Eduovisual
Behavioral Health
Insomnia: outpatient evaluation and CBT-I
— Occurs ≥3 nights/week for ≥3 months (chronic insomnia disorder); <3 months = short-term/acute insomnia
— Must cause daytime impairment: fatigue, mood disturbance, cognitive dysfunction, occupational/social impairment, daytime sleepiness, or accident risk
— Occurs despite adequate opportunity to sleep (rules out sleep deprivation from work/lifestyle constraints)
— 10–15% of US adults meet criteria for chronic insomnia; 30–35% report insomnia symptoms
— More common in women, older adults, shift workers, and patients with psychiatric or chronic medical illness
— Associated with increased risk of depression, hypertension, type 2 diabetes, falls in elderly, and motor vehicle crashes
— Outpatient adult complains of "trouble sleeping," fatigue, irritability, or poor concentration
— Patient requesting a "sleeping pill refill" — your job is to evaluate, not just prescribe
— Older adult with new falls, cognitive complaints, or polypharmacy that includes a Z-drug or benzodiazepine
— Comorbid depression, anxiety, chronic pain, CHF, COPD, GERD, BPH, menopause — all common drivers
— Sleep-onset (initiation) — classic in anxiety, restless legs, delayed sleep phase
— Sleep-maintenance — classic in depression, OSA, nocturia, chronic pain, alcohol use
— Early-morning awakening — classic for major depression
— Nonrestorative sleep — consider OSA, periodic limb movement disorder, fibromyalgia
Board pearl: Step 3 expects you to diagnose insomnia clinically by history alone — polysomnography is not indicated for uncomplicated insomnia. Order PSG only when OSA, periodic limb movement disorder, narcolepsy, or parasomnia is suspected.
— Bedtime, sleep latency (minutes to fall asleep), number/duration of awakenings, final wake time, time out of bed
— Total sleep time and sleep efficiency = (time asleep ÷ time in bed) × 100; <85% is abnormal
— Daytime consequences: naps, fatigue, concentration, mood, driving safety
— Ask patient to keep a 2-week sleep diary before the next visit — this is the single most useful outpatient tool
— Insomnia Severity Index (ISI): ≥15 = clinically significant insomnia, used to track response
— Epworth Sleepiness Scale (ESS): screens for excessive daytime sleepiness; high ESS points more toward OSA or narcolepsy, not pure insomnia
— PHQ-9 and GAD-7 for comorbid depression/anxiety (drives nearly half of chronic insomnia cases)
— Caffeine after noon, alcohol within 3 hours of bed (fragments sleep), nicotine, late heavy meals
— Screen/blue-light exposure, irregular bedtime, daytime napping, working/scrolling in bed
— Shift work, jet lag, caregiver awakenings, pets in bed
— Stimulating: pseudoephedrine, bupropion, SSRIs (esp. fluoxetine), stimulants for ADHD, corticosteroids, beta-agonists, theophylline
— Diuretics dosed late cause nocturia-driven awakenings — move to morning
— Beta-blockers (especially lipophilic propranolol/metoprolol) cause nightmares/insomnia
— Alcohol, cannabis, opioid withdrawal, benzodiazepine rebound
— Depression, GAD, PTSD, bipolar; chronic pain; OSA; RLS; CHF/orthopnea; COPD; GERD; BPH/OAB nocturia; menopausal vasomotor symptoms; hyperthyroidism
Step 3 management: Don't label insomnia "primary" before screening for depression, OSA, RLS, and substance use — treating the driver often resolves the insomnia without hypnotics.
— Fatigued affect, periorbital edema, yawning; BP often elevated (insomnia is an independent HTN risk factor)
— BMI and neck circumference (>17 in men, >16 in women) — raises OSA pretest probability
— Resting tachycardia or tremor → consider hyperthyroidism or stimulant/caffeine excess
— Mallampati class III–IV, crowded oropharynx, macroglossia, retrognathia, tonsillar hypertrophy
— Nasal obstruction, deviated septum, turbinate hypertrophy
— STOP-BANG ≥3 = intermediate risk, ≥5 = high risk for OSA → refer for polysomnography
— JVD, S3, bibasilar crackles, peripheral edema → CHF-driven orthopnea/PND masquerading as insomnia
— Wheeze or prolonged expiration → nocturnal asthma/COPD exacerbation
— Resting hypoxia → nocturnal desaturation, supplemental O2 consideration
— Bradykinesia, rigidity, REM sleep behavior history → Parkinson disease / Lewy body
— Sensory exam in legs, peripheral pulses; ask about urge to move legs at rest relieved by movement → restless legs syndrome
— Joint tenderness, trigger points → fibromyalgia, OA-driven sleep fragmentation
— Mood, affect, anhedonia, anxiety, suicidal ideation
— Cognitive screen (MoCA/MMSE) in elderly with insomnia + memory complaints — sleep loss can mimic or unmask dementia
— Thyromegaly, lid lag, tremor → hyperthyroidism
— Prostate exam and AUA symptom score in older men with nocturia
— Vasomotor symptoms, vaginal atrophy in perimenopausal women
Key distinction: A normal exam is expected in primary chronic insomnia — the value of the exam is to rule out medical mimics (OSA, CHF, hyperthyroidism, RLS, BPH) that change management entirely.
