Chronic insomnia disorder with residual depression and long-term Z-drug use (MEQ)

(i) Formulation. Chronic insomnia disorder (onset and maintenance, multi-year course, frequency, daytime impairment) comorbid with residual MDD. Maintaining factors: alcohol (shortens latency, fragments architecture), long-term zopiclone with tolerance/dependence pattern, possible OSA (BMI, snoring), and likely Spielman perpetuating behaviours (extended time in bed, sleep effort). Differentials: OSA vs pure psychiatric insomnia, circadian delay less likely from stem, substance-related sleep disruption, medical causes not yet excluded, residual depression driving middle insomnia. Treat insomnia as a disorder even when comorbid.^[1][6]

(ii) Assessment/investigations. Structured sleep history and 1–2 week diary; substances; suicide risk; driving risk (near-miss is a red flag). Partner history for apnoeas. ISI for severity/response; ESS if sleepiness/driving is the issue. STOP-BANG-type OSA screen. Review medications and OTCs. Consider sleep study given OSA probability; do not delay CBT-I solely for PSG waitlists. Baseline mood scales; medical labs as indicated (TFT, FBC, glucose).^[1][2]

(iii) Stepped plan. Psychoeducation; stop alcohol as hypnotic. CBT-I first-line — stimulus control, sleep restriction with occupational safety planning, cognitive therapy, relaxation, education; face-to-face or digital per access.^[1][2][3][6] Optimise depression treatment in parallel (not instead of CBT-I). Hypnotic deprescribing: shared plan to taper zopiclone, avoid escalation, do not replace with open-ended quetiapine for primary insomnia. Short-term bridge only if needed during CBT-I with exit criteria. Sedating antidepressant only if depression warrants, knowing hangover/weight/OSA risks. Morin-type teaching: meds may help short-term; CBT-I durability is superior long-term.^[1][8]

(iv) OSA and work. Refer sleep medicine; weight management; alcohol reduction. Pending assessment, discuss temporary work/driving safety after near-miss, OHS liaison as appropriate, jurisdiction fitness-to-drive principles. CPAP if moderate–severe OSA confirmed — support adherence and mood in parallel.^[6]

(v) Depression/suicide evidence. Longitudinal meta-analysis shows insomnia predicts incident depression; sleep disturbance associates with suicidal ideation/attempt/death — document SI carefully and treat sleep as part of risk reduction, not optional comfort care.^[4][5]