What treatment options are available for insomnia in a 47-year-old patient with a history of generalized anxiety disorder and depression who is currently taking sertraline (selective serotonin reuptake inhibitor)?

From the Guidelines

For a 47-year-old with insomnia who has generalized anxiety and depression and is taking sertraline, I recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment. This non-pharmacological approach includes sleep hygiene education, stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring, as supported by the American Academy of Sleep Medicine clinical practice guideline 1.

Key Considerations

• CBT-I is a multicomponent intervention that has been shown to be effective in improving sleep quality and reducing symptoms of insomnia, with a strong recommendation based on moderate-quality evidence 1.
• If medication is needed, consider adding low-dose trazodone (25-50mg at bedtime) which can be effective for insomnia and works well with sertraline, or mirtazapine (7.5-15mg at bedtime) which can help with sleep while potentially augmenting antidepressant effects, as suggested by recent studies 1.
• Avoid benzodiazepines and Z-drugs for long-term use due to dependency risks, and instead consider short-term relief with low-dose doxepin (3-6mg) or melatonin (1-3mg) while CBT-I takes effect.
• Evaluate whether the insomnia might be related to inadequate control of anxiety or depression, in which case optimizing the sertraline dose might help, and consider whether sertraline timing is contributing to sleep problems, with morning administration typically preferred 1.

Complementary Measures

• Regular sleep schedule
• Avoiding caffeine after noon
• Limiting screen time before bed
• Creating a comfortable sleep environment

These measures can help improve sleep quality and reduce symptoms of insomnia, and should be used in conjunction with CBT-I and any necessary medication adjustments. As noted in the American Academy of Sleep Medicine clinical practice guideline, CBT-I is the treatment of choice for most patients with insomnia, and should be prioritized over pharmacological interventions whenever possible 1.

From the Research

Treatment Options for Insomnia

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is a recommended treatment for insomnia, especially for patients with comorbid psychiatric disorders such as generalized anxiety disorder and depression 2, 3, 4, 5, 6.
• CBT-I has been shown to be effective in improving insomnia symptoms, as well as reducing symptoms of depression and anxiety 2, 4, 5, 6.
• The treatment involves five key components: sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques 3.

Considerations for Patients with Generalized Anxiety and Depression

• Patients with generalized anxiety disorder and depression may benefit from CBT-I as a first-line treatment for insomnia, given the high comorbidity rates between these conditions 2, 4, 6.
• CBT-I may be particularly useful for patients who are already taking antidepressant medications, such as sertraline, as it can help improve sleep quality and reduce symptoms of depression and anxiety 2, 5.
• The treatment can be delivered in-person, via telehealth, or in a group setting, although more research is needed to determine the effectiveness of these different modalities 5.

Efficacy of CBT-I

• Studies have shown that CBT-I can lead to moderate to large effect sizes for reducing insomnia symptoms, as well as symptoms of depression and anxiety 4, 5, 6.
• Approximately 61% of patients with insomnia disorder and generalized anxiety disorder responded to CBT-I, and 26-48% remitted 6.
• CBT-I has also been shown to improve functional impairment, quality of life, and treatment perception, while reducing adverse events 6.