Insomnia Resolution Protocol

Chronic insomnia affects 10-30% of adults - difficulty falling asleep, staying asleep, or early morning awakening ≥3 nights/week for ≥3 months. Consequences: Fatigue, cognitive impairment, mood disturbance, increased risk of depression, hypertension, diabetes, obesity, mortality. Perpetuating cycle: Initial insomnia (trigger - stress, illness) → anxiety about sleep → maladaptive behaviors (staying in bed trying to sleep, napping, caffeine, alcohol) → chronic insomnia. CBT-I breaks cycle. CBT-I: Most effective long-term treatment for chronic insomnia (more effective than medications - 70-80% success rate, maintains long-term vs medications that only work while taking). Components: Sleep restriction (paradoxical - limits time in bed to actual sleep time, consolidates sleep, increases sleep drive), stimulus control (bed = sleep only, breaks association of bed with wakefulness), cognitive restructuring (addresses catastrophic thoughts about sleep - "I need 8 hours or I can't function" → "I can function on less sleep, worrying makes it worse"). 6-8 sessions with therapist or app-based (Sleepio). Sleep restriction: Core CBT-I component. If sleeping 5 hours but in bed 8 hours (sleep efficiency 62.5%), only allow 5.5 hours in bed. Sounds harsh but consolidates sleep. Once efficiency >85%, gradually expand window by 15-30 min. Highly effective but requires discipline (temporary sleep deprivation before improvement - not safe for seizure disorder, bipolar, shift work). Melatonin: 0.3-0.5mg is physiologic dose (most supplements are 3-10mg - too much causes next-day grogginess, tolerance). Melatonin is chronobiotic (times sleep) not sedative. Best for circadian issues (jet lag, shift work, delayed sleep phase). Take 30-60 min before desired sleep time. Glycine: 3g before bed shown in studies to improve sleep quality, lower core body temperature (sleep requires 1-2°F core temp drop). Inexpensive, safe. Magnesium: Deficiency causes insomnia. Glycinate form best absorbed, calming. 400-800mg at night. Sleep hygiene: Often dismissed as insufficient alone (true for chronic insomnia - needs CBT-I) but foundational. Consistent schedule, dark room, cool temp (65-68°F), no screens (blue light suppresses melatonin - use blue blockers if must use), no caffeine after 2pm (half-life 5-6 hours - afternoon coffee affects bedtime), no alcohol (disrupts sleep architecture despite initial sedation). Medications: Last resort for chronic insomnia. Benzodiazepines (Restoril, Halcion) and Z-drugs (Ambien, Lunesta) cause tolerance, dependence, next-day cognitive impairment, rebound insomnia, increased fall risk in elderly. Short-term OK (<2 weeks), long-term problematic. Safer options: Trazodone 25-100mg (off-label, sedating antidepressant, no tolerance), doxepin 3-6mg (low-dose antihistamine, FDA-approved for insomnia, no tolerance), melatonin, herbals. Sleep apnea: Screen if snoring, daytime fatigue, witnessed apneas (stop breathing during sleep). 25% of adults have OSA. Untreated causes hypertension, cardiovascular disease, stroke, insomnia. Test and treat with CPAP. Catastrophic thinking: "I need 8 hours or I'll be exhausted" → self-fulfilling prophecy (anxiety prevents sleep). CBT-I reframes: "I can function on less sleep, worrying makes it worse, I'll get the sleep I need eventually." Reduces performance anxiety. Chronic insomnia is treatable - CBT-I is cure, not just management. Invest in CBT-I (therapist or app), practice sleep hygiene, use supplements as bridge, address underlying causes. Avoid long-term sedatives. Sleep is foundation of health - prioritize it.