Summary

Insomnia is a sleep disorder characterised by persistent difficulty with sleep initiation, maintenance, consolidation, or quality despite adequate opportunity for sleep, resulting in daytime impairment (Fatigue, Poor concentration, Mood disturbance). Chronic Insomnia Disorder is defined as symptoms occurring ≥3 nights per week for ≥3 months. Insomnia is extremely common, affecting ~10% of adults chronically. It is often comorbid with psychiatric conditions (Depression, Anxiety), medical conditions (Chronic pain, COPD, Heart failure), and other sleep disorders (OSA). First-line treatment is Cognitive Behavioural Therapy for Insomnia (CBT-I), which is highly effective and has durable effects. Pharmacotherapy (Z-drugs, Short-acting Benzodiazepines) should be reserved for short-term use when CBT-I is unavailable or ineffective. Melatonin may be considered in patients ≥55 years. Long-term hypnotic use is discouraged due to dependence, tolerance, and adverse effects. [1,2]

Clinical Pearls

CBT-I is First-Line: Cognitive Behavioural Therapy for Insomnia is more effective than medication in the long term and should be offered first.

"3-3 Rule" for Chronic Insomnia: ≥3 nights per week for ≥3 months.

Don't Prescribe Long-Term Hypnotics: Z-drugs and Benzodiazepines are for short-term use only (2-4 weeks). Risk of dependence, next-day sedation, falls.

Always Screen for Comorbidities: Depression, Anxiety, Sleep Apnoea, Restless Legs, Chronic Pain, Substance use.

• CBT-I: Effective in ~70-80%. Durable effect (Maintains improvement years later).
• Pharmacotherapy: Less durable. Symptoms often return on stopping.
• Chronic Course: Many patients have waxing/waning symptoms over years.
• Addressing Comorbidities: Improves outcomes.

Key Guidelines

What is Insomnia?

Insomnia is difficulty falling asleep, staying asleep, or waking too early, even when you have enough chance to sleep. It makes you feel tired and unable to function well during the day.

What causes it?

Stress, life changes, medical conditions, pain, or mental health issues (like anxiety or depression) can trigger it. Sometimes it becomes a habit – your body "learns" not to sleep well.

How is it treated?

The best treatment is Cognitive Behavioural Therapy for Insomnia (CBT-I). This is a talking therapy that helps change the thoughts and behaviours that keep insomnia going. It is more effective than sleeping tablets in the long run.

Sleep hygiene is also important: keeping a regular schedule, avoiding caffeine/alcohol, limiting screens, and making your bedroom comfortable.

Sleeping tablets (like Zopiclone) are sometimes used for short periods (2-4 weeks), but they are not a long-term solution because they can become addictive and have side effects.

Common Exam Questions

1. First-Line Treatment: "What is the first-line treatment for Chronic Insomnia?"
   • Answer: Cognitive Behavioural Therapy for Insomnia (CBT-I).
2. Definition of Chronic Insomnia: "How is Chronic Insomnia defined?"
   • Answer: Symptoms ≥3 nights per week for ≥3 months.
3. Why Avoid Long-Term Hypnotics?: "Why are hypnotics not recommended long-term?"
   • Answer: Risk of Dependence, Tolerance, Next-day sedation, Falls (Especially in elderly), Cognitive impairment.
4. Early Morning Waking: "Early morning awakening is classically associated with which psychiatric condition?"
   • Answer: Depression.

Viva Points

• CBT-I Components: Explain Sleep Restriction and Stimulus Control.
• Melatonin: Licensed for ≥55 years in UK.

Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.