How do primary care physicians evaluate and manage a patient with chronic insomnia lasting several years?

Approaching a Patient with Chronic Insomnia in Primary Care

Primary care physicians should immediately initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as the standard first-line treatment for any patient presenting with chronic insomnia lasting several years, while simultaneously conducting a focused diagnostic evaluation to identify contributing medical, psychiatric, and substance-related factors. 1

Initial Screening and Diagnosis

Begin by confirming the diagnosis using two screening questions: (1) "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" and (2) "Does the problem with your sleep negatively affect your daytime functioning?" 2 If both answers are yes, chronic insomnia disorder is likely present, defined as sleep difficulties occurring ≥3 nights per week for ≥3 months with associated daytime dysfunction. 1

At the initial visit, patients must complete three essential assessments: 1

• A general medical/psychiatric questionnaire to identify comorbid disorders
• The Epworth Sleepiness Scale to rule out other sleep disorders (significant sleepiness suggests sleep apnea or narcolepsy, not typical insomnia)
• A two-week sleep diary documenting bedtime, wake times, sleep latency, nighttime awakenings, total sleep time, and naps

Focused Clinical Evaluation

Sleep History Components

Document the specific insomnia pattern: difficulty falling asleep (sleep-onset latency), difficulty staying asleep (wake after sleep onset), or early-morning awakening. 1 Characterize pre-sleep conditions including bedroom environment (light, noise, temperature), activities incompatible with sleep (TV watching, phone use, eating in bed), and the patient's mental state at bedtime (anxious versus relaxed). 1

Assess daytime consequences systematically: fatigue is more common than actual sleepiness in chronic insomnia patients; evaluate for irritability, mood disturbance, cognitive difficulties (memory, attention, concentration), and quality of life impairment affecting work, relationships, and social activities. 1

Medical and Psychiatric Comorbidities

Screen for medical conditions that cause or exacerbate insomnia: cardiovascular disease, chronic pain, gastrointestinal disorders (GERD), pulmonary conditions (asthma, COPD), neurological disorders, and endocrine disorders (hyperthyroidism). 1, 2 Psychiatric disorders account for 40-50% of chronic insomnia cases, with anxiety and depression being the most common. 1, 3 Younger patients (<45 years) are more likely to have anxiety-related insomnia, while older patients may have fewer identified comorbidities. 4

Medication and Substance Review

Systematically review medications that disrupt sleep: 1

• Antidepressants (SSRIs, SNRIs, MAOIs)
• Stimulants (caffeine, methylphenidate, amphetamines)
• Cardiovascular drugs (β-blockers, α-agonists, diuretics)
• Pulmonary medications (theophylline, albuterol)
• Decongestants (pseudoephedrine, phenylephrine)

Assess caffeine intake (timing and quantity), alcohol use (causes sleep fragmentation despite initial sedation), nicotine use, and recreational drugs. 1

What NOT to Order

Polysomnography and Multiple Sleep Latency Testing are NOT indicated for routine insomnia evaluation. 1 These tests should only be ordered when you suspect obstructive sleep apnea (loud snoring, witnessed apneas, significant daytime sleepiness), periodic limb movement disorder, narcolepsy, or when treatment fails despite appropriate interventions. 1

Treatment Algorithm

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

CBT-I must be initiated immediately as the foundation of treatment, demonstrating superior long-term efficacy compared to medications with sustained benefits after discontinuation. 1, 5 CBT-I includes four core components: 5

1. Stimulus control therapy: Go to bed only when sleepy, maintain consistent sleep-wake times, avoid naps, use bed only for sleep, leave bed after 20 minutes if unable to sleep
2. Sleep restriction therapy: Track total sleep time for 1-2 weeks, then limit time in bed to match actual sleep time (gradually increase as sleep efficiency improves)
3. Cognitive therapy: Address distorted beliefs about sleep and catastrophic thinking
4. Relaxation training: Progressive muscle relaxation, deep breathing exercises

CBT-I can be delivered through in-person therapy, digital platforms, or self-help materials when specialist access is limited. 6, 7

Pharmacotherapy Decision Points

If CBT-I alone is insufficient after 2-4 weeks, add pharmacotherapy while continuing CBT-I. 1, 5 The medication sequence follows a strict hierarchy:

First-Line Pharmacotherapy

For sleep-onset insomnia: Short-acting benzodiazepine receptor agonists (zolpidem 5-10 mg, zaleplon 5-10 mg) or ramelteon 8 mg. 1, 5 Ramelteon is preferred for patients with substance use history (non-DEA scheduled, zero addiction potential). 5, 8

For sleep-maintenance insomnia: Low-dose doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes with minimal anticholinergic effects at this dose) or eszopiclone 2-3 mg. 1, 5, 8

Second-Line Options

If initial benzodiazepine receptor agonist or ramelteon fails, switch to an alternative agent within the same class based on symptom pattern (sleep onset versus maintenance). 1, 5

Third-Line Options

Sedating antidepressants (trazodone 50-150 mg, mirtazapine, amitriptyline) are reserved for patients with comorbid depression/anxiety or when first-line agents fail. 1, 5 Note: Trazodone has insufficient efficacy data as monotherapy for primary insomnia despite widespread use. 8

Agents to Avoid

Never prescribe as first-line: 1, 5, 8

• Over-the-counter antihistamines (diphenhydramine, doxylamine): lack efficacy data, cause anticholinergic effects, tolerance develops in 3-4 days
• Traditional benzodiazepines (lorazepam, temazepam): higher dependency risk, falls, cognitive impairment, respiratory depression
• Atypical antipsychotics (quetiapine, olanzapine): insufficient evidence, significant metabolic side effects
• Barbiturates and chloral hydrate: not recommended for insomnia
• Herbal supplements (valerian, melatonin): insufficient efficacy data for chronic insomnia

Critical Implementation Points

Patient education before prescribing any medication must include: 1

• Treatment goals and realistic expectations (improvement, not perfection)
• Safety concerns (take only when 7-8 hours available for sleep, no alcohol, no driving if awakened early)
• Potential side effects and drug interactions
• Complex sleep behaviors (sleep-driving, sleep-walking) requiring immediate discontinuation
• Plan for lowest effective dose and shortest duration

Follow-up schedule: Reassess every 2-4 weeks initially to evaluate effectiveness, monitor for adverse effects (daytime sedation, falls, cognitive impairment), and determine continued need for medication. 1 Attempt medication tapering when conditions allow, facilitated by concurrent CBT-I. 1

Long-term management: Chronic hypnotic use may be necessary for severe refractory insomnia, but requires consistent follow-up, ongoing effectiveness assessment, and monitoring for new or worsening comorbid conditions. 1 Dosing can be nightly, intermittent (3 nights/week), or as-needed based on patient response. 1

Common Pitfalls to Avoid

Do not prescribe medications as first-line monotherapy without attempting CBT-I. Current practice shows 51.5% of primary care patients receive medications as initial treatment, while only 5% receive CBT-I referral—this is contrary to evidence-based guidelines. 4

Do not overlook comorbid conditions. Psychiatric and chronic pain disorders have insomnia rates of 50-75%, and treating the underlying condition is essential for insomnia resolution. 1

Do not continue ineffective medications. If a patient reports no improvement after 1-2 weeks at therapeutic doses, switch agents rather than increasing doses or adding multiple medications. 1

Do not ignore excessive daytime sleepiness. This symptom is uncommon in primary insomnia and suggests obstructive sleep apnea, narcolepsy, or other sleep disorders requiring polysomnography. 1