What is the best approach to treating middle insomnia in an adult patient?

Treating Middle Insomnia (Sleep Maintenance Insomnia)

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment, and if pharmacotherapy is needed, use low-dose doxepin 3-6 mg or eszopiclone 2-3 mg specifically for sleep maintenance problems. 1, 2

First-Line Treatment: CBT-I

All adults with middle insomnia must receive CBT-I before or alongside any medication, as it produces sustained improvements for up to 2 years and directly addresses wake after sleep onset (WASO), which is the hallmark of middle insomnia. 1, 3

Core CBT-I Components for Middle Insomnia

• Sleep restriction therapy is particularly effective for middle insomnia—calculate actual total sleep time from a 1-2 week sleep log, then restrict time in bed to match only actual sleep duration (minimum 5 hours) to consolidate sleep and reduce nighttime awakenings. 3, 4

• Stimulus control requires leaving the bed within 20 minutes if awakening occurs and unable to return to sleep—engage in quiet, non-stimulating activity in dim light until genuinely sleepy, then return to bed. 3, 4

• Maintain rigid wake time every morning regardless of sleep quality the previous night, and avoid daytime napping, as these strengthen circadian rhythm and reduce middle-of-night awakenings. 3

• Moderate-quality evidence shows CBT-I reduces wake after sleep onset and improves sleep efficiency specifically in patients with middle insomnia. 1

Implementation Details

• CBT-I typically requires 4-8 sessions over 6 weeks, with in-person therapist-led delivery being most effective, though digital CBT-I is acceptable when in-person is unavailable. 4

• Improvements are gradual but durable—counsel patients that initial mild sleepiness and fatigue resolve quickly, but sustained benefits continue long after treatment ends. 3, 4

Pharmacotherapy for Middle Insomnia

Only add medication after CBT-I has been attempted or when CBT-I is insufficient, using shared decision-making to discuss benefits, harms, and the short-term nature of pharmacologic treatment. 1

First-Line Pharmacologic Options

• Low-dose doxepin 3-6 mg is specifically recommended for sleep maintenance insomnia, with moderate-quality evidence showing it reduces wake after sleep onset by 22-23 minutes and improves sleep efficiency, total sleep time, and sleep quality. 1, 2

• Eszopiclone 2-3 mg is recommended for both sleep onset and maintenance insomnia, with low-to-moderate quality evidence showing improvement in wake after sleep onset in the general population and older adults. 1, 2

• Zolpidem 10 mg (5 mg in elderly) addresses both sleep onset and maintenance, though the lower dose is mandatory in patients ≥65 years due to increased fall risk and cognitive impairment. 2

• Suvorexant (orexin receptor antagonist) is specifically suggested for sleep maintenance insomnia, with moderate-quality evidence showing it reduces wake after sleep onset by 16-28 minutes through a unique mechanism of inhibiting wakefulness rather than inducing sedation. 1, 2

Treatment Selection Algorithm

• For middle insomnia alone: Start with doxepin 3-6 mg or suvorexant, as these specifically target sleep maintenance. 2

• For combined sleep onset and maintenance: Use eszopiclone 2-3 mg or zolpidem 10 mg (5 mg if ≥65 years). 2, 4

• For comorbid depression/anxiety: Use sedating antidepressants like doxepin or mirtazapine as they simultaneously address mood and sleep maintenance. 2

• For patients with substance abuse history: Avoid benzodiazepines; consider ramelteon or suvorexant due to minimal abuse potential. 2

Critical Safety Considerations

• All hypnotics carry risks including daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, and cognitive impairment, particularly in elderly patients. 1, 4

• Observational studies link hypnotic use to increased risk of dementia, serious injury, and fractures, though most data comes from benzodiazepine studies. 1

• Use the lowest effective dose for the shortest duration possible—FDA labeling indicates these medications are intended for short-term use only (typically <4 weeks). 1, 2

• Elderly patients require dose adjustments: zolpidem maximum 5 mg, and consider ramelteon 8 mg or doxepin 3 mg as safest choices due to minimal fall risk. 2

Medications to Avoid

• Trazodone is explicitly NOT recommended for sleep maintenance insomnia, as trials show modest improvements in sleep parameters but no improvement in subjective sleep quality, with harms outweighing benefits. 2

• Over-the-counter antihistamines (diphenhydramine) should not be used due to lack of efficacy data, anticholinergic effects, daytime sedation, and delirium risk especially in elderly patients. 2

• Long-acting benzodiazepines carry increased risks without clear benefit and should be avoided. 2

Common Pitfalls to Avoid

• Failing to implement CBT-I before or alongside pharmacotherapy is the most common error—medications should supplement, not replace, behavioral interventions. 4

• Using medications long-term without periodic reassessment—reassess every 2-4 weeks initially, and attempt medication tapering after 4-8 weeks when sleep consolidates. 2, 3

• Prescribing doses appropriate for younger adults in elderly patients—age-adjusted dosing is mandatory (e.g., zolpidem 5 mg maximum in ≥65 years). 2

• Allowing patients to stay in bed "trying to sleep" during middle-of-night awakenings—this worsens conditioned arousal and perpetuates the problem. 4

Monitoring and Follow-Up

• Reassess after 1-2 weeks to evaluate efficacy on sleep maintenance, daytime functioning, and adverse effects including morning sedation and cognitive impairment. 2

• If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders such as sleep apnea, restless legs syndrome, or circadian rhythm disorders. 2

• Consider referral to a sleep medicine specialist if insomnia persists despite these interventions. 3