Evaluation of chronic insomnia, delayed sleep phase, nightmares and sleep problems related to depression-anxiety; cognitive behavioral therapy for insomnia (CBT-I) and short-term medication when needed.
Indication
- Difficulty falling asleep, frequent awakenings or early-morning awakening (chronic insomnia — 3+ nights per week, longer than 3 months)
- Daytime functional impairment, attention and memory problems due to insufficient sleep
- Sleep problems accompanying depression, anxiety disorder or post-traumatic stress disorder
- Circadian rhythm disturbances developed with shift work
- Nightmares, night terrors or REM sleep behavior disorder
- Sleep disturbance from restless legs syndrome — differential diagnosis
- Individuals at risk of dependence due to long-term sleep medication use (those needing a medication-free treatment plan)
Preparation
- Keeping a sleep diary (1-2 weeks) — bedtime, time to fall asleep, night awakenings, wake time, daytime sleepiness
- Reviewing current sleep hygiene habits (caffeine, alcohol, screen use, sleep environment)
- If sleep apnea is suspected, referral to chest medicine/sleep center for polysomnography (sleep test)
- Excluding medical causes such as thyroid function tests, iron and B12 levels
How it's performed
- Detailed sleep history and psychiatric assessment; whether it is a primary sleep disorder or secondary to another psychiatric or medical condition is determined
- CBT-I (cognitive behavioral therapy for insomnia), the gold-standard treatment, is planned — includes sleep restriction, stimulus control, cognitive restructuring, relaxation techniques and sleep-hygiene education
- CBT-I usually takes 6-8 sessions and provides more lasting results than medication in the long term
- In acute, short-term cases, sleep medication (z-drug family, melatonin receptor agonist, low-dose sedating antidepressant) may be considered for a limited period (2-4 weeks)
- If accompanying depression, anxiety or trauma is present, treating the underlying psychiatric condition is the priority
- Imagery rehearsal therapy (IRT) for nightmares; light therapy and melatonin treatment may be planned for delayed sleep phase
Post-procedure
- Weekly or every-other-week CBT-I sessions for the first 4-6 weeks; afterwards spaced out as needed
- The sleep diary is continued throughout treatment; progress is evaluated objectively
- If medication is used, a discontinuation plan is made within a short period (preferably 2-4 weeks); long-term benzodiazepine use is avoided
- Continuation and re-evaluation of treatment for comorbid depression-anxiety
- Lifestyle recommendations — regular sleep-wake schedule, pre-sleep routine, restriction of caffeine, alcohol and screens
Risks
- Long-term use of benzodiazepines and z-drugs may cause dependence, tolerance, daytime drowsiness and risk of falls (especially in older adults)
- Temporary increase in insomnia (rebound insomnia) on medication discontinuation — managed by gradual tapering
- Transient daytime fatigue during the initial sleep-restriction phase of CBT-I
- Dry mouth, morning drowsiness and weight changes with sedating antidepressants
- Missing underlying sleep apnea — the condition may worsen if only medication is given; polysomnography is essential when suspected
FAQ
Can I recover without using sleep medication?
Yes. For chronic insomnia, CBT-I produces more lasting results than medication and is recommended as the first-line treatment. Most patients experience significant improvement in 6-8 sessions.
Have I become dependent on sleep medication?
Long-term (weeks-months) use of benzodiazepines or z-drugs can cause physical and psychological dependence. In this situation, planned, gradual tapering combined with CBT-I can help discontinue the medication. Do not stop the medication on your own.
I have snoring and excessive daytime sleepiness — is it just insomnia?
These symptoms suggest obstructive sleep apnea. A polysomnography sleep test is needed; the treatment approach differs from insomnia (typically CPAP). Accurate diagnosis is important.
Can I take melatonin?
Melatonin may help especially in delayed sleep phase syndrome, jet lag and insomnia in older adults; however, random use is not recommended. Dose and timing should be determined by a physician.
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