📚 Module Overview
On completion of this module, you will be able to:
- Define insomnia and differentiate between short-term and chronic insomnia.
- Identify key secondary causes and risk factors for insomnia, including medications.
- Outline the principles of non-pharmacological management, focusing on sleep hygiene and CBT-i.
- Describe the appropriate, short-term use of hypnotics according to NICE guidelines.
- Recognise the risks associated with long-term hypnotic use and apply deprescribing principles.
- Advise patients on DVLA regulations related to sleepiness.
- Apply knowledge to a clinical case study on deprescribing.
- CBT-i is first-line: For chronic insomnia, Cognitive Behavioural Therapy for Insomnia (CBT-i) is the most effective long-term treatment, not medication.
- Hypnotics are short-term only: If used, hypnotics should be prescribed at the lowest effective dose for the shortest possible duration (typically 1 week, max 2-4 weeks).
- Non-pharmacological first: Always address sleep hygiene and underlying causes before considering medication.
- Deprescribing is a priority: Proactively identify and support patients on long-term hypnotics to taper off them safely.
- Driving is a key concern: Any drug causing daytime sleepiness can impair driving. Patients must be counselled appropriately.
🔍 Assessment & DiagnosisNICE CKS
Insomnia is defined as difficulty getting to sleep, staying asleep, or having non-restorative sleep, despite adequate opportunity. For a clinical diagnosis, this must be associated with significant daytime impairment (e.g., fatigue, poor concentration, mood disturbance).
Types of Insomnia
- Short-term (acute) insomnia: Symptoms for <3 months. Often triggered by a specific stressor (e.g., exams, bereavement).
- Chronic insomnia: Symptoms occur at least 3 nights per week for ≥3 months.
Key Assessment Steps
A thorough history is essential to identify underlying causes and contributing factors.
| Assessment Area | Key Questions & Considerations |
|---|---|
| Sleep History | Use a sleep diary. Ask about bedtime, wake time, sleep latency (time to fall asleep), number of awakenings, and duration. Are they sleepy during the day? |
| Secondary Causes | Screen for medical conditions (chronic pain, nocturia, respiratory issues), mental health (anxiety, depression), and other sleep disorders (restless legs syndrome, obstructive sleep apnoea). |
| Medication Review | Review prescribed and OTC drugs. Common culprits include SSRIs, steroids, beta-blockers, decongestants, and stimulants. |
| Substance Use | Ask about caffeine, alcohol, and nicotine intake, especially close to bedtime. Alcohol may help sleep onset but fragments sleep later. |
| Cognitions & Behaviours | Explore unhelpful thoughts (e.g., "I'll never cope tomorrow") and behaviours (e.g., clock-watching, napping, excessive time in bed awake). |
🧠 Non-Pharmacological Management
Non-drug interventions are the cornerstone of managing insomnia, particularly for chronic cases.
Sleep Hygiene
Sleep hygiene refers to habits and environmental factors that promote good quality sleep. It should be advised for all patients.
- Routine: Go to bed and wake up at the same time every day, even on weekends.
- Environment: Ensure the bedroom is dark, quiet, cool, and comfortable.
- Avoid Stimulants: No caffeine, nicotine, or alcohol for at least 4-6 hours before bed.
- Wind-Down: Establish a relaxing pre-sleep routine (e.g., warm bath, reading, listening to calm music). Avoid screens (phones, TVs) for at least an hour before bed.
- The 20-Minute Rule: If you can't sleep after 20 minutes, get out of bed. Do something relaxing in another room until you feel sleepy, then return to bed. The bed should be for sleep and intimacy only.
- Daytime Habits: Get regular exercise (but not too close to bedtime). Avoid long or late-afternoon naps.
Cognitive Behavioural Therapy for Insomnia (CBT-i)
CBT-i is the first-line treatment for chronic insomnia. It is more effective than hypnotics in the long term. It addresses the unhelpful thoughts and behaviours that perpetuate insomnia.
- Stimulus Control: Re-associates the bed/bedroom with sleep.
- Sleep Restriction: Limits time in bed to the actual time spent asleep, which builds "sleep drive". This can initially cause more daytime sleepiness.
- Cognitive Restructuring: Challenges negative thoughts and worries about sleep.
