Continued information gathering 

A thorough understanding of Peter’s sleeping patterns, which includes medical and social histories, is needed to try and identify the cause of his symptoms. 

Peter tells you he normally is not affected by poor sleep but says that he has lots on his mind and when he goes to bed finds it hard to stop thinking about things. He says his poor sleeping has been keeping his wife awake at night too. 

His sister died about three months ago. He is generally in good health and has no medical problems. From the information gathered so far, the death of his sister appears to be the precipitating event as to the cause of his insomnia. 

Problem refinement

At this point it would be useful to see if there are any other factors that could be contributing to his poor sleeping and determine what he has been doing to cope with the death of his sister. Peter tells you he has thrown himself into his work to keep himself busy (he is sales director for a coffee company) but it is when he is at home in the evenings that he is not coping too well. 

He admits to drinking more alcohol than usual in the evenings. His bed times are variable and he has noticed that he has been getting tired at work and has been drinking more coffee during the day to perk himself up. 

He has not been going to the gym as often as he used to because he has lost motivation.

Increased alcohol and caffeine intake coupled with erratic bedtimes will all contribute to his sleeping difficulty. 

These additional pieces of information confirm your thinking that the death of his sister is the cause of his insomnia and his coping strategies are contributing to his present state.

Management: self-care options

Peter should be given advice on how he could improve his sleep. A number of measures could be put in place to help him:

• Maintain a regular bedtime and awakening time
• Reduce the amount of coffee consumed, especially in the evening
• Try to limit or avoid alcohol in the evening, especially just before going to bed
• Try to go back to the gym but do not exercise too late in the evening
• Make sure the bedroom is comfortable and not too warm
• Do not watch TV, use the computer or read in bed (i.e. avoid mental activity)
• If unable to go to sleep, get up and do something, returning to bed when sleepy.

Providing written advice material should also be considered. For example, ‘How to sleep better' guides.

Prescribing options and safety netting

Besides managing the acute presentation of insomnia, there is a need to explore how Peter can better cope with managing his grief and assessing if he is depressed. 

A referral to the GP and a grief counsellor should be considered. The GP may instigate a sleep aid (non-benzodiazepine) for up to a week. If depression is diagnosed, then use of a selective serotonin inhibitor (SSRI) maybe warranted.

However, some SSRIs can themselves aggravate insomnia so, if instigated, daytime dosing is advisable.