Nine steps to managing insomnia in primary care
It’s one of the most common reasons people visit their GPs, and the drugs used to treat it can be highly addictive. Insomnia can have nebulous causes and varying symptoms, which often make it difficult to manage.
A new Viewpoint published this month in JAMA brings together the latest evidence and recommendations for managing insomnia. The authors say insomnia disorder can be diagnosed if sleep difficulties occur at least three nights a week for at least three months, as long as the patient has had adequate opportunity for sleep and the sleeplessness cannot be explained by medications, substance abuse or any other disorder.
Cognitive behavioural treatment (CBT) is the recommended initial treatment for chronic insomnia. Brief behavioral treatment for insomnia, an approach derived from CBT, can also be used, and involves four simple interventions to help increase “sleep drive”:
- Reducing time in bed to match actual sleep duration;
- Getting up at the same time each day, regardless of sleep duration;
- Not going to bed unless sleepy;
- Not staying in bed unless asleep.
Pharmacological treatment is best for patients with acute insomnia, in conjunction with CBT, although the evidence for drugs in managing insomnia disorder remains weak. If medication is prescribed, the approved drugs for insomnia are benzodiazepines and benzodiazepine receptor agonists, the melatonin receptor agonist ramelteon, the tricyclic doxepin and the orexin receptor antagonist suvorexant. But these medications should be used only on a short-term basis, and in shared decision-making with the patient.
Here are are nine key steps to managing insomnia:
- Assess sleep and daytime symptoms and treat any comorbid conditions.
- For acute insomnia, consider a short-acting hypnotic (eg, temazepam or zolpidem 3-4 nights weekly for 3-4 weeks), then taper and discontinue.
- For chronic insomnia disorder, start the patient on an cognitive behavioral intervention.
- Assess sleep and daytime symptom response to treatment.
- If symptoms continue with CBT, consider combined treatment using a drug appropriate for sleep onset or sleep maintenance symptoms.
- If symptoms continue with pharmacotherapy, consider switching class of hypnotic (eg, benzodiazepine or benzodiazepine receptor agonist to doxepin, ramelteon, or suvorexant).
- If symptoms continue, evaluate other contributing factors (eg, life events, new medical or psychiatric disorder) and address with psychosocial, behavioral, or medical treatment.
- If the insomnia disorder is completely treatment-resistant, refer to a sleep specialist for evaluation of other sleep-wake disorders, including sleep apnea.
- Monitor for long-term treatment response and sequelae such as depressive or anxiety disorder, substance use disorder, or neurodegenerative disorder.