Basics

Short term insomnia – several weeks, follows an event eg. dog died

Chronic insomnia – > 3 months

• requires detailed history

Contributing factors include:

Anxiety/depression – including insomnia phobia

Medication effects eg. stimulants, steroids, beta blockers

Substances eg. caffeine

Pain

Restless legs

Sleep apnoea

3 facets to management of chronic insomnia

Address main contributing factor

CBT-I – firstline management if possible – should be specific for insomnia – involves reducing time spent in bedroom, cognitive work around sleep phobia/beliefs

Medications -risk of dependency is actually very low but caution if high risk patient profile

• Benzodiazepines
• Melatonin
• Sedating antidepressant eg. mirtazapine, amitriptyline
• Orexin inhibitors 
• Sedating antihistamines

Consider half life of drug – initial insomnia could use short acting drug like zolpidem or melatonin IR