Physicians discuss strategies for managing chronic insomnia

In a new Annals ‘Beyond the Guidelines,’ a clinical psychologist and sleep physician debate the management of a patient with chronic insomnia who has been treated with medications. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

Insomnia, which is characterized by persistent sleep difficulties in association with daytime dysfunction, is a common concern in clinical practice. Chronic insomnia disorder is defined as symptoms that occur at least 3 times per week and persist for at least 3 months. Recent guidelines published by the American Academy of Sleep Medicine (AASM) recommended multicomponent cognitive behavioral therapy (CBT) and a limited number of medications that might be useful for insomnia.

BIDMC Grand Rounds discussants, Eric S. Zhou, Ph.D., an Assistant Professor at Harvard Medical School and a clinical psychologist at Dana-Farber Cancer Institute, and Eric Heckman, MD, an Instructor at Harvard Medical School and sleep specialist and pulmonologist at Beth Israel Deaconess Medical Center, discuss the case of a 64-year-old man who experienced difficulty getting to sleep and early morning awakening for decades. The patient was prescribed zolpidem many years ago, which was initially taken as needed but now is a daily necessity to get to sleep. More recently, trazodone was added to his regimen. The patient has also been diagnosed with obstructive sleep apnea (OSA).

In their assessment, both Drs. Zhou and Heckman agree that CBT is the preferred intervention in the patient’s situation. Dr. Heckman would first evaluate and treat the patient for OSA and other comorbid conditions such as restless leg syndrome that might affect his sleep, while Dr. Zhou would dispel the commonly held belief that patients all require 8 hours of sleep per night as part of his treatment. Dr. Zhou and Mr. F would also collaborate on identifying his individual sleep need through a structured process involving sleep restriction and, subsequently, expansion. Dr. Heckman would consider a streamlined, clinic-based behavioral intervention focusing on sleep restriction and stimulus control if CBT was not accessible or acceptable to the patient. He would not insist on discontinuation of medications immediately but would attempt to stop trazodone followed by reduction in the dose of zolpidem over time as tolerated.