Priority Topic: Insomnia

​Key Feature 3: In all patients with insomnia, provide advice about sleep hygiene (ex: limiting caffeine, limiting naps, restricting bedroom activities to sleep and sex, using an alarm clock to get up at the same time each day). 
Skill: Clinical Reasoning, Patient Centered
Phase: Treatment

The Foundation for Medical Practice Education (aka McMaster Module) on Insomnia provides a clear and succinct breakdown of the evidence-based approached to behavioural and cognitive strategies that can be used to decrease insomnia. They state, "Non-pharmacologic treatment is first-line therapy for insomnia. There is high evidence that behavioural and cognitive techniques are effective forms of therapy for long-term results, especially when used in combination with other therapies."

1. Sleep hygiene principles
   1. Regular exercise 
   2. Stimulant avoidance
2. Cognitive Behavioural Therapy for Insomnia (CBT-I)
   1. Discuss sleep hygiene and determine patient’s commitment to making necessary changes to improve sleep.
   2. Recommend that patients keep a sleep diary. 
   3. Encourage patients to maintain a strict and constant routine of going to bed and getting up. 
   4. Strengthen appropriate thoughts about sleep. “Sleep needs to be allowed to occur, which can be very difficult for people who are trying desperately to enter that state.” Consider stimulus control to reduce those states of arousal, through strategies that include deep breathing and meditation. 
   5. Educate about sleep restriction. This therapy may seem counterintuitive to patients who feel that extension (not restriction) of sleep time makes more sense. It is important to avoid daytime napping. 

The Insomnia McMaster Module provides some background information on the utility of CBT-I

• "Cognitive Behaviour Therapy for insomnia (CBT-I) is structured psychotherapy that can help identify and change beliefs and behaviours affecting the ability to sleep. Since a large majority of patients suffering from insomnia are seldom (if ever) seen by a provider with specialty-training in CBT-I, it is important that primary care clinicians become familiar with the method.
• "There is high evidence that CBT-I maintains its effectiveness over the long term (12+ months) and can be more effective than medication. Up to 80% of patients showed continued improvement after discontinuation of therapy. CBT-I might also provide long-term relief from recurrence of symptoms. CBT-I is a long-term approach for the following: chronic (persistent) unexplained insomnia; insomnia with accompanying psychiatric and medical disorders; and insomnia that is conditioned or learned (ex: negative association)."
• "Clearly advise patients that results with CBT-I will not be as quick as medication and will require some effort and patience. In the longer term, results will be more lasting without the risk for tolerance or the adverse effects that can accompany pharmacologic approaches."

See attached files for a sleep diary format, a more detailed approach to CBT-I, a patient handout on strategies to improve sleep:

Sleep diary
File Size:	53 kb
File Type:	pdf

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CBT-I
File Size:	54 kb
File Type:	pdf

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Strategies to get a better night's sleep
File Size:	74 kb
File Type:	pdf

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