What is the best approach for a 22-year-old female with insomnia (inability to sleep), sleeping 5-6 hours per night, who has tried melatonin (a hormone that regulates sleep) and is now requesting sleeping medication?

Approach to a 22-Year-Old Female with Insomnia Requesting Sleep Medication

Before prescribing any sleep medication, you must first implement Cognitive Behavioral Therapy for Insomnia (CBT-I), which is the gold standard initial treatment for chronic insomnia and demonstrates superior long-term efficacy compared to medications. 1, 2

Step 1: Assess Whether This Is Actually Insomnia Requiring Treatment

5-6 hours of sleep may be sufficient for some young adults, and treatment should only be pursued if there is daytime impairment. Evaluate for:

• Daytime consequences: fatigue, difficulty concentrating, mood changes, impaired work/school performance 1
• Sleep onset difficulty (taking >30 minutes to fall asleep) versus sleep maintenance problems (waking during the night) 1
• Duration: symptoms present for at least 3 months occurring at least 3 nights per week 1
• Underlying causes: depression, anxiety, substance use, medical conditions, medications, sleep apnea, restless legs syndrome 1, 2

Require a 2-week sleep diary documenting bedtime, wake time, sleep latency, nighttime awakenings, total sleep time, daytime napping, caffeine/alcohol use, and stress levels before proceeding 2

Step 2: Implement CBT-I First (Not Optional)

CBT-I must be initiated before or alongside any pharmacotherapy—this is non-negotiable per guidelines. 1, 2 CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 2

Core CBT-I Components to Implement:

Stimulus Control Therapy 1:

• Go to bed only when sleepy
• Use bed only for sleep and sex (no TV, phone, reading, work)
• If unable to sleep within 20 minutes, leave bedroom and return only when drowsy
• Wake at same time every morning regardless of sleep obtained
• No daytime napping (or limit to 30 minutes before 2pm)

Sleep Restriction Therapy 1:

• Calculate average total sleep time from sleep diary (e.g., 5.5 hours)
• Restrict time in bed to match total sleep time (minimum 5 hours)
• Increase time in bed by 15-20 minutes weekly if sleep efficiency >85%
• Decrease time in bed by 15-20 minutes if sleep efficiency <80%

Sleep Hygiene 1, 2:

• Regular exercise (not within 2 hours of bedtime)
• Avoid caffeine after noon, no nicotine or alcohol in evening
• Keep bedroom cool, dark, quiet
• No screens 30-60 minutes before bed
• Hot bath 90 minutes before bedtime

Relaxation Training 1:

• Progressive muscle relaxation
• Diaphragmatic breathing exercises
• Guided imagery

Cognitive Restructuring 1:

• Address beliefs like "I can't sleep without medication" or "My life will be ruined if I can't sleep"

Step 3: If CBT-I Alone Is Insufficient After 4-6 Weeks, Add Pharmacotherapy

For Sleep Onset Insomnia (Difficulty Falling Asleep):

First-line options 1, 2:

• Zolpidem 5 mg (lower dose for women per FDA) taken immediately before bed with 7-8 hours remaining for sleep 1, 3
• Ramelteon 8 mg taken 30 minutes before bed—this is non-controlled with no abuse potential, making it ideal for young patients 1, 2, 4
• Zaleplon 10 mg for sleep onset only 1, 2

For Sleep Maintenance Insomnia (Waking During Night):

First-line options 1, 2:

• Eszopiclone 2-3 mg for both sleep onset and maintenance 1
• Zolpidem 5 mg (also effective for maintenance) 1
• Low-dose doxepin 3-6 mg specifically for sleep maintenance 1, 4

Why Melatonin Failed:

The American Academy of Sleep Medicine explicitly recommends against melatonin for chronic insomnia due to insufficient evidence of efficacy. 1 Over-the-counter melatonin supplements lack standardization, have short half-lives, and studies show only 9-minute reduction in sleep latency compared to placebo. 1, 5

Step 4: Medication Selection Algorithm

Choose based on specific sleep complaint pattern:

1. If primary complaint is falling asleep: Start ramelteon 8 mg (safest, non-controlled) or zolpidem 5 mg 1, 2, 4
2. If primary complaint is staying asleep: Start eszopiclone 2 mg or doxepin 3 mg 1, 4
3. If both onset and maintenance problems: Start eszopiclone 2 mg or zolpidem 5 mg 1

Prescribe for short-term use only (4-5 weeks maximum initially) with plan for reassessment. 1, 3 Medication should supplement, not replace, ongoing CBT-I. 1, 2

Critical Safety Counseling Required:

• Take medication only when able to dedicate 7-8 hours to sleep 3
• Do not take with or after meals (delays absorption) 3
• Risk of next-morning impairment of driving and activities requiring alertness 3
• Risk of complex sleep behaviors (sleep-walking, sleep-driving)—stop medication immediately if these occur 1, 2
• No alcohol or other CNS depressants 3
• Reassess after 1-2 weeks for efficacy and side effects 2

Common Pitfalls to Avoid:

• Prescribing medication without implementing CBT-I first—this violates guideline recommendations and leads to worse long-term outcomes 1, 2
• Using diphenhydramine or other antihistamines—explicitly not recommended due to lack of efficacy, rapid tolerance (3-4 days), and anticholinergic effects 1, 4
• Prescribing trazodone—explicitly not recommended by guidelines despite common off-label use 1, 4
• Continuing medication long-term without reassessment—insomnia persisting beyond 7-10 days requires evaluation for underlying sleep disorders like sleep apnea 2
• Assuming 5-6 hours requires treatment—only treat if daytime impairment is present 1, 2