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Question 1: A 53-year-old woman presents with insomnia. She has a history of hypothyroidism, and recent thyroid function tests were normal. The patient reports lifelong intermittent sleep-onset and maintenance insomnia, which has been persistent for the past year after transitioning to a new job. She reports a high level of job-related stress in the first 1-2 months after starting her new job, but she states that her current level of work-related stress is low. The patient's main source of anxiety is her insomnia. When trying to fall asleep, she worries excessively about getting enough sleep and the impact of her insomnia on her ability to function the next day. She reports a “bad experience” with zolpidem in the past and does not wish to take any hypnotic medications going forward. The patient denies snoring and has a BMI of 22. She denies sadness or anhedonia and reports regular bed and wake times. What is the next step in management?

  1. Polysomnogram (PSG)

  2. Cognitive behavioral therapy for insomnia (CBTI)

  3. Initiation of antidepressant

  4. Initiation of hypnotic besides zolpidem

Reference: 1. Morin C. Psychological and behavioral treatments for insomnia I: approaches and efficacy. Principles and practice of sleep medicine, 5th ed. Kryger M, Roth T, Demet WC, eds. Philadelphia, PA: Elsevier/Saunders. 2010. 866-883. 2. Edinger J. et al. Psychological and behavioral treatments for insomnia II: implementation and specific populations. Principles and practice of sleep medicine, 5th ed. Kryger M, Roth T, Demet WC, eds. Philadelphia, PA: Elsevier/Saunders. 2010. 884-904.

Question 2: A 45-year-old male presents with sleep-onset and sleep-maintenance insomnia for the past month in the setting of a divorce. The patient's primary medical doctor gave him a prescription for zolpidem. He has taken zolpidem 10mg for the last 5 nights and reports resolution of his sleep-onset insomnia but persistent difficulty remaining asleep until morning. The patient's bedtime is 10:00pm, and his alarm is set for 6:00am. He does not nap during the day. When he does not set his alarm, he wakes by 6:30am. Which option will optimize this patient’s acute insomnia treatment?



  1. Zaleplon

  2. Ramelteon

  3. Melatonin

  4. Zolpidem extended-release

  5. Light therapy

 

Reference: 1. Krystal A. Pharmacologic treatment of insomnia: other medications. Principles and practice of sleep medicine, 5th ed. Kryger M, Roth T, Demet WC, eds. Philadelphia, PA: Elsevier/Saunders. 2010. 916-930. 2. Walsh J, Roth T. Pharmacologic treatment of insomnia: benzodiazepine receptor agonists. Principles and practice of sleep medicine, 5th ed. Kryger M, Roth T, Demet WC, eds. Philadelphia, PA: Elsevier/Saunders. 2010. 905-915

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