Practical Recommendations for Hypnotic Switching in Insomnia Management: A Canadian Expert Clinical Framework

Authors

  • Walter Chow, B.Sc. (Pharmacy), MD
  • Atul Khullar, MD, MSc, FRCPC, DABPN University of Alberta, Edmonton, Alberta
  • Fiore Lalla, MDCM, FRCP Fiore Lalla Medical Services
  • Serge Lessard, MD, FRCPC University of Ottawa, University of Copenhagen, Introspect Clinic, Ontario Review Board, College of Physicians and Surgeons of Ontario
  • Alan Lowe, BScPhm, MD, FRCPC Department of Psychiatry University of Toronto, Toronto, ON
  • Diane McIntosh, MD University of British Columbia, Vancouver, B.C.

DOI:

https://doi.org/10.58931/cpct.2025.3s0148

Abstract

Insomnia disorder is a complex condition in which patients experience difficulties with sleep initiation, sleep maintenance, or early morning awakening. Chronic insomnia is defined as dissatisfying sleep quality or quantity, occurring at least three times per week, that has persisted for at least three months.

Insomnia is common, with a higher incidence in certain subpopulations, including older adults (≥65 years of age) and patients with psychiatric and physical comorbidities, such as depression, anxiety, dementia, restless leg syndrome, obstructive sleep apnea, chronic pain, and alcohol or substance use disorders. Individuals experiencing insomnia often have disrupted sleep architecture, with polysomnography showing reduced time spent in the rejuvenating slow wave and rapid eye movement (REM) sleep stages. As such, insomnia can seriously impair daytime functioning, cognition, and quality of life. Further, insomnia may result in a higher risk of various conditions, including cardiovascular disease, obesity, and diabetes, though the association between insomnia and these comorbidities is likely bi-directional. Unfortunately, for a variety of reasons, the diagnosis is often missed or trivialized in medical practice. Given the profound impact of chronic insomnia, a proactive diagnosis and successful treatment is essential.

The primary non-pharmacologic treatment option available for insomnia is cognitive behavioural therapy for insomnia (CBT-I), which focuses on sleep hygiene techniques, sleep restriction, circadian rhythm therapy, and cognitive therapy. Although CBT-I is the first-line treatment for insomnia and should always be recommended, it may not always be available in a timely manner, it can be costly and not every patient can afford it, some patients choose to opt out, and may not be sufficient as a single therapy approach. Thus, in many cases, pharmacotherapy may be needed in addition to or instead of CBT-I to treat insomnia and improve daytime functioning and associated cardiovascular and metabolic risks. Of note, patients also often self-medicate with over-the-counter medications, including cannabis products.

Currently, commonly prescribed medications for insomnia include benzodiazepine receptor agonists (BZDs; e.g., lorazepam, clonazepam) and Z-drugs (e.g., zolpidem, zopiclone, eszopiclone).10 In addition, despite their risks, antidepressants (e.g., trazodone, mirtazapine), and antipsychotics (e.g., quetiapine) have also been used to treat insomnia despite being off-label and promoting sleep indirectly.

Author Biographies

Walter Chow, B.Sc. (Pharmacy), MD

Dr. Walter Chow completed his Degree in Pharmacy in 1980 at the University of British Columbia. He went on to complete a Residency in Hospital Pharmacy at Royal Inland Hospital in Kamloops BC before working as a clinical pharmacist at St. Paul’s Hospital and the BC Drug and Poison Information Center. He returned to the University of British Columbia to complete his Medical Degree in 1986. During his medical training, he received scholarships in obstetrics and gynecology, pediatrics, general surgery and internal medicine. His broad interest and ability made him the ideal candidate to pursue a career as a family medicine specialist. He completed his rotating internship at Victoria General Hospital before setting up practice in Victoria. Since 1987, he has been in full time family practice. His passion for post graduate medical education has led him to be involved in the development and delivery of over 30 programs annually for the last 20 years. He is a highly sought-after speaker on the regional and national level for continuing education program delivery to physicians, pharmacists and other health care professionals. His areas of special interest include providing current evidence-based primary care management of asthma, COPD, cardiovascular risk assessment, diabetes, osteoarthritis, osteoporosis, mental health disorders, and electronic medical records. In 2020, he was the recipient of the BC College of Family Physicians Coin in honor of his work in continuing medical education.

