CFPC Key Features

  1. In patients presenting with sleep complaints take a careful history to distinguish insomnia from specific psychiatric diagnoses or other sleep-related diagnoses (e.g., sleep apnea, periodic limb movements, restless legs syndrome, sleepwalking, sleep talking).

  2. When assessing patients with sleep complaints:

    • Obtain a collateral history from the bed partner or parents, if possible and appropriate

    • Assess the contribution of drugs (prescription, over-the-counter, recreational), caffeine, and alcohol

  3. In all patients with insomnia:

    • Provide appropriate advice about sleep hygiene (e.g., limiting caffeine, naps, and screen time, following regular sleep schedule, limiting bedroom activities to sleep and sex)

    • Offer other non-pharmacological options, such as cognitive behavioural therapy

  4. When initiating sleep medications:

    • Educate the patient about risks and discuss these medications’ time-limited effects

    • Use hypnotic medications judiciously (e.g., prescribe only when disordered sleep has a severe impact on function, and only with a clear indication)

    • Negotiate a reduction and cessation plan with the patient

  5. When a patient with a long-term history of using sleep medication presents for renewal of their prescription reassess, educate, and discuss tapering and alternative therapies.

General Overview

  • Definition: Difficulty initiating sleep, maintaining sleep or non-restorative/non-refreshing sleep, causing clinically significant distress or impairments in function

    • Acute: <3 months duration

      • Often sudden onset and associated with stress or disrupted sleep schedule

    • Chronic: >3 months for > nights/week, impairs daytime function

    • Both acute and chronic can be subdivided into initial (sleep-onset), middle (sleep-maintenance) or late (sleep-offset) insomnia


💡 The term "secondary insomnia" (i.e., insomnia stemming from another condition) may be avoided since it is often not possible to draw firm conclusions about the direction of causality between insomnia and comorbidities. Successful treatment requires attention to both insomnia and comorbidities.

  • Psychiatric

    • Depression**

    • Anxiety**

    • Substance use (especially EtOH, caffeine, nicotine, stimulants)

    • Post-traumatic stress disorder

  • Medical

    • Hyperthyroidism

    • Diabetes

    • Medication (CNS stimulants/depressants, bronchodilators, antidepressants, beta antagonists, glucocorticoids)

  • Sleep Disorders

    • Hypersomnolence disorder

    • Narcolepsy

    • Circadian rhythm sleep-wake disorders

      • Delayed sleep-wake phase disorder (sleep normally if go to bed later and wake up later)

        • Common in adolescents

      • Advanced sleep-wake phase disorder (sleep normally if go to bed earlier and wake up earlier)

      • Non-REM Sleep Arousal Disorders

        • Sleep terrors

        • Sleep walking

    • Restless legs syndrome

    • Obstructive Sleep Apnea**


  • Sleep habits

    • Sleep latency (time to fall asleep), sleep efficacy (sleeping vs. time in bed), duration, disturbance

    • Activities (exercise, exposure to light/screens)

  • Stressors

  • Impact on life/function

  • Alcohol

  • Drugs

  • Medications (including over-the-counter, herbal)

  • Caffeine

  • Collateral from bed-partner or household members


  • Sleep clinic if suspect OSA or limb movement (or does not respond to treatment), or

    • Nocturnal polysomnography for sleep apnea or periodic limb movements of sleep

  • Consider TSH, fasting glucose

  • Consider Ferritin, Mg, renal function, B12 (restless leg syndrome)


💡 Goal is improved continuity and quality of sleep (not 8 hours of sleep)

  • Non-Pharmacological Summary

    • Discuss sleep hygiene, determine patient's commitment to improve sleep

    • Sleep diary

    • Strict and constant routine of going to bed and getting up

    • Strengthen appropriate thoughts about sleep

      1. Sleep needs to be allowed to occur, which can be very difficult for people trying desperately to enter that state

      2. Consider stimulus control, and relaxation therapy (meditation)

      3. Sleep restriction, avoid day-time napping

Sleep Hygiene

  • No caffeine/alcohol within 6h of bedtime

    • Alcohol helps with sleep initiation but impairs sleep maintenance

  • No nicotine (including replacement) close to bedtime

  • No excessive liquids or heavy evening meal before bedtime

  • Moderate physical activity, avoid heavy exercise within 3h of bedtime

  • Minimize noise and light

  • Temperature (avoid too warm)