— The workup exists to identify reversible contributors and exclude mimics, not to "prove" insomnia
— Step 3 stems often hinge on choosing history + sleep diary over expensive testing
— 2-week sleep diary (or validated app/actigraphy if available): records bedtime, sleep latency, awakenings, naps, caffeine/alcohol, mood
— Insomnia Severity Index at baseline and to monitor response
— PHQ-9 and GAD-7 — depression/anxiety are present in ~40–50% of chronic insomnia
— STOP-BANG and Epworth — risk-stratify for OSA
— Substance use screen including caffeine quantification, alcohol, cannabis, nicotine
— TSH if symptoms of hyper- or hypothyroidism, atrial fibrillation, weight change
— CBC, ferritin, iron studies — ferritin <75 ng/mL warrants iron repletion if RLS is suspected (high-yield)
— BMP/glucose/A1c if polyuria, nocturia, or uncontrolled diabetes suspected
— BNP if orthopnea/PND; vitamin B12 in elderly; urinalysis for occult infection driving nocturia
— Toxicology when stimulant or substance use is suspected
— Polysomnography, home sleep apnea testing, MSLT, brain MRI, EEG — not indicated for uncomplicated chronic insomnia
— Actigraphy is optional, useful when circadian rhythm disorder is suspected
— Clearly document duration ≥3 months, frequency ≥3 nights/week, and daytime impairment to support the ICD-10 diagnosis and CBT-I referral
CCS pearl: On a CCS-style outpatient case, order sleep diary, ISI, PHQ-9, GAD-7, STOP-BANG, and TSH/ferritin if indicated — then advance the clock 2 weeks and review the diary before prescribing anything.
— Suspected obstructive sleep apnea (witnessed apneas, loud snoring, gasping, high STOP-BANG, refractory HTN, daytime sleepiness)
— Suspected periodic limb movement disorder or atypical RLS not responding to treatment
— Suspected parasomnia with injury risk, violent behavior, or REM sleep behavior disorder (acts out dreams — predicts synucleinopathy)
— Suspected narcolepsy (combined with next-day MSLT: mean sleep latency ≤8 min and ≥2 SOREMPs)
— Treatment-refractory insomnia not responding to CBT-I and appropriate pharmacotherapy
— Appropriate for uncomplicated moderate-to-high pretest probability OSA in adults without significant cardiopulmonary disease
— Not appropriate when CHF, COPD with hypoventilation, neuromuscular disease, or non-OSA sleep disorder is suspected — use in-lab PSG instead
— Wrist-worn motion sensor estimating sleep/wake over 1–2 weeks
— Best for circadian rhythm disorders (delayed/advanced sleep phase, shift work, non-24-hour) and to corroborate paradoxical insomnia where reported sleep ≪ actual sleep
— Not a substitute for PSG when OSA is the question
— Sleep medicine: refractory insomnia, suspected narcolepsy/RBD, complex parasomnia
— Psychiatry: severe comorbid mood/anxiety, PTSD-related nightmares, suspected bipolar (hypnotics can destabilize)
— Behavioral sleep medicine psychologist: CBT-I delivery — in-person, group, or digital CBT-I (e.g., SHUTi, Sleepio)
— Patient reports near-zero sleep but actigraphy/PSG shows normal sleep architecture
— Treat with CBT-I and education, not hypnotics
Board pearl: REM sleep behavior disorder in an older man is a red flag — order PSG and counsel about a >80% lifetime risk of evolving Parkinson disease, DLB, or MSA.
