Treatment options

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a gold standard for initial insomnia treatment.

“CBT-I has comparable efficacy and better durability of treatment gains compared to medication,” noted Dr. Klingaman. “This is likely due, at least in part, to its focus on teaching clients to use sleep strategies on their own after treatment discontinuation; a unique advantage over pharmacological approaches.”

Severe or refractory insomnia or chronic comorbid illness are common among patients diagnosed with schizophrenia. For these patients, “long-term use of sleep aids may be warranted,” Dr. Klingaman said. “However, clinical guidelines for the treatment of insomnia outline the importance of administering an adequate trial of cognitive and behavioral psychotherapy when using medications to treat both acute and chronic insomnia, rather than relying on pharmacological treatment as a standalone intervention.”

“For insomnia treatment, I always, always say the main therapy is cognitive behavioral therapy—the way you think and take action,” agreed Dr. Dasgupta. “Sleep hygiene, that’s the foundation.”

Insomnia treatment is highly individualized. 

“You need to spend a lot of time with your patient, to know what the underlying disorder is, and to treat the underlying disorder as well as the insomnia—and to really assure your patients that cognitive behavioral therapy has acute and chronic benefits,” Dr. Dasgupta said.

A given medication will oftentimes work with some patients and not others, Dr. Dasgupta said.

“Different people will experience different kinds of symptoms, so it is important to recognize this variability between people and understand what they may have already tried that does and does not work for their own circumstance,” Dr. Klingaman advised. “Some people may be distressed at night because of anxiety, paranoia, or hallucinations. Those may find it helpful to practice relaxation strategies at night, do “grounding” exercises, or use acceptance and mindfulness strategies to manage distress due to their symptoms.”

Daytime carryover effects of sedating medications are sometimes a problem, and medication timing can affect sleep onset or quality. “In these cases, ask whether the client would like education on the effects of these medications,” advises Dr. Klingaman. “If so, provide education on these possible effects, as well as discussing whether they may want to pursue any changes in type, timing or dosage, as appropriate and feasible to better manage the side effects’ impact on sleep.”

“You also have to look at the drug-drug interactions; you have to weigh costs and benefits,” he said. “But it can only benefit the clinician and the patient to have more drugs out there to consider when we talk about having more options for treating insomnia.”

Communication with patients can be key, but even this should be individualized.

“It is important to recognize that people vary in how much they prefer to be involved in shared decision-making,” cautioned Dr. Klingaman. “For instance, discussing with clients at the outset whether they want to be offered options and/or discuss their opinions about treatment and/or be involved in actually making final treatment decisions will help both parties be on the same page, clarify goals, and help contribute to a healthy working alliance. […] At the outset, it is also worthwhile to understand a persons’ goals with regard to managing sleep and wakefulness problems to guide the type of education and treatment strategies offered. Also, clients may change over time and depending on their provider in how much they want to be involved, so checking in periodically is important.”