Clinical Management of Insomnia Disorder

In an article Authored by Charles F. Reynolds III, MD, University of Pittsburgh School of Medicine, management of Insomnia has been vividly outlined and the same has been published online in JAMA.

According to the author, the central feature of insomnia disorder is dissatisfaction with sleep quantity or quality, associated with difficulty falling asleep, maintaining sleep, or early morning awakening.In insomnia disorder, Sleep difficulties occur at least 3 nights per week for at least 3 months and are not better explained by use of substances, medications, or by another disorder thereby causing clinically significant distress or impairment in important areas of functioning.

The diagnosis of insomnia relies on patient history from both the patient and bed partner. Self-report questionnaires and sleep diaries are often used to assess insomnia severity, identify behaviors contributing to persistent insomnia, and monitor treatment effects, according to the author.

The treatment can be divided into :

1. Cognitive Behavioral Treatment

• The American College of Physicians (ACP) recommends cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder.


• CBT-I is a multimodal treatment that combines education (eg, healthy sleep practices and expectations), stimulus control instructions, time-in-bed restriction, and relaxation training.


• CBT-I can be delivered by trained therapists and by self-guided, fully automated online programs. Brief behavioral treatment for insomnia (BBTI) delivered in a single initial session with 2 to 3 brief follow-up visits in person or by telephone.


• BBTI includes 4 behavioral interventions that improve sleep consolidation by increasing sleep "drive," reinforcing sleep regularity, reducing arousal and increasing associations between bed and sleep:

(1) reduce time in bed to match actual sleep duration,

(2) get up at the same time every day, regardless of sleep duration,

(3) do not go to bed unless sleepy, and

(4) do not stay in bed unless asleep.

2. Pharmacological Treatment

US Food and Drug Administration (FDA)–approved prescription medications for insomnia include benzodiazepines and benzodiazepine receptor agonists (BzRAs), the melatonin receptor agonist ramelteon, the tricyclic drug doxepin, and the orexin receptor antagonist suvorexant.

Pharmacological treatment is most appropriate for patients with acute insomnia (<3 months) and should be considered as an adjunct to cognitive behavioral treatment for patients with chronic insomnia disorder.

Dr. Charles F. Reynolds has very lucidly earmarked Treatment Approach for the treating physicians and which includes-

Step 1: Evaluation

• Evaluate sleep and daytime symptoms and comorbid conditions.


• Optimize treatment of comorbid conditions.

Step 2: Initial Treatment

• Acute insomnia diagnosis: consider short-acting hypnotic (eg, temazepam or zolpidem 3-4 nights weekly for 3-4 weeks), then taper and discontinue.


• Chronic insomnia disorder diagnosis: implement cognitive behavioral intervention.

Step 3: Evaluate Response and Treatment

• Evaluate sleep and daytime symptom response.


• Continued symptoms with cognitive behavioral intervention: consider combined treatment using a drug appropriate for sleep onset or sleep maintenance symptoms.


• Continued symptoms with pharmacotherapy: consider switching class of hypnotic (eg, benzodiazepine or benzodiazepine receptor agonist to doxepin, ramelteon, or suvorexant).

Step 4: Evaluate Response and, if Symptoms Continue, Reevaluate Diagnosis

• Reevaluate and treat comorbid disorders.


• Evaluate other contributing factors (eg, life events, new medical or psychiatric disorder) and address with psychosocial, behavioral, or medical treatment.

Step 5: Treatment-Resistant Insomnia Disorder Diagnosis

• Refer to sleep specialist for evaluation of other sleep-wake disorders, including sleep apnea.

Step 6: Monitor

• Monitor for long-term treatment response and sequelae such as depressive or anxiety disorder, substance use disorder, or neurodegenerative disorder.

Use of cognitive behavioral therapy for insomnia is recommended as the first-line treatment. Pharmacotherapy of insomnia disorder, if used, should be on a short-term basis, and in shared decision making with the patient.

For more details click on the link: doi:10.1001/jama.2017.15683