— Step 1: confirm diagnosis, review sleep diary, treat reversible contributors (depression, OSA, RLS, pain, nocturia, medications, substances)
— Step 2: deliver sleep hygiene education as a floor, not a treatment — alone, it is inadequate for chronic insomnia
— Step 3: offer CBT-I as first-line (ACP, AASM, VA/DoD all recommend over medications)
— Step 4: pharmacotherapy as adjunct or when CBT-I unavailable/refused/insufficient
— Step 5: reassess at 4–6 weeks with repeat ISI and sleep diary
— Superior durability (effects persist 1–3+ years), no tolerance, no dependence, no fall/cognitive risk
— Effective in elderly, comorbid depression, chronic pain, cancer survivors, perimenopause
— Comparable short-term efficacy to hypnotics with better long-term outcomes
— Accessible via in-person therapy, group programs, telehealth, and digital CBT-I apps
— Stimulus control: bed only for sleep/sex; get out of bed if awake >20 min; consistent wake time
— Cognitive restructuring: address catastrophic thoughts ("I'll fail tomorrow if I don't sleep")
— Relaxation training: diaphragmatic breathing, progressive muscle relaxation, mindfulness
— I sleep restriction: limit time in bed to actual sleep time (minimum 5–5.5 h), then titrate up as efficiency >85–90%
— Psychoeducation about sleep physiology and homeostatic drive
— Sleep hygiene: caffeine cutoff, exercise timing, environment, light exposure
— Avoid in bipolar disorder (can trigger mania), uncontrolled seizures, and occupations requiring vigilance (commercial drivers, pilots) until stabilized
Step 3 management: When the stem asks "most appropriate next step" for chronic insomnia, the answer is almost always CBT-I, not zolpidem.
— Use medication as short-term adjunct to CBT-I or when CBT-I unavailable/declined
— Lowest effective dose, shortest duration, scheduled re-evaluation (typically 2–4 weeks)
— Match drug to insomnia phenotype: sleep-onset vs. sleep-maintenance
— Counsel on next-day sedation, complex sleep behaviors, driving, and dependence
— Sleep-onset insomnia: ramelteon, zaleplon, triazolam, low-dose zolpidem
— Sleep-maintenance insomnia: suvorexant/lemborexant (DORAs), low-dose doxepin (3–6 mg), zolpidem ER, eszopiclone, temazepam
— Either pattern: eszopiclone, zolpidem, DORAs
— Nonbenzodiazepine BZD-receptor agonists; shorter half-life, less next-day grogginess than BZDs
— FDA boxed warning: complex sleep behaviors (sleep-driving, sleep-eating) — discontinue if any episode
— Zolpidem: women and elderly get lower dose (5 mg IR, 6.25 mg ER) due to slower metabolism
— Avoid in elderly when possible (Beers criteria)
— Promote sleep by blocking wakefulness rather than enhancing GABA — favorable for elderly and maintenance insomnia
— Avoid in narcolepsy; caution with CYP3A inhibitors; can cause next-day somnolence, sleep paralysis
— Selective H1 antagonism at this dose; excellent for sleep maintenance, minimal anticholinergic effect, no dependence — good elderly choice
— Ramelteon for sleep-onset; nonscheduled, no dependence, modest efficacy
— OTC melatonin 0.5–3 mg, 2–3 h before bed — best for circadian disorders, weaker for primary insomnia
— Diphenhydramine/doxylamine, OTC PM products — anticholinergic, avoid in elderly (Beers)
— Chronic benzodiazepines — dependence, falls, cognitive impairment, withdrawal seizures
— Off-label trazodone — common but limited evidence; reserve for comorbid depression
Board pearl: Avoid diphenhydramine in patients ≥65 — strong anticholinergic burden, falls, delirium, urinary retention.
— In-person individual with a behavioral sleep medicine specialist (gold standard)
— Group CBT-I (4–8 sessions) — comparable efficacy, lower cost, often available in VA and integrated systems
— Digital CBT-I: SHUTi, Sleepio, Somryst (FDA-cleared prescription digital therapeutic), Insomnia Coach (VA, free)
— Brief Behavioral Treatment for Insomnia (BBTI): 4 sessions, primary care–deliverable, focuses on stimulus control and sleep restriction
— Telehealth CBT-I is reimbursable and effective — Step 3 favors when access is the barrier
— OSA: CPAP first-line; oral appliance, positional therapy, hypoglossal nerve stimulator, weight loss/GLP-1, bariatric surgery
— Restless legs syndrome: iron repletion if ferritin <75; first-line gabapentin enacarbil, pregabalin, or gabapentin; dopamine agonists (pramipexole, ropinirole) now second-line due to augmentation
— Depression-related insomnia: sedating antidepressants at night — mirtazapine, trazodone; avoid activating SSRIs at bedtime
— PTSD nightmares: prazosin (titrate, monitor orthostasis); image rehearsal therapy
— Menopausal vasomotor insomnia: hormone therapy (if appropriate), SSRIs/SNRIs (paroxetine, venlafaxine), gabapentin, fezolinetant
— Chronic pain: optimize analgesia, duloxetine, gabapentinoids; avoid late opioid dosing
— Nocturia: evening fluid restriction, move diuretics to morning, treat BPH (alpha-blocker, 5-ARI)
— Slow taper (10–25% dose reduction every 1–2 weeks) paired with CBT-I improves success and prevents rebound insomnia
— Anticipate rebound for 1–2 weeks; reassure patient
CCS pearl: When the vignette describes long-term zolpidem use with falls or memory complaints in an elderly patient, the right move is start CBT-I and begin a gradual taper, not abrupt discontinuation.
