Ms. F, a 42-year-old divorced woman, presents for evaluation of chronic insomnia. She complains of difficulty falling asleep, often 30 minutes or longer, and difficulty maintaining sleep during the night, with frequent awakenings that often last 30 minutes or longer. These symptoms occur nearly every night, with only one or two "good" nights per month. She typically goes to bed around 10:00 p.m. to give herself adequate time for sleep, and she gets out of bed around 7:00 a.m. on work days and as late as 9:00 a.m. on weekends. Her nighttime sleep problems result in daytime irritability and difficulty focusing and organizing her thoughts, which subjectively impair her work as an administrative assistant, although her performance evaluations have been satisfactory. She says that she has "no energy for anything extra," that her house is a mess, and that she routinely declines invitations to join social and even family activities. Her insomnia began approximately 5 years ago during a period of increased life stress related to a difficult divorce and a job change. At that time she was diagnosed with major depression and was started on a successful trial of escitalopram, which she continues at a dose of 10 mg/day. Her current symptoms are distinct from those that were associated with her episode of major depression. She denies pervasive sadness or loss of interest, but she is very frustrated with her inability to function more effectively, which she attributes to her insomnia. In fact, she believes that her cognitive difficulties and irritability are most noticeable after nights of particularly poor sleep. Her medical history is unremarkable other than a past history of Graves’ disease. She has been treated with levothyroxine for the past 15 years. How should Ms. F be evaluated? What medical testing, if any, would be appropriate? What factors should be considered in formulating a treatment plan? What treatments would be appropriate?

Ms. F’s physician ordered further medical testing, including assessment of thyroid function tests, which showed normal T4, T3, and thyroid-stimulating hormone levels. Given that Ms. F’s insomnia had a course independent of her prior major depression, a diagnosis of primary insomnia was made. Initial discussion with the patient focused on sleep education, including the need for an adequate duration of wakefulness each day to promote sleep drive at night. The variability of the patient’s sleep hours and her excessively long time in bed were also discussed. A treatment plan was agreed upon using the four general rules discussed above, based on sleep restriction and stimulus control principles; the patient was given a "prescription" of going to bed at 11:00 p.m. and getting out of bed no later than 6:00 a.m. each day. She was also asked to keep a sleep diary. At follow-up 4 weeks later, the sleep diary showed improved consolidation of her nighttime sleep, although Ms. F still felt tired during the day. She thought that her cognitive function was mildly improved. A trial of a short-acting hypnotic, zolpidem, was then initiated, with the patient maintaining the same sleep hours. Subsequent follow-up in another month demonstrated further improvements in sleep consolidation at night, but with some feelings of morning sedation, occurring approximately three nights out of the week. The patient felt more in control of her sleep problem. It was agreed that intermittent use of zolpidem might be appropriate. Thus, the patient began a trial of zolpidem intermittently, while maintaining attention to her sleep behaviors. She was advised to use her medication if she had several bad nights in a row, if she felt particularly stressed, or if she needed the certainty of consolidated sleep before important activities the following day. Several months later, she reported general improvement in her sleep, to a tolerable level. Her mood also remained stable, with no evidence of reemergence of depression.