Insomnia
Diagnosis
Insomnia disorder requires difficulty initiating or maintaining sleep, or early awakening, with daytime consequences, occurring despite adequate opportunity, for at least 3 nights per week for 3 months. It is diagnosed clinically; PSG is not routine but is indicated when another sleep disorder is suspected.
Behavioral management
Cognitive behavioral therapy for insomnia (CBT-I) is first-line. Components include stimulus control, sleep restriction (limiting time in bed to average total sleep time, then titrating up), relaxation, cognitive restructuring, and sleep hygiene. Sleep restriction improves sleep efficiency but must be used cautiously in bipolar disorder or occupations with safety risk.
Pharmacologic management
Use the lowest effective dose for the shortest time. Options include nonbenzodiazepine hypnotics (zolpidem, eszopiclone), dual orexin receptor antagonists (suvorexant, lemborexant), melatonin agonists (ramelteon), and sedating antidepressants (low-dose doxepin, trazodone). Benzodiazepines and Z-drugs carry dependence, falls, and complex sleep behaviors. Avoid hypnotics in untreated OSA without addressing the breathing disorder.
Traps
Do not diagnose insomnia when the real problem is a delayed sleep phase; ask about sleep timing on free days. Distinguish primary insomnia from insomnia comorbid with depression or pain, which needs treatment of the underlying condition. Sleep hygiene alone is rarely sufficient.
Rule of thumb: If a patient sleeps 6 hours but spends 10 hours in bed, prescribe sleep restriction (time in bed ≈ 6 hours) rather than adding a hypnotic.