— Normal aging: lighter sleep, earlier bedtime/wake, more arousals, reduced slow-wave sleep — not pathologic alone
— Higher prevalence of OSA, RLS, nocturia, pain, polypharmacy, depression, dementia — always screen for these first
— CBT-I is first-line and well-tolerated in elderly; reduces falls vs. hypnotics
— Benzodiazepines (any) — falls, fractures, delirium, MVCs
— Z-drugs (zolpidem, zaleplon, eszopiclone) — same fall/delirium risk
— First-generation antihistamines (diphenhydramine, doxylamine, hydroxyzine) — anticholinergic delirium, urinary retention
— Tertiary TCAs at hypnotic doses (amitriptyline, imipramine)
— Low-dose doxepin 3–6 mg — minimal anticholinergic effect at this dose, excellent maintenance agent
— Ramelteon — no dependence, safe in renal/hepatic adjustments
— DORAs (lemborexant, suvorexant) — generally well-tolerated; monitor for daytime somnolence and falls
— Avoid even "safe" hypnotics if recent falls, dementia, or CNS depressants on board
— Zaleplon, zolpidem, eszopiclone: no significant renal adjustment but accumulate with severe dysfunction
— Gabapentin/pregabalin (for RLS): dose-reduce per CrCl
— Melatonin and ramelteon: no renal adjustment needed
— Pramipexole (RLS): renally cleared — adjust dose
— Eszopiclone: max 2 mg in severe hepatic impairment
— Zolpidem: lower dose; avoid in severe hepatic disease
— Ramelteon, suvorexant, doxepin: avoid or dose-reduce in moderate-severe hepatic impairment
— Benzodiazepines: prefer lorazepam, oxazepam, temazepam (no active metabolites) if absolutely needed
Board pearl: Insomnia + new falls + chronic zolpidem in a 78-year-old → stop zolpidem, start CBT-I, address polypharmacy. This is a near-classic Step 3 stem.
— Insomnia is extremely common, especially third trimester (nocturia, reflux, back pain, fetal movement, anxiety)
— First-line: CBT-I and sleep hygiene — no fetal risk, durable benefit, validated in pregnancy
— Screen for restless legs syndrome (prevalence ~20% in pregnancy) — check ferritin, supplement iron
— Screen for OSA — gestational HTN, preeclampsia, GDM risk increase with untreated OSA
— Pharmacotherapy: avoid benzodiazepines (cleft palate risk first trimester, neonatal withdrawal third trimester), avoid Z-drugs when possible
— If essential: diphenhydramine or doxylamine are considered relatively safe short-term; low-dose doxepin data limited; melatonin not well-studied — avoid routine use
— Frequent awakenings are normative — counsel and support sleep consolidation, partner-shared feeds
— Screen aggressively for postpartum depression (insomnia is both symptom and risk factor)
— Avoid long-acting BZDs in lactation; short-acting agents (zolpidem) with timed dosing after a feed may be acceptable
— Most pediatric insomnia is behavioral — bedtime resistance, sleep-onset association disorder
— First-line: parent-led behavioral interventions (consistent routine, extinction methods, limit screens)
— Adolescents: delayed sleep phase syndrome is common — treat with morning bright light, evening melatonin 0.3–0.5 mg 3–5 h before desired sleep, and gradual phase advance
— Avoid prescription hypnotics in children; melatonin commonly used in autism/ADHD-related insomnia with reasonable evidence
— Shift work disorder: insomnia during desired sleep + sleepiness during work shift
— Interventions: strategic napping, scheduled caffeine early in shift, dark glasses on morning commute, blackout curtains, melatonin before daytime sleep
— Modafinil/armodafinil FDA-approved for shift work disorder excessive sleepiness — not for the insomnia component
Key distinction: In pregnancy, CBT-I is the answer; in adolescents with late bedtime and late wake, the answer is delayed sleep phase disorder treated with light + low-dose melatonin, not a hypnotic.
