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Insomnia

Insomnia

Difficulty initiating or maintaining sleep, or non-restorative sleep, with associated daytime impairment (fatigue, mood disturbance, poor concentration, impaired function). One of the most common presenting complaints in general practice, and frequently over-treated with hypnotics before behavioural approaches are properly trialled.

Diagnosis

  • Acute/short-term insomnia — <3 months, usually with an identifiable trigger (stress, acute illness, jet lag, a new medication, shift work) — often resolves as the trigger resolves.
  • Chronic insomnia disorder — difficulty sleeping ≥3 nights/week for ≥3 months, with daytime impairment, adequate opportunity for sleep (i.e. not simply self-imposed sleep restriction), and not better explained by another sleep disorder, medical condition, or substance.

Assess for and screen out other primary sleep disorders and contributors before treating as primary insomnia:

  • Obstructive sleep apnoea (loud snoring, witnessed apnoeas, morning headache, obesity, daytime sleepiness out of proportion to reported sleep quantity).
  • Restless legs syndrome (an urge to move the legs, worse at rest/evening, relieved by movement).
  • Circadian rhythm disorders (e.g. delayed sleep phase, common in adolescents/young adults; shift work disorder).
  • Depression/anxiety (early-morning waking and low mood suggest depression; difficulty settling with racing thoughts suggests anxiety).
  • Substance/medication effects — caffeine (including late-day intake), alcohol (fragments sleep despite initially aiding onset), nicotine, stimulants, corticosteroids, some antidepressants (activating SSRIs/SNRIs, if dosed in the evening), beta-blockers.
  • Pain, nocturia, menopausal vasomotor symptoms, hyperthyroidism.

A sleep diary over 1–2 weeks (bed/wake times, perceived sleep latency and quality, naps, caffeine/alcohol use) is a useful, low-cost assessment tool before committing to a treatment plan.

Management

Sleep hygiene and behavioural measures (first-line)

  • Regular wake time every day (including weekends) — this anchors the circadian rhythm more effectively than a regular bedtime.
  • Only go to bed when sleepy; if not asleep within ~20 minutes, get up and do a quiet, non-stimulating activity until sleepy again (stimulus control) — the goal is to stop the bed becoming associated with wakeful frustration.
  • Avoid daytime naps, or limit to a short early-afternoon nap if unavoidable.
  • Limit caffeine (especially afternoon/evening) and alcohol; avoid nicotine close to bedtime.
  • Regular daytime exercise, but not vigorously close to bedtime.
  • Reduce evening screen/bright-light exposure; keep the bedroom dark, quiet, and cool.
  • Address any specific worry driving pre-sleep rumination (e.g. a scheduled “worry time” earlier in the evening).

Cognitive behavioural therapy for insomnia (CBT-i)

The first-line treatment for chronic insomnia disorder, more effective and more durable than hypnotic medication with none of the dependence/tolerance risk. Combines stimulus control, sleep restriction therapy (temporarily limiting time in bed to consolidate sleep, then gradually extending it), cognitive restructuring around unhelpful beliefs about sleep, and relaxation training. Delivered by a psychologist, or increasingly via structured online/app-based programs where face-to-face access is limited.

Pharmacotherapy

Reserve for short-term use, or as an adjunct while CBT-i takes effect — not as first-line or long-term monotherapy, given tolerance, dependence, and adverse-effect risk (see Benzodiazepines, Zolpidem and Zopiclone for detailed dosing/withdrawal guidance, which applies equally here). General principles:

  • Use the lowest effective dose, for the shortest duration (ideally days, ceiling of a few weeks) — there’s little justification for hypnotic prescribing beyond a few days at a time.
  • Melatonin has a more favourable safety profile than benzodiazepines/Z-drugs and can help circadian-rhythm-related insomnia (e.g. delayed sleep phase, jet lag, shift work) or in older patients, though evidence for benefit in general chronic insomnia is modest.
  • Sedating antidepressants (e.g. low-dose mirtazapine, amitriptyline) are sometimes used off-label for insomnia, particularly with comorbid depression/pain, but carry their own adverse-effect burden and aren’t first-line for insomnia alone.
  • Avoid long-term hypnotic use in older patients especially — increased falls and cognitive-impairment risk with limited added benefit over CBT-i.