How do you sequence pharmacologic treatments for primary insomnia?

First, be sure you have already addressed deficiencies in sleep hygiene:

• Room at 65 degrees F
• Wearing earplugs
• Complete darkness (no visible hand in front of face)
• No clock
• Golden hour before bed
• ETOH, nicotine, and caffeine reduction with cessation of 4 hours before bed
• Writing a list of worries
• B...

I very seldom recommend medications. There is both physical dependency and psychological dependency (patients feeling they need to take something to sleep). I use sleep logs and establish sleep restrictions, e.g., 5 hours only in bed with no naps in the day. Dealing with cognitive distortions where ...

1. Sleep diary
2. Sleep hygiene reinforcement
3. GAD/Depression Screening
4. Discuss actigraphy, irregular sleep wake cycles, and sleep state misperception
5. Trial of melatonin
6. Sleep study (HST/Lab)
7. Treat OSAS if present
8. Trial of somnolence agent therapies

I had a good experience with prescribing orexin inhibitors Dayvigo as well as the new upcoming Quviviq as they block wakefulness and do not induce drowsiness. They may also have a good effect on reducing daytime sleepiness.

I would love to hear how others address the trackers such as Oura rings, Apple watches, etc. I've found that they have dramatically increased my patients' anxiety about sleep and hence, their perceived insomnia.

The best way I've found is to suggest that they speak with their partners who provide su...

Most of the time, I start with 12.5 mg extended-release zolpidem for my patients. If their sleep remains unsatisfactory, I then consider switching to eszopiclone. Ramelteon is rarely used in my practice, if at all. Trazodone and doxepin would be the next step. I generally avoid benzodiazepines like ...