Chronic insomnia with depression and hypnotic dependence (MEQ)

(i) Formulation. Chronic insomnia disorder (sleep onset and maintenance, frequency and multi-year course, daytime impairment) comorbid with residual MDD. Contributing/maintaining factors: alcohol (shortens latency but fragments architecture), long-term zopiclone with likely tolerance/dependence pattern, possible OSA (BMI, snoring). Differentials: primary vs comorbid insomnia (both treated), circadian delay less likely given description, RLS not described, medical pain/thyroid not yet excluded, substance-induced sleep disorder component from alcohol/hypnotic.^[1][4][7]

(ii) Assessment/investigations. Structured sleep history and 1–2 week diary; substances; suicide risk; driving/occupational sleepiness (near-miss is a red flag). Partner history for apnoeas. ISI/ESS as clinical tools. Screen OSA (STOP-BANG-type factors). Review medications. Consider sleep study given high OSA probability; not required to start CBT-I for typical insomnia features but should not delay OSA pathway. Baseline mood scales; medical labs as indicated (TFT, FBC, glucose, etc.).^[4][1]

(iii) Stepped plan. Psychoeducation; stop using alcohol as hypnotic. CBT-I first-line (stimulus control, sleep restriction with occupational safety planning, cognitive therapy, relaxation, education) — face-to-face or digital depending on access; evidence for clinically meaningful benefit.^[1][2][3][7] Optimise depression treatment in parallel (not instead of CBT-I). Hypnotic deprescribing: shared plan to taper zopiclone (slow taper if dependence features), avoid dose escalation, do not replace with open-ended quetiapine for primary insomnia. Short-term bridge only if needed during CBT-I initiation with exit criteria. Sedating antidepressant choices only if depression warrants, knowing hangover/OSA weight risks.^[1][7]

(iv) OSA and work. Refer sleep medicine; weight management; alcohol reduction. Pending assessment, discuss temporary work safety (no forklift if sleepy), employer/OHS liaison as appropriate, legal fitness-to-drive/operate machinery principles by jurisdiction. CPAP if moderate–severe OSA confirmed — support adherence.^[4]

(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.^[5][6]