Insomnia

Clinic A/P, adults

Diagnosis
H&P
DDx & Etiologies: Evaluate for diseases that cause insomnia.
2-week sleep log/diary.
Diagnostic tests:
Treatment
–Sleep hygiene and stimulus control counseling, provided.
-CBT, 1st-line treatment. Referral entered.
–AAFP 2017 Algorithm for Treatment of Insomnia reviewed with the patient.
–Insomnia medications: Will start short-term pharmacotherapy if insomnia doesn’t improve with sleep hygiene, stimulus counseling, and CBT. Prescriptions will be only short-term and limited to five weeks or less, per AAFP 2017.

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Trazodone 25-50mg po QHS
OR
Doxepin 10mg po QHS (5mg in elderly patients).
Try over the counter melatonin

Have counseled the patient to use caution in driving.
Don’t combine sedating medications with alcohol.
Discussed s/e profile of medications.

In the future, will consider Polysomnography if there is the concern for another sleep disorder.

*** Trazodone can be combined with SSRIs.

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The general approach to a patient with Insomnia.

  1. Look for diseases that cause it (DDx),
    If not, do
  2. Sleep hygiene and stimulus control counseling
    If not, do
  3. CBT
    If not, give
  4. Medications

 

References
JAMA. 2017;318(20):1973–1974. Clinical Management of Insomnia Disorder.
N Engl J Med 2015; 373:1437-1444. Insomnia Disorder. http://www.nejm.org/doi/full/10.1056/NEJMcp1412740
Am Fam Physician.2017 May 15;95(10):669-670. Treatment of Chronic Insomnia in Adults: ACP Guideline. http://www.aafp.org/afp/2017/0515/p669.html
Am Fam Physician. 2017 Jul 1;96(1):29-35. Insomnia: Pharmacologic Therapy. http://www.aafp.org/afp/2017/0701/p29.html
Am Fam Physician. 2007 Aug 15;76(4):517-526. Treatment Options for Insomnia. http://www.aafp.org/afp/2007/0815/p517.html
Shanghai Archives of Psychiatry 26.6 (2014): 363–364. “Combining Antidepressants.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4311111/

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