— Cardiovascular: increased incidence of hypertension, coronary artery disease, atrial fibrillation, stroke; insomnia with objective short sleep duration carries the highest risk
— Metabolic: insulin resistance, weight gain, increased risk of type 2 diabetes
— Psychiatric: 2–4× risk of incident major depression; predicts depression relapse; increased anxiety and suicidality
— Cognitive: impaired attention, working memory, executive function; possible acceleration of cognitive decline in elderly
— Safety: drowsy driving — comparable impairment to alcohol; increased workplace and home accidents
— Immune: reduced vaccine response, increased infection risk
— Mortality: modest increase in all-cause mortality with chronic insomnia plus short sleep
— Z-drugs/BZDs: falls, hip fractures, MVCs, complex sleep behaviors, anterograde amnesia, dependence, rebound insomnia, withdrawal seizures (BZDs)
— Diphenhydramine and anticholinergics: delirium, urinary retention, constipation, possible long-term dementia risk signal
— DORAs: next-day somnolence, sleep paralysis, hypnagogic hallucinations; rare suicidal ideation signal
— Trazodone: orthostasis, priapism (rare), serotonergic interactions
— Mirtazapine: weight gain, sedation, rare agranulocytosis
— Sleep restriction phase: transient daytime sleepiness for 1–2 weeks — counsel against driving long distances or operating heavy machinery during initial titration
— Frustration/dropout if not properly coached — schedule close follow-up
— Hypnotic → daytime fatigue → stimulant; hypnotic → falls → hip fracture → opioid → constipation → laxative — a classic geriatric cascade to recognize
Board pearl: Insomnia + uncontrolled hypertension despite three agents → screen for OSA; treating OSA frequently improves both BP and the "insomnia."
— Suspected OSA, central sleep apnea, hypoventilation syndromes — order HSAT or PSG
— Suspected narcolepsy (cataplexy, sleep paralysis, hypnagogic hallucinations, excessive daytime sleepiness) — PSG + MSLT
— Suspected REM sleep behavior disorder — dream enactment, injury to self or bed partner; PSG confirms loss of REM atonia
— Refractory insomnia despite adequate CBT-I trial and ≥2 appropriate pharmacotherapy trials
— Complex parasomnias with injury risk (sleepwalking, sleep-related eating, sexsomnia)
— Suspected circadian rhythm disorder needing chronotherapy or actigraphy
— Primary care lacks capacity for CBT-I and digital CBT-I has been unsuccessful
— Significant cognitive distortions, catastrophizing, or trauma-related sleep disturbance
— Comorbid moderate-severe depression, bipolar disorder, PTSD with nightmares, substance use disorder
— Suicidal ideation — escalate urgently per safety protocol
— Suspected bipolar disorder before initiating sleep restriction (can precipitate mania)
— Benzodiazepine or barbiturate withdrawal — risk of seizure, autonomic instability; admit for monitored taper
— Acute psychosis or mania precipitated by sleep deprivation
— Severe suicidal ideation with sleep deprivation
— Suspected fatal familial insomnia (rare prion disease — progressive insomnia, dysautonomia, dementia) — neurology referral
— Commercial drivers, pilots, transit operators with untreated OSA or chronic hypnotic use → DOT/FAA reporting requirements vary; document and counsel
— Counsel against driving when initiating CBT-I sleep restriction or hypnotics
Step 3 management: Witnessed apneas + AM headaches + refractory HTN + BMI 36 → answer is polysomnography and CPAP referral, not a sleep aid prescription.
— Loud snoring, witnessed apneas, gasping arousals, morning headaches, daytime sleepiness, refractory HTN, AFib
— High STOP-BANG, elevated BMI/neck — order PSG or HSAT; CPAP is first-line
— Urge to move legs, worse at rest, worse evening/night, relieved by movement
— Check ferritin (target >75 ng/mL); first-line alpha-2-delta ligands (gabapentin enacarbil, pregabalin)
— Dopamine agonists associated with augmentation — now second-line
— Bed partner reports repetitive leg kicks during sleep; nonrestorative sleep
— Diagnosed on PSG; treat if symptomatic similarly to RLS
— Excessive daytime sleepiness, cataplexy (type 1), sleep paralysis, hypnagogic hallucinations, fragmented night sleep
— PSG + MSLT (≤8 min mean latency, ≥2 SOREMPs); low CSF orexin in type 1
— Treat: modafinil/armodafinil, sodium oxybate, pitolisant, solriamfetol
— Delayed sleep phase (adolescents/young adults): can't fall asleep until late, can't wake early — bright light AM, low-dose melatonin evening
— Advanced sleep phase (elderly): early sleep onset and early wake — evening bright light
— Shift work disorder and jet lag: timed light, melatonin, scheduled naps
— Non-24-hour (often blind patients): tasimelteon
— NREM: sleepwalking, night terrors, confusional arousals (typically children, family history)
— REM: RBD (older adults, prodromal synucleinopathy); nightmare disorder (PTSD)
Key distinction: Insomnia = trouble sleeping despite adequate opportunity. Insufficient sleep syndrome = inadequate opportunity (work hours, caregiving) — treated by extending time in bed, not hypnotics.
