Shift-work insomnia and alcohol as a sleep aid
Ms. T is a 34-year-old emergency department nurse who has worked rotating day–night shifts for six years. For eight months she has had difficulty falling asleep and staying asleep, with 4–5 hours of fragmented sleep before day shifts. She drinks two glasses of wine most evenings to wind down, takes melatonin 10 mg about one hour before bed, and often scrolls on her phone in bed. She reports fatigue, irritability, and reduced concentration at work but no depressed mood. Blood pressure is 132/84 mm Hg, and she takes no other medications. She asks whether she should increase melatonin to 20 mg or get a prescription for a stronger sleeping pill because she cannot continue feeling this way. She is worried about making a medication error at work.
1. What is your first-line assessment and treatment plan for Ms. T’s insomnia, and how do you respond to her request for a stronger sleeping pill?
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First-line treatment is cognitive behavioral therapy for insomnia (CBT-I), not a stronger pill. Ask for a 2-week sleep diary: bedtimes, sleep latency, awakenings, naps, caffeine, alcohol, and shift pattern. Screen for depression, anxiety, restless legs, sleep apnea (snoring, witnessed apneas, daytime sleepiness), and medication effects. CBT-I components include stimulus control (bed only for sleep; get up if awake more than 20 minutes), sleep restriction to average sleep time plus 30 minutes, relaxation, cognitive restructuring, and relapse prevention. Deliver via an evidence-based digital program or a trained clinician. For shift work, plan anchored sleep and strategic naps. A benzodiazepine or Z-drug would worsen next-day alertness and risk dependence; avoid. Melatonin 10 mg is higher than needed; if used for shift timing, 0.5–3 mg timed before target sleep is more appropriate. Follow up in 2–4 weeks.
2. How would you address her alcohol use and the safety of melatonin in this context?
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Use a nonjudgmental AUDIT-C and ask about quantity, timing, and consequences. Two glasses most nights is above low-risk limits for a woman and likely contributes to fragmented sleep, even if she feels it helps her fall asleep. Explain the rebound: alcohol increases night awakenings and suppresses REM sleep. Advise reducing to no alcohol on work nights and not using it as a sleep aid; if she has features of alcohol use disorder (craving, loss of control, withdrawal), offer treatment rather than abrupt cessation alone. Melatonin: short-term use is generally safe, but 10 mg is supraphysiologic; a lower dose of 0.5–3 mg, taken 1–2 hours before target sleep, is preferable. Avoid driving after melatonin and do not combine it with sedatives. Monitor mood and sleep.
3. What shift-work and sleep-hygiene strategies would you prioritize, and what follow-up is needed?
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Prioritize shift-work strategies: after a night shift, protect a 7–8 hour sleep block with blackout curtains, earplugs, and phone off; avoid caffeine within 6 hours of sleep; use bright light during the first half of the shift and dim light before commuting home. Keep a consistent anchor sleep time on days off. Avoid heavy meals and alcohol near bedtime. Use a 20–30 minute nap before night shifts if feasible. Sleep hygiene alone is not CBT-I but supports it. Follow up in 2 weeks with the sleep diary, review adherence, and reassess for sleep apnea if fatigue persists. Coordinate with occupational health for schedule regularity.