  • Avoid watching/checking clock

Stimulus control

  • Re-associate bed/bedroom with sleep

  • Go to different room if sleep onset >15 minutes

  • Wake-up at same time each day despite how little sleep

Sleep Consolidation (Restriction therapy)

  • Sleep prescription to improve sleep efficacy (minimize bed time)

  • Avoid napping

  • Prescribe minimum sleep time (eg. 7h) + 30 minutes bedtime

    • Monitor by sleep logs

    • Once sleeping for >90% of time in bed for two weeks consecutively, and slowly increase bed time

Relaxation therapy

  • Stress management, relaxation techniques (breathing, light exercise, stretching, yoga)

CBT-I (Cognitive Behavioural Therapy for Insomnia)

  • Address inappropriate beliefs and attitudes that perpetuate insomnia

    • Unrealistic sleep expectations (eg. must have 9h of sleep)

    • Misconceptions about causes of insomnia (eg. chemical imbalance)

    • Amplifying consequences (eg. cannot function after sleeping poorly)

    • Performance anxiety, loss of control



General Principles:

  • Generally pharmacotherapy has high risks

    • Fatigue

    • Cognitive effects (memory impairment)

    • Fall, motor vehicle accident, fracture, mortality

  • Minimal benefits

    • Increased total sleep time by 25 minutes

    • Decrease sleep latency by 10 minutes

  • Consider pharmacotherapy only when disordered sleep has a severe impact on function, and only with a clear indication

  • Discuss goals/expectations, safety concerns, side effects

    • Beware of increased risks of adverse events in elderly patients especially with benzodiazepines and benzo-like/“Z” drugs (e.g., zopiclone, zolpidem)

  • Only prescribe as an adjunct (not alternative) to non-pharmacological measures

  • Ideally prescribe at lowest effective dose for short-term <7 days

  • Long-term use may be considered in severe insomnia resistant to CBT-I, but must be regularly re-assessed at each visit

    • Consider discussing reduction and cessation plan, and alternative therapies for patients on chronic pharmacotherapy for insomnia

      • Beware risk of rebound insomnia when deprescribing

Preferred agents:

  • Histamine receptor antagonists

    • Doxepin 6mg PO qHS

      • Doxepin 10mg (generic) may be cheaper

      • Minimal side effects and minimal risk of tolerance

        • Preferred in elderly

  • Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines)

    • Zopiclone 3.75-7mg PO qHS

      • Short half-life

      • Side effect: Metallic taste, daytime sleepiness

      • Risk of tolerance/dependence

    • Zolpidem 5-10 mg SL qHS

      • Caution in elderly

      • Risk of tolerance/dependence

    • Temazepam 15-30mg PO qHS

      • Intermediate half-life (higher risk of daytime sleepiness)

      • Avoid in elderly

      • Risk of tolerance/dependence

  • Variable evidence for natural sources (and variable quality control if OTC):

    • Melatonin 0.3-5mg (consider 0.1-0.5mg physiologic doses)

      • Preferred in pediatric population, especially if comorbid ADHD or ASD

      • Often first-line as high safety profile, low price, and ease of availability

    • L'Tryptophan 500mg-2000mg

    • Valerian 400-900mg

Other agents (generally not recommended unless also treating comorbidity):

  • Antidepressants: e.g., mirtazapine, amitriptyline, nortriptyline

  • Antipsychotics: e.g., quetiapine, (Seroquel), methotrimeprazine (Nozinan)

  • Muscle relaxants: e.g., cyclobenzaprine

Avoid off-label antihistamines (e.g., dimenhydrinate, diphenhydramine, doxylamine).


  • First visit

    • Assess and treat comorbidity

    • Sleep hygiene and behavioural interventions/CBT

    • Consider sleep diary

    • Consider investigation/pharmacotherapy based on patient

  • F/U 2-4 weeks

    • Evaluate sleep efficiency, daytime symptoms

    • Reinforce behavioural interventions/CBT

    • Review pharmacotherapy

  • F/U 3 months

    • If limited progress, referral to sleep medicine program or psychologist

Last edited 2020-11-12 B. Paul, K. Chan