— Major depression — early-morning awakening, anhedonia, fatigue, hopelessness; PHQ-9 ≥10; treat depression and insomnia concurrently
— Generalized anxiety disorder — racing thoughts at sleep onset, muscle tension; SSRIs/SNRIs + CBT
— PTSD — nightmares, hypervigilance; prazosin, trauma-focused therapy, image rehearsal
— Bipolar disorder — decreased need for sleep during mania (not insomnia distress); mood stabilizer, avoid sleep restriction
— Substance use disorders — alcohol, cannabis, stimulants, opioid use/withdrawal
— Hyperthyroidism — tremor, palpitations, heat intolerance, weight loss; TSH
— Menopause — vasomotor symptoms; consider HRT, SSRIs, gabapentin, fezolinetant
— Cushing syndrome, pheochromocytoma — rare but cause arousal-driven insomnia
— CHF — orthopnea, PND, nocturnal cough; optimize diuresis (morning dosing), afterload reduction
— COPD/asthma — nocturnal dyspnea, cough; optimize controller therapy, avoid evening albuterol overuse
— Nocturnal angina, arrhythmias
— BPH/overactive bladder — nocturia; alpha-blockers, anticholinergics or beta-3 agonists, behavioral fluid management
— Diabetes with hyperglycemia → osmotic nocturia
— Osteoarthritis, fibromyalgia, neuropathic pain — sleep-maintenance insomnia; treat pain, duloxetine/gabapentinoids
— RA flares with morning stiffness
— Parkinson disease, dementia (sundowning, sleep fragmentation), chronic migraine, stroke
— Fatal familial insomnia (rare prion) — progressive untreatable insomnia + dysautonomia + dementia
— Stimulants, decongestants, corticosteroids, beta-agonists, theophylline, late diuretics, activating antidepressants, beta-blockers (nightmares)
Board pearl: Insomnia that is actually early-morning awakening with anhedonia and weight loss is depression — the answer is start an SSRI and consider CBT, not zolpidem.
— CBT-I benefits persist 1–3+ years; reinforce stimulus control and consistent wake time as the durable backbone
— Encourage continued sleep diary for 1–2 weeks at each relapse trigger (life stressor, illness, travel)
— Provide relapse-prevention plan: brief "booster" CBT-I sessions or self-directed refresher modules
— Plan from the start: state expected duration at first prescription (typically 2–4 weeks)
— Gradual taper 10–25% every 1–2 weeks; longer for chronic users
— Combine taper with CBT-I in parallel — improves taper success significantly
— Counsel about rebound insomnia lasting 1–2 weeks — not treatment failure
— Consistent wake time 7 days/week is more important than consistent bedtime
— Caffeine cutoff 8–10 hours before bedtime; limit alcohol within 3 hours of bed
— Regular daytime aerobic exercise (not within 2–3 hours of bed)
— Morning bright light exposure, dim evening light, cool dark bedroom
— Limit naps to <30 minutes and before 3 PM (avoid entirely if struggling with sleep onset)
— Annual depression and anxiety screening (PHQ-9, GAD-7)
— OSA: CPAP adherence checks, mask fit, weight management, GLP-1 if obesity
— RLS: recheck ferritin annually; monitor for dopamine agonist augmentation
— Medication reconciliation each visit — flag new stimulating agents or late diuretics
— Document insomnia diagnosis to support insurance coverage of CBT-I, digital CBT-I (Somryst), and DORAs
— Leverage telehealth and group CBT-I for access; VA and integrated systems have established pathways
Step 3 management: A successful insomnia visit ends with a diagnosis, a sleep diary plan, a CBT-I referral or digital prescription, comorbidity screening, and a 4–6 week follow-up — not just a prescription pad.
