restriction fails to produce meaningful improvement. 1, 2, 3

• Allowing variable weekend sleep schedules (sleeping in to "catch up") perpetuates circadian misalignment and worsens weekday insomnia. 1, 3

• Continuing screen use before bedtime—even with blue-light filters—remains cognitively stimulating and delays sleep onset. 1, 3

• Failing to address maladaptive beliefs about sleep (e.g., "I need 8 hours or I'll fail at work") maintains performance anxiety that perpetuates insomnia. 1, 2