- Delivery: Can be delivered face-to-face, in groups, or via digital platforms like Sleepio or Sleepstation (available on the NHS in many areas).
💊 Pharmacological Management (BNF Reference)
Pharmacological treatment should only be considered for severe, short-term insomnia when non-pharmacological methods have failed. It is not recommended for chronic insomnia.
Hypnotic Therapy NICE CKSBNF
The goal is short-term relief from severe, disabling insomnia. Choose a hypnotic with a short half-life to minimise next-day effects.
| Treatment Line | Medication Examples & Dosages | Monitoring Requirements & Key Alerts |
|---|---|---|
| First-Line (Short-Term) |
'Z-drug' (if a hypnotic is indicated):
NICE advises choosing the one with the lowest acquisition cost. |
Monitoring:
|
| Alternative Option (in ≥55 years) |
Prolonged-release Melatonin:
|
Monitoring:
|
| Not Recommended / Off-Label |
Benzodiazepines (e.g., Temazepam): Similar efficacy and risks to Z-drugs, but longer half-lives can lead to more next-day "hangover" effects.
Antihistamines (e.g., Diphenhydramine, Promethazine): Available OTC but not recommended by NICE due to limited efficacy, significant next-day sedation, and anticholinergic side effects. Antidepressants (e.g., Trazodone, Mirtazapine): Sometimes used off-label for their sedative effects but not recommended for insomnia without comorbid depression due to lack of evidence and side-effect profile. |
These should generally be avoided for the primary treatment of insomnia. Their use can complicate deprescribing efforts and may mask underlying conditions. |
🔄 Deprescribing Hypnotics
Long-term use of benzodiazepines and Z-drugs is associated with dependence, falls, accidents, and potential cognitive impairment. Proactive deprescribing is a key safety initiative.
- Engage & Educate: Discuss the rationale for stopping (risks of long-term use outweigh benefits). Frame it as a positive step towards better, more natural sleep.
- Agree on a Plan: Tapering should be gradual and patient-led. A typical starting point is reducing the dose by 10-25% every 2-4 weeks. The final stages of the taper are often the most difficult.
- Switching (Optional): For short-acting benzodiazepines, some guidelines suggest switching to an equivalent dose of Diazepam to make tapering smoother due to its long half-life, but this is not always necessary, especially for Z-drugs.
- Manage Withdrawal: Reassure the patient that withdrawal symptoms (rebound insomnia, anxiety, irritability) are temporary. If severe, maintain the current dose until stable before resuming the taper more slowly.
- Provide Non-Pharmacological Support: The taper is an ideal time to introduce and reinforce sleep hygiene and refer for CBT-i.
🚗 Driving Regulations (DVLA)
The law is clear: it is an offence to drive if your driving is impaired by any drug, whether prescribed or illegal.
- Patients starting or changing the dose of a hypnotic must be advised not to drive or operate machinery if they feel sleepy, dizzy, or have blurred vision or poor concentration, even the day after taking the tablet.
- This advice applies to anyone suffering from insomnia that causes excessive daytime sleepiness.
- Patients must be able to perform an emergency stop and should not drive if they feel unable to do so safely.
- If a patient has chronic, excessive sleepiness that affects their driving, they have a legal duty to inform the DVLA.
🎯 OSCE Preparation
Counselling a Patient Requesting Sleeping Tablets
Scenario: Mrs. Jones, 58, comes to the pharmacy. "I've been so stressed at work and haven't slept properly for weeks. Can the doctor just give me some sleeping tablets like I had years ago? They really worked."
Key Communication & Counselling Steps:- Acknowledge & Empathise: "It sounds like you're having a really tough time at the moment. Not being able to sleep on top of work stress is exhausting."
- Gather Information (Assess): "To give you the best advice, can I ask a bit more about your sleep? What time do you go to bed? What happens when you try to sleep? What have you tried so far?" (Gently probe for red flags, other causes, and sleep hygiene).
- Explain the Modern Approach to Insomnia: "I understand the tablets helped before. The way we think about sleep problems has changed a lot. We now know that while sleeping tablets can help for a few days, they don't solve the underlying problem and can cause issues like dependence and grogginess the next day. The most effective long-term solution is to retrain our brain and body's natural sleep patterns."