— 2 weeks after initial visit: review sleep diary, confirm diagnosis, reinforce sleep hygiene, initiate CBT-I
— 4–6 weeks: repeat ISI, assess CBT-I adherence, review medication response and adverse effects
— 3 months: reassess need for ongoing pharmacotherapy, plan taper
— Annually thereafter: screen for relapse, comorbidity changes, medication review
— Sleep diary (gold standard for outpatient): track sleep latency, total sleep time, sleep efficiency, awakenings, daytime symptoms
— ISI: drop of ≥7 points or score <8 indicates remission
— Actigraphy or consumer wearables (Oura, Fitbit) — useful trend data; counsel patients not to over-interpret nightly numbers (can drive orthosomnia — anxiety about sleep tracking)
— Normalize that most adults need 7–9 hours; older adults often function well on 6.5–7.5
— Lying in bed awake worsens conditioning — get out of bed if awake >20 minutes
— One bad night is not catastrophic; homeostatic drive corrects within 1–2 nights
— Avoid clock-watching — turn the clock away
— Caffeine half-life is 5–6 hours; even afternoon coffee can fragment sleep
— Alcohol shortens latency but fragments second half of the night
— Set realistic expectations: improvement typically over 4–8 weeks
— Sleep restriction is the most effective and least liked component — coach through the rough first 1–2 weeks
— Use motivational interviewing for ambivalence
— Counsel against driving in first 1–2 weeks of sleep restriction or hypnotic initiation
— Document discussion; for commercial drivers/pilots, address fitness-for-duty implications
CCS pearl: In a CCS case, after initiating CBT-I or a hypnotic, advance the clock 4 weeks, then re-order ISI and sleep diary — that's the expected monitoring rhythm.
— Document discussion of complex sleep behaviors (sleep-driving, sleep-eating, sleep-calling) with Z-drugs and DORAs — FDA boxed warning for zolpidem, zaleplon, eszopiclone
— Discuss tolerance, dependence, rebound insomnia, and intended duration of therapy at the first prescription
— Document a planned tapering strategy in the chart from day one
— Counsel against driving for at least 8 hours after a Z-drug and the morning after zolpidem ER and DORAs
— Drowsy driving is comparable to driving with BAC ~0.08; document the counseling
— Commercial drivers (DOT), pilots (FAA), train operators: chronic hypnotic use and untreated OSA carry fitness-for-duty implications — physicians have an ethical obligation to counsel and document; jurisdiction-specific mandatory reporting may apply (e.g., suspected OSA in commercial drivers)
— Co-prescribing opioids + benzodiazepines or Z-drugs carries an FDA boxed warning for respiratory depression and death — avoid; if unavoidable, document risk-benefit
— Three or more CNS-active medications dramatically increases fall risk — deprescribing is a patient-safety intervention
— Hospital-initiated hypnotics frequently get inappropriately continued at discharge — perform med reconciliation and discontinue if started for transient hospital insomnia
— Communicate any new hypnotic, taper plan, or CBT-I referral in the discharge summary to the PCP
— Benzodiazepines and Z-drugs are Schedule IV — check state PDMP before prescribing
— Concern for diversion, doctor-shopping, or misuse triggers safer prescribing limits
— Suicidal ideation with hypnotic stockpiling — consider blister packs, limited quantities, family-held medications
— CBT-I access is uneven — proactively offer digital and group options to reduce disparities; document language preferences and cultural context around sleep
Board pearl: Continuing a hospital-started zolpidem on the discharge summary of an 80-year-old admitted for delirium is a patient-safety failure — the expected Step 3 answer is to stop it and arrange CBT-I.
