What are the treatment options for a patient with ongoing sleep issues?

Treatment of Ongoing Sleep Issues

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all patients with chronic sleep problems, as it is designated as the standard of care and produces clinically meaningful improvements sustained for up to 2 years. 1, 2

Diagnostic Approach

Before initiating treatment, categorize the sleep disorder:

• Insomnia: Difficulty falling asleep and/or maintaining sleep at least 3 times per week for at least 4 weeks, accompanied by distress 3
• Excessive sleepiness with snoring/apneas: Use STOP questionnaire to screen for obstructive sleep apnea (OSA); confirm with polysomnography or home sleep studies 3
• Excessive sleepiness with leg discomfort: Check ferritin levels; levels <45-50 ng/mL indicate treatable restless legs syndrome (RLS) 3
• Excessive sleepiness with cataplexy/vivid dreams: Consider narcolepsy; diagnose with multiple sleep latency tests and polysomnography 3

First-Line Treatment: CBT-I

The American College of Physicians provides a strong recommendation that CBT-I be used as initial treatment, and the American Academy of Sleep Medicine designates it as standard of care for chronic insomnia in adults of all ages 1, 2:

Core Components of CBT-I

• Stimulus control: Go to bed only when sleepy, get out of bed if unable to sleep within 20 minutes, use bed only for sleep and sex 2
• Sleep restriction therapy: Limit time in bed to match actual sleep duration based on sleep logs to enhance sleep drive and consolidate sleep 2
• Cognitive therapy: Address distorted beliefs about sleep 2
• Relaxation techniques: Progressive muscle relaxation or biofeedback 2
• Sleep hygiene education: Regular morning/afternoon exercise, daytime bright light exposure, keep bedroom dark/quiet/comfortable, avoid heavy meals/alcohol/nicotine near bedtime 3, 2

Implementation Details

• Treatment typically requires 4-8 sessions over 6 weeks 1
• In-person, therapist-led programs are most beneficial; digital CBT-I is an effective alternative when in-person therapy is unavailable 1
• Improvements are gradual but sustained, unlike pharmacotherapy which shows degradation after discontinuation 1

Critical Pitfall

• Do not rely on sleep hygiene education alone—it lacks efficacy as a single intervention and must be combined with stimulus control and sleep restriction 1, 2

Second-Line Treatment: Pharmacotherapy

Only consider pharmacotherapy after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making 1, 2:

When to Add Medications

• If sleep disturbances persist after 2-4 weeks of behavioral interventions 2, 4
• Document sleep patterns with sleep logs before and during treatment 2, 4

Medication Options

FDA-approved hypnotics:

• Eszopiclone: Effective for sleep maintenance; use lowest effective dose due to dose-related CNS depression and next-day impairment at 2-3 mg doses 2, 5
• Zolpidem: Risk of complex sleep behaviors (sleep-driving, sleep-walking) may occur at recommended doses; discontinue immediately if these occur 6
• Temazepam: Alternative benzodiazepine option 2

Low-dose sedating antidepressants:

• Trazodone 25-50 mg at bedtime: First choice for adding to behavioral therapy 2, 4
• Doxepin 3-6 mg at bedtime: Alternative if trazodone ineffective 2, 4

Medications to Avoid

• Benzodiazepines for long-term use: Risk of dependence, tolerance, cognitive impairment 2, 4
• Antihistamines (diphenhydramine, doxylamine): Anticholinergic effects, daytime sedation, delirium risk especially in older adults 2
• Antipsychotics as first-line: Metabolic side effects 2

Important Safety Considerations

• Downward dose adjustment needed when combining with other CNS depressants (benzodiazepines, opioids, tricyclic antidepressants, alcohol) 5, 6
• Patients must have full night of sleep remaining (7-8 hours) to minimize next-day impairment 5, 6
• Attempt medication tapering after 4-8 weeks when sleep consolidates 2

Condition-Specific Treatments

Obstructive Sleep Apnea

• Continuous positive airway pressure (CPAP), surgery, or oral appliances 3
• Weight loss and exercise 3
• Refer to sleep specialist 3

Restless Legs Syndrome

• Dopamine agonists, benzodiazepines, gabapentin, and/or opioids 3
• Refer to sleep specialist 3

Narcolepsy

• Psychostimulants such as modafinil or methylphenidate 3

Adjunctive Interventions

• Physical activity: Yoga and exercise improve sleep quality, daytime functioning, and sleep efficiency in patients with sleep disruption 3
• Psychosocial interventions: Psychoeducational therapy, supportive expressive therapy, mindfulness meditation, or mind-body bridging as adjuncts to CBT-I 3

Critical Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment—this violates guideline recommendations and deprives patients of more effective, durable therapy 1, 2
• Do not prescribe sleep medications without concurrent behavioral therapy—this leads to dependence without addressing underlying sleep architecture problems 2
• Screen for underlying causes before assuming primary insomnia: sleep apnea, RLS, medication side effects, pain, nocturia, psychiatric conditions 2
• Failure of insomnia to remit after 7-10 days indicates need to evaluate for primary psychiatric/medical illness 3, 5, 6