- Introduce Non-Pharmacological Options (Sleep Hygiene): "There are some simple but powerful things we can try first. For example, having a really regular sleep schedule, even on weekends, and creating a wind-down routine an hour before bed can make a huge difference. Have you heard of 'sleep hygiene'?"
- Introduce CBT-i: "For longer-term problems, a type of therapy called CBT-i is now the number one recommended treatment. It's like physiotherapy for your sleep and has been shown to work better than tablets. Many people can now access it for free online through the NHS."
- Safety Netting & Shared Plan: "I'd recommend trying these sleep hygiene tips for a week or two. I can give you a leaflet with the key points. If things don't improve, it would be a good idea to chat with your GP. They can check for any other causes and refer you for CBT-i. We generally avoid starting sleeping tablets now unless the situation is very severe and only for a very short time."
⭐ Bonus: Clinical Pharmacist Case Study
The Patient: Deprescribing in Primary Care
Patient Profile: Mr. Frank Smith, a 78-year-old man, is flagged on a practice search for being on repeat zopiclone for over 2 years. He has a history of falls, hypertension and osteoarthritis.
Current Medications: Amlodipine 5mg OD, Co-codamol 30/500 QDS, Zopiclone 3.75mg ON.
The Challenge: Mr. Smith has been invited for a medication review. He is reluctant to stop his zopiclone. "It's the only thing that helps me sleep, doctor. I'm worried what will happen if I stop."
Pharmacist's Consultation & Plan (SOAP Note Format)
- Subjective: Patient reports taking zopiclone every night for 2 years. Believes he cannot sleep without it. Expresses anxiety about stopping. He mentions he still feels tired most days and had a fall in his garden last month (no serious injury).
- Objective: Age 78. PMH: falls, HTN, OA. On long-term zopiclone against guidelines. Co-codamol may also cause drowsiness.
- Assessment:
- Inappropriate long-term hypnotic use: Patient is dependent on zopiclone. The medication is likely causing next-day sedation (patient "still feels tired"), contributing to his falls risk. The benefit is likely minimal and is primarily preventing withdrawal.
- High falls risk: Combination of age, zopiclone, and opioid (co-codamol) puts him at a very high risk of falls and fractures.
- Plan:
- Discuss Rationale: Empathise with his concerns. Gently explain that over time, the body gets used to sleeping tablets and they stop working as well. Explain the link between the tablet, daytime grogginess, and his recent fall. Frame stopping as a way to feel more alert during the day and reduce his risk of a serious injury.
- Collaborate on Tapering Plan: Propose a very slow, manageable taper. "We'll do this at your pace." Suggest reducing to 3/4 of a tablet (approx. 2.8mg) for 4 weeks. Give him a tablet cutter. If that goes well, reduce to half a tablet (1.875mg) for another 4 weeks, and so on.
- Provide Support: Introduce sleep hygiene principles as something positive he can do to help the process. Provide a simple patient leaflet. Arrange a follow-up call in 2 weeks to see how he is coping.
- Safety Netting: Reassure him that it's normal to have some difficult nights, but this will improve. Tell him to call the practice if he is struggling, and the plan can be adjusted. Emphasise that he should not stop the tablet suddenly.
Example Consultation Dialogue
Pharmacist: "Thanks for coming in, Mr. Smith. I wanted to chat about your zopiclone sleeping tablet. I know you've been on it for a while. How are you finding it?"
Patient: "I can't sleep without it. I'm worried about stopping."
Pharmacist: "That's a very common feeling, and I completely understand. What's interesting is that when our bodies get used to these tablets, they often stop giving us a good quality sleep and can leave us feeling groggy the next day. You mentioned you still feel tired and I'm also concerned about your fall last month. These tablets can affect our balance. I think by slowly reducing it, we could actually help you feel more alert and steadier on your feet."
Patient: "But what if I can't sleep at all?"
Pharmacist: "That's why we would do it incredibly slowly, at a pace you're comfortable with. We wouldn't stop it suddenly. We could start by just shaving a tiny bit off the dose. We'll also give you some tips on non-drug ways to improve sleep. How would you feel about giving that a try, with me supporting you along the way?"