— Chronic insomnia: ≥3 nights/week for ≥3 months with daytime impairment
— Sleep efficiency <85% is abnormal; sleep latency >30 min or WASO >30 min are clinically meaningful
— ISI: 0–7 none, 8–14 subthreshold, 15–21 moderate, 22–28 severe
— Chronic insomnia first-line: CBT-I
— Elderly insomnia: CBT-I, then low-dose doxepin or DORA if pharmacotherapy needed
— RLS first-line: alpha-2-delta ligands (gabapentin enacarbil); check ferritin >75
— OSA first-line: CPAP
— Delayed sleep phase: morning bright light + low-dose evening melatonin
— PTSD nightmares: prazosin
— Shift work sleepiness: modafinil
— Narcolepsy with cataplexy: sodium oxybate or pitolisant
— Diphenhydramine in elderly (Beers)
— Chronic benzodiazepines in elderly
— Opioid + BZD/Z-drug combination (FDA boxed warning)
— Dopamine agonists as first-line RLS (augmentation)
— Zolpidem: women get half the dose; sleep-driving warning
— Suvorexant/lemborexant: avoid in narcolepsy
— Ramelteon: melatonin receptor agonist, unscheduled, no dependence
— Low-dose doxepin (3–6 mg): pure H1 antagonism at this dose, no anticholinergic burden
— Trazodone: orthostasis, priapism, off-label
— Melatonin: best for circadian disorders, weaker for primary insomnia; 0.3–0.5 mg often sufficient
— Insomnia + obesity + HTN → screen OSA
— Insomnia + leg discomfort relieved by movement → RLS, check ferritin
— Insomnia + early-morning awakening + anhedonia → depression
— Insomnia + dream enactment in older man → RBD, prodromal synucleinopathy
— Adolescent "can't fall asleep, sleeps fine on weekends" → delayed sleep phase
Step 3 management: When in doubt on a chronic insomnia stem, the answer is CBT-I; when in doubt in an elderly stem on a hypnotic, the answer is deprescribe and start CBT-I.
— 45-year-old with 6 months of difficulty falling asleep, normal exam, PHQ-9 = 4
— Trap answers: zolpidem, diphenhydramine, polysomnography
— Correct answer: refer for CBT-I (or initiate sleep diary + sleep hygiene + CBT-I)
— 78-year-old on zolpidem 10 mg nightly for 2 years; recent fall, mild cognitive complaints
— Trap answers: switch to diphenhydramine, add melatonin
— Correct: gradual zolpidem taper + initiate CBT-I; review for OSA, depression, polypharmacy
— Obese 55-year-old man, snoring, witnessed apneas, refractory HTN, BMI 36, ESS 14
— Trap: prescribe a hypnotic
— Correct: order polysomnography (or HSAT); CPAP if confirmed
— Early-morning awakening, anhedonia, weight loss, PHQ-9 = 18
— Correct: start SSRI, consider CBT, treat depression — insomnia improves with it
— Sleep-onset complaints, "creepy crawly" leg sensations relieved by movement, ferritin 28
— Correct: iron repletion + gabapentin enacarbil; not a hypnotic
— Correct: delayed sleep phase disorder — morning bright light + low-dose melatonin 3–5 h before desired sleep
— Correct: prazosin + trauma-focused CBT/image rehearsal therapy
— Correct: CBT-I; check ferritin for RLS; avoid benzodiazepines
— Correct: discontinue hypnotic at discharge; do not continue at home
— Correct: order PSG for REM sleep behavior disorder; counsel about synucleinopathy risk; melatonin or clonazepam
Board pearl: The Step 3 examiners almost always reward the non-pharmacologic, root-cause answer over the prescription on insomnia stems.
Chronic insomnia is a clinical diagnosis treated first with CBT-I — pharmacotherapy is adjunctive, time-limited, and matched to the patient's phenotype and comorbidities.
— ≥3 nights/week for ≥3 months with daytime impairment despite adequate sleep opportunity
— Use a 2-week sleep diary, ISI, PHQ-9, GAD-7, and STOP-BANG; reserve PSG for suspected OSA, narcolepsy, RBD, or refractory cases
— Always screen for OSA, RLS (check ferritin >75), depression, medications, alcohol, caffeine, and nocturia
— Stimulus control, sleep restriction, cognitive restructuring, relaxation, sleep hygiene — durable for years
— Deliver in-person, via group, or through digital CBT-I (Somryst, Sleepio, SHUTi, VA Insomnia Coach)
— Effective and preferred in elderly, pregnancy, and patients with comorbid depression or chronic pain
— Sleep-onset: ramelteon, zaleplon, low-dose zolpidem
— Sleep-maintenance: low-dose doxepin, DORAs (suvorexant, lemborexant), zolpidem ER
— Avoid diphenhydramine and chronic BZDs in elderly (Beers); avoid opioid + BZD/Z-drug combos (FDA boxed warning)
— Pair every prescription with a documented taper plan and CBT-I referral
— Reassess at 4–6 weeks with sleep diary and ISI; advance the CCS clock and re-evaluate
— Reconcile medications at every transition of care; do not continue inpatient-started hypnotics at discharge
— Reinforce consistent wake time, morning light, caffeine and alcohol limits, and offer booster CBT-I sessions for relapse triggers
Step 3 management: On almost every Step 3 insomnia vignette, the winning answer is identify and treat the driver + CBT-I, with pharmacotherapy reserved as a short, intentional adjunct.