A 26-year-old man presents with insomnia, having trouble falling asleep and waking several times at night. What is the most appropriate first-line treatment?

A 26-year-old man presents with insomnia, having trouble falling asleep and waking several times at night. What is the most appropriate first-line treatment?

• A. Sleep hygiene advice
• B. Refer to a psychology/CBT program
• C. Start a benzodiazepine at bedtime
• D. Use an over-the-counter sleep aid containing diphenhydramine

Answer: (A)

Insomnia in this setting is best approached first with nonpharmacologic strategies that address daily habits and the sleep environment. Sleep hygiene advice gives practical, low-risk steps that can significantly improve how quickly you fall asleep and how often you wake during the night. Key points include sticking to a consistent sleep-wake schedule, creating a dark, quiet, comfortable bedroom, avoiding caffeine and heavy meals close to bedtime, limiting screen time before bed, and establishing a relaxing wind-down routine. These changes target behaviors that perpetuate wakefulness and fragmented sleep, making them a safe starting point before considering medications. If sleep problems persist after a few weeks, CBT for insomnia is a highly effective next step, offering structured strategies to change thoughts and behaviors around sleep. It can be delivered in person or via digital programs and has strong evidence behind it, but it’s typically pursued after initial sleep hygiene efforts or when insomnia becomes chronic. Pharmacologic options, such as benzodiazepines, carry risks like dependence, tolerance, and cognitive impairment, so they aren’t first-line. Over-the-counter sleep aids containing diphenhydramine can cause next-day sedation and anticholinergic side effects, and they are not recommended for long-term use.

Insomnia in this setting is best approached first with nonpharmacologic strategies that address daily habits and the sleep environment. Sleep hygiene advice gives practical, low-risk steps that can significantly improve how quickly you fall asleep and how often you wake during the night. Key points include sticking to a consistent sleep-wake schedule, creating a dark, quiet, comfortable bedroom, avoiding caffeine and heavy meals close to bedtime, limiting screen time before bed, and establishing a relaxing wind-down routine. These changes target behaviors that perpetuate wakefulness and fragmented sleep, making them a safe starting point before considering medications.

If sleep problems persist after a few weeks, CBT for insomnia is a highly effective next step, offering structured strategies to change thoughts and behaviors around sleep. It can be delivered in person or via digital programs and has strong evidence behind it, but it’s typically pursued after initial sleep hygiene efforts or when insomnia becomes chronic.

Pharmacologic options, such as benzodiazepines, carry risks like dependence, tolerance, and cognitive impairment, so they aren’t first-line. Over-the-counter sleep aids containing diphenhydramine can cause next-day sedation and anticholinergic side effects, and they are not recommended for long-term use.