The Waco Guide

Yes
Unable to participate in
CBT-I or remaining
symptoms despite CBT-I
No
Chronic Insomnia
(Insomnia Disorder DSM5)
Assess for comorbidities
(e.g., pain, COPD, CHF,
hyperthyroid, GERD,
diabetes,
neurodegenerative
disorders)
Optimize medical treatment
Assess for psychiatric comorbidities
(e.g., depression, anxiety, bipolar
disorder, PTSD)
Optimize psychiatric treatment; see
appropriate decision support
Is patient currently taking
sedative hypnotic for insomnia?
CBT-I and then consider
taper of pharmacotherapy
Assess for comorbid sleep
disorder (e.g., RLS, OSA)
Optimize medical treatment;
refer for polysomnography if
OSA suspected
Assess medication / substance abuse history
(e.g., stimulants, glucocorticoids,
antidepressants, ETOH, caffeine)
Minimize insomnia-producing
medications if possible; limit or
d/c late day caffeine, ETOH
Circadian sleep-wake
rhythm disorder
Appropriately timed light therapy
+ melatonin
First-line treatment:
CBT-I
SOR A
Pharmacotherapy (SOR B)
- Consider treatment for 4-5 weeks, then discuss slow taper
combined with CBT-I guidance
- Some individuals will require chronic therapy
Sleep-maintenance insomnia
EszopicloneZolpidem Suvorexant DoxepinTrazodoneGabapentin Zolpidem ER
Contraindications to sleep restriction component:
seizure disorder, bipolar disorder, high risk for falls
Available in person, online,
app, self-help books
Sleep-onset insomnia
EszopicloneZolpidem Trazodone DoxepinGabapentin Zolpidem ER
Shortest
half-life
Longest
half-life
Shortest
half-life
Longest
half-life
Core components of CBT-I
1. Sleep restriction
2. Stimulus control
3. Sleep hygiene
4. Relaxation training

Is patient currently taking sedative hypnotic for insomnia?

Evaluate for the following:

Does the patient suffer from sleep-onset insomnia or sleep-maintenance insomnia?