A good assessment of onset, extent, duration, onset, severity, triggers of the sleep problem, in conjunction with the standard review of systems, is the first step.  Once done, treatment options can be considered.

Cognitive Behavioral Therapy (CBT) interventions have a high rate of long-term efficacy, and CBT should be employed with all patients, even those with health care issues and medication needs.   When using CBT, the complications and risks associated with sleep aid medications can be avoided or minimized and for intractable cases, doses may be able to be contained.

CBT has been shown to be helpful as an adjunctive treatment for insomnia in depression when used with antidepressant medication. It has also been helpful with other co-morbid concerns, like chronic pain, fibromyalgia, substance abuse, and anxiety disorders. Some patients may be able to taper off of sleep medications after participating in CBT treatment for insomnia.   The central focus of CBT treatment is on improving the patient’s sleep hygiene.

Predisposing factors, precipitating events, and perpetuating mechanisms all contribute to the development of chronic primary sleep difficulties. Some individuals may be particularly predisposed or vulnerable to sleep difficulties because of a dysfunctional biological sleep system. When such individuals are confronted with precipitating circumstances (for example: a stressful life event), they can develop an acute sleep disturbance. This sleep disturbance can be perpetuated if the patient develops poor sleep hygiene practices (for example: daytime napping, spending excessive time in bed, etc) to try to cope with the sleep difficulty.

Therefore, although predisposing and precipitating factors contribute to insomnia, poor sleep hygiene is seen as a critical sustaining element in the sleep disturbance. One key element of CBT for insomnia is to correct those sleep habits that ostensibly sustain or add to the patients’ sleep problems.

Modified CBT intervention can be provided in the primary care office, though referral to a formal program is appropriate for most as well.   CBT requires a discussion about the rationale for the treatment and some basic education about sleep norms, circadian rhythms, effects of aging, of medications and drugs and the effects of sleep deprivation.   Typical CBT techniques include sleep scheduling, stimulus control, relaxation, cognitive restructuring, sleep hygiene, and medication tapering techniques.   Typically the behavioral treatment uses stimulus control and sleep restriction strategies to normalize standardize the patient’s sleep/wake schedule, eliminate sleep incompatible behaviors, and restrict time in bed (TIB) in an effort to force the development of an efficient, consolidated sleep profile and pattern. It is important to maintain and review sleep logs to help with troubleshooting problems that may occur along the way.

Here is a case example to illustrate the role that CBT for insomnia can play in the primary care setting:

35yo male with a history of Type I Diabetes well controlled on insulin and no previous psychiatric history who presents with longstanding (since high school) difficulty with initiating and maintaining sleep. Various medication trials (Benadryl, Ambien, Elavil, OTC agents) have worked for short periods of time but then cease to be helpful. He has been stable, denies other mood or anxiety symptoms and has been able to maintain working.   Education and guidance on sleep hygiene is helpful in some respects but medication requests recur.   A referral for a sleep study is made with normal findings and a recommendation for referral to a formal CBT sleep treatment group.

If you are interested in more information, here are some websites that might be useful:

http://www.med.unc.edu/neurology/sleepclin/jdedingrCBTManual.pdf

http://www.journalsleep.org/Articles/260209.pdf

https://adaa.org/sites/default/files/Runko_177.pdf

Treatment options include therapy or a combination of therapy and medication:

• For patients with mild-moderate symptoms, a therapy approach is preferred, with the option incorporate medication if the therapy is not effective.
• For patients with moderate-severe symptoms with significant impairment in daily functioning, it may be warranted to consider starting with a combination of medication and therapy.

The key is that therapy is the important component to treatment of anxiety disorders in pediatrics, with medication used as an adjunctive treatment when needed. Therapy to address anxiety can easily be tailored to work with very young patients and is very effective. Types of therapy used include: cognitive behavioral therapy, exposure response prevention therapy, and relaxation techniques, among others.

Medications used to treat anxiety fall into two general categories: medications that treat the underlying anxiety and prevent future symptomatology and medications that treat acute symptoms, such as a panic attack. Medications in the first category include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), mirtazipine, and buspirone.  The SSRIs are the first line agents. This class includes: fluoxetine, citalopram, escitalopram, sertraline, fluvoxamine, and paroxetine.  Although prompt relief may result, just as with treating depression, the medication may take 4-6 weeks to have full impact, so patience is important.  Also of note, often a higher dose may be needed to fully treat anxiety symptoms as compared to depressive symptoms.

The motto to “start low and go slow” remains relevant to limit activation and thereby increase anxiety during the titration process. So, for example if one is considering prescribing citalopram for anxiety for a 10 year-old patient, consider starting at 5 mg q-day for one week then 10 mg q-day for 1 week then 20 mg q-day and assessing the response. Some patients experience akathisia (internal feeling of restlessness), which can feel like a worsening of their anxiety, if the dose is titrated too quickly. Other side effects include sleep disturbance, GI upset and headache but most of these symptoms are dose related and will resolve over time.

The treatment of anxiety disorders in pediatric patients is mostly off label. Only fluoxetine (ages 7+), sertraline (ages 6+) and fluvoxamine (ages 8+) have FDA approval for treatment of obsessive-compulsive disorder (OCD).

When prescribing any antidepressant medication to treat anxiety, it is appropriate to review the FDA black box warning about the increased risk of spontaneous reporting of suicidal thoughts, even if the medication is not being prescribed to treat depression per se.

When prescribing a medication, it is standard practice to first use an SSRI.  If a patient has 2 or more adequate (in terms of dose and length of treatment) trials of SSRIs that are ineffective, one could consider an alternative, either an SNRI (venlafaxine or duloxetine) or mirtazapine, but consultation or referral to psychiatry would be advised in such situations. If there is some benefit from the SSRI, one could consider augmentation with mirtazapine or buspirone. The primary side effects to be concerned with mirtazapine include sedation and increased appetite. Buspirone has an onset of action of about 2 weeks. The primary side effects to be concerned with include: dizziness, fatigue and GI upset. Occasionally the atypical antipsychotics are considered as adjunctive treatment to treatment-resistant OCD.

Benzodiazepines, are rarely used in this population. Pediatric patients can have a paradoxical reaction to them and exhibit behavioral disinhibition. Other side effects include: physiological and psychological addiction, confusion, sedation and impaired fine motor coordination. If a medication to treat acute anxiety is needed, for example for a teenager who has very occasional panic attacks, one could consider hydroxyzine 25-50 mg on a prn basis, which is not associated with dependence. Side effects include: sleepiness, dizziness, and dry mouth.

When feasible, the use of rating scales can help in these efforts by documenting severity and monitoring clinical progress.   A good tool to review, the SCARED, is accessible at. http://www.pediatricbipolar.pitt.edu/content.asp?id=2333#3304 and a broader array of tools is listed at the following website http://www2.massgeneral.org/schoolpsychiatry/screening_anxiety.asp