From the Guidelines
Management of difficulty staying asleep (sleep maintenance insomnia) should begin with cognitive behavioral therapy for insomnia (CBT-I), which includes sleep restriction, stimulus control, and sleep hygiene practices, as recommended by the American College of Physicians 1.
Key Components of CBT-I
- Sleep restriction: limiting time in bed to actual sleep time, gradually increasing as sleep efficiency improves
- Stimulus control: using the bed only for sleep and sex, leaving the bedroom when unable to sleep, and maintaining consistent sleep-wake times
- Sleep hygiene: avoiding caffeine after noon, limiting alcohol, exercising regularly (but not close to bedtime), creating a cool, dark, quiet sleeping environment, and establishing a relaxing bedtime routine
Medication Options
If non-pharmacological approaches are insufficient, short-term medication options may be considered, such as:
- Low-dose doxepin (3-6mg) 1
- Eszopiclone (1-3mg) 1
- Trazodone (25-100mg) taken 30 minutes before bedtime for 2-4 weeks
Important Considerations
- Avoid using benzodiazepines or Z-drugs long-term due to dependency risks
- Combine medication with ongoing behavioral strategies
- Address any underlying conditions like sleep apnea, restless legs syndrome, or depression that may be contributing to sleep maintenance problems
Recent Guidelines
The American Academy of Sleep Medicine recommends psychological and behavioral interventions, including CBT-I, as the first-line treatment for insomnia disorder 1. The American College of Physicians also recommends CBT-I as the initial treatment for chronic insomnia disorder in adults 1.
From the FDA Drug Label
Eszopiclone tablets are used in adults for the treatment of a sleep problem called insomnia. Symptoms of insomnia include: trouble falling asleep, waking up often during the night
Call your doctor if your insomnia worsens or is not better within 7 to 10 days. This may mean that there is another condition causing your sleep problems.
The recommended management strategies for insomnia, specifically difficulty staying asleep, include taking eszopiclone tablets exactly as prescribed, right before getting into bed, and being able to get a full night's sleep before being active again 2. It is also important to note that eszopiclone tablets may cause serious side effects, such as sleepiness during the day, and may not be suitable for everyone, especially those with a history of depression, mental illness, or suicidal thoughts.
- Key considerations:
- Take eszopiclone tablets as prescribed
- Get a full night's sleep before being active again
- Monitor for serious side effects
- Consult a doctor if insomnia worsens or does not improve within 7 to 10 days
- Important safety information: eszopiclone tablets can cause abnormal thoughts and behavior, and may lead to dependence or abuse 2.
From the Research
Management Strategies for Insomnia
The management of insomnia, specifically difficulty staying asleep, can be approached through various strategies.
- Non-pharmacologic interventions, such as cognitive-behavioral therapy, stimulus-control therapy, relaxation, paradoxical intention, and sleep restriction, have been found to be efficacious treatments for insomnia 3.
- These methods can be applied directly by mental health practitioners or primary care providers, or by referral to a specialist.
- Exercise and relaxation techniques are also recommended as part of a non-pharmacologic approach to managing insomnia 4.
- Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine, may also be considered 4.
Pharmacologic Interventions
Pharmacologic treatments for insomnia include nonbenzodiazepine hypnotic medications, such as zolpidem, zaleplon, and eszopiclone, which have been shown to be effective in improving sleep quality 5.
- Melatonin receptor agonists, such as ramelteon, have also been found to be effective in improving sleep quality and reducing sleep onset time 5, 6.
- Low-dose doxepin has been demonstrated to be effective for sleep maintenance insomnia, particularly in the latter third of the night 5.
- However, pharmacologic treatments should be used with caution, as they can have adverse effects and may be associated with dependence and abuse 7.
Considerations for Treatment
When choosing a treatment approach for insomnia, it is essential to consider the individual's specific needs and circumstances.
- Non-pharmacologic interventions are generally recommended as the first-line treatment for insomnia 4.
- Pharmacologic treatments may be considered for individuals who have not responded to non-pharmacologic interventions or who have comorbid conditions that require medication 5.
- Primary care physicians can play a crucial role in managing insomnia, and referral to a specialist may be necessary for refractory cases 4.