Atul Khullar, MD, MSc, FRCPC, DABPN, University of Alberta, Edmonton, Alberta

Dr. Atul Khullar, MD, MSc, FRCPC, DABPN (Cert sleep medicine), DABOM, FAASM, is a psychiatrist and sleep specialist who focuses on the integrative management of obesity, sleep, mood/anxiety and attention deficit disorders in age groups from adolescence onwards. He is a Clinical Associate Professor at the University of Alberta and the medical director of the Northern Alberta Sleep Clinic.

Fiore Lalla, MDCM, FRCP, Fiore Lalla Medical Services

Fiore Lalla is a Mcgill graduate who has worked at the West Island Montreal Health and Social services center for the last 25 years, almost 15 of them as chief and medical director of the Mental Health division. He has published on the patient and systemic benefits of long acting antipsychotic treatments, and created the OPTIMA motivational education tool for long acting treatment. He is the chairman of the Lakeshore General Hospital foundation and has clinical interests in treatment resistant depression and psychosis; he is also determined to help patients with psychotropic side effects and diagnosing missed ADHD.

Serge Lessard, MD, FRCPC, University of Ottawa, University of Copenhagen, Introspect Clinic, Ontario Review Board, College of Physicians and Surgeons of Ontario

Dr. Serge Lessard earned his medical degree from McMaster University in 1996 and completed his psychiatry residency at the University of Ottawa. He pursued postdoctoral training in neuropharmacology in Europe and the United States. Currently, Dr. Lessard serves as an Assistant Professor at the University of Ottawa and a Lecturer at the University of Copenhagen. After 25 years of hospital practice, he is now in private practice. He is the Medical Director of the Introspect Clinical Research Center, where he conducts pharmacological research and provides specialized consultations in polypharmacy. Dr. Lessard opened an ADHD clinic in 2010 and specializes in the treatment of ADHD and common comorbidities. A recognized expert in his field, Dr. Lessard acts as a global advisor to several pharmaceutical boards dedicated to mood disorders, anxiety, insomnia and ADHD. He was appointed to a DSM-5 subcommittee tasked with evaluating comorbidities in mood disorders. He also serves as a scientific advisor for peer-reviewed journals. He was recently co-author of the new Canadian Consensus for the treatment of chronic insomnia. Dr. Lessard has chaired numerous educational programs and has given conferences globally. He is the cofounder of The Canadian Community Psychiatrist Association. With a strong commitment to medical education, he emphasizes the application of evidence-based science in clinical practice. His dedication to teaching was recognized by the University of Ottawa, where he was awarded "Professor of the Year – Best Educator."

Alan Lowe, BScPhm, MD, FRCPC, Department of Psychiatry University of Toronto, Toronto, ON

Dr. Alan Lowe is a Psychiatrist, Neuropsychiatrist and Sleep Specialist, with a special interest in the Neuropharmacology of Sleep, Psychotropic medications, and their impact on Sleep Architecture. He has been Principal Investigator and participated in many Research Studies and Clinical Trials in Sleep and Psychiatry. He is currently Psychiatry Staff at North York General Hospital and affiliated with Woodbine-Steeles Sleep clinic. He previously was associated with the Mood Disorders Research and Treatment Service at Queen’s University and was Director of the Epilepsy Neuropsychiatry Program, Toronto Western Hospital- University Health Network, where he completed a Neuropsychiatry and Sleep Fellowship. He completed his Psychiatry Residency at the University of Toronto, Medical Degree at McMaster University, Pharmacy Degree from the University of Toronto and is an Assistant Professor of Psychiatry, University of Toronto.

Diane McIntosh, MD, University of British Columbia, Vancouver, B.C.

Dr. Diane McIntosh is a widely respected psychiatrist, author, educator, mental health advocate, and authority on the diagnosis and treatment of mood and anxiety disorders. In addition to over 20 years’ of direct experience providing psychiatric care to patients, Diane’s career-long focus has been on improving access to mental health knowledge and expertise through technology and education. She co-founded SwitchRx, an online psychotropic switching tool used by over 75,000 healthcare professionals worldwide, and PsychedUp, a continuing medical education program developed to encourage appropriate and rational prescribing of psychiatric medications. She is the author of bestseller This is Depression, a comprehensive and evidence-based guide to one of the most common and debilitating disorders.

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2025-09-18

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Chow W, Khullar A, Lalla F, Lessard S, Lowe A, McIntosh D. Practical Recommendations for Hypnotic Switching in Insomnia Management: A Canadian Expert Clinical Framework. Can Prim Care Today [Internet]. 2025 Sep. 18 [cited 2025 Sep. 23];3(s01):2–12. Available from: https://canadianprimarycaretoday.com/article/view/3-s01-Chow_et_al

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