What are the best treatment options for a patient experiencing insomnia, specifically trouble staying asleep, considering potential underlying medical conditions such as sleep apnea or restless leg syndrome?

Treatment Approach for Sleep Maintenance Insomnia

Start with cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, as it provides superior long-term outcomes compared to medications and should be implemented before or alongside any pharmacologic intervention. 1

Initial Assessment and Screening

Before initiating any treatment, screen for underlying conditions that may be causing or exacerbating sleep maintenance problems:

• Screen for obstructive sleep apnea (OSA) using the STOP questionnaire if the patient has observed apneas or snoring, as OSA commonly presents with insomnia symptoms rather than classic daytime sleepiness 1
• Check ferritin levels to evaluate for restless legs syndrome (RLS), particularly if the patient reports uncomfortable leg sensations or urge to move legs that worsen at night; ferritin levels <45-50 ng/mL indicate a treatable cause 1
• Review all medications as multiple drug classes directly cause or exacerbate insomnia, including β-blockers, diuretics causing nocturia, and SSRIs like fluoxetine 2
• Evaluate for depression and anxiety, as depression increases insomnia risk 2.5-fold and anxiety disorders perpetuate sleep disturbance cycles 2

Non-Pharmacologic Interventions (First-Line)

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is the gold standard treatment and has been shown in randomized controlled trials to reduce mean wakefulness by almost 1 hour per night in patients with chronic insomnia 1. Key components include:

• Stimulus control: Associate bed with sleep only, not wakefulness 3
• Sleep restriction: Limit time in bed to actual sleep time, then gradually increase 3
• Cognitive restructuring: Address maladaptive thoughts about sleep 1
• Relaxation techniques: Progressive muscle relaxation meets criteria for empirically-supported treatment 3

Sleep Hygiene Education

Implement these evidence-based practices 1:

• Regular morning or afternoon exercise (not evening) 1
• Daytime exposure to bright light 1
• Keep sleep environment dark, quiet, and comfortable with temperature and humidity control 1
• Establish regular bedtime and rise time 1
• Avoid heavy meals, alcohol, and nicotine near bedtime 1
• Put electronic devices in silent/off mode (except diabetes management devices if applicable) 1
• Avoid daytime naps and limit caffeine in evening 1

Physical Activity

Physical activity improves sleep quality and efficiency in randomized controlled trials, with yoga interventions showing significant improvements in global sleep quality, daytime functioning, and sleep efficiency (all P≤.05) 1.

Pharmacologic Options (When Non-Pharmacologic Approaches Are Insufficient)

For Sleep Maintenance Specifically

Important caveat: The evidence provided focuses heavily on sleep onset rather than sleep maintenance. Most FDA-approved medications target sleep onset latency rather than middle-of-night awakenings.

• Ramelteon is FDA-approved specifically for difficulty with sleep onset, not sleep maintenance, and clinical trials showed it reduced latency to persistent sleep but was studied primarily for sleep initiation 4
• The 16 mg dose of ramelteon conferred no additional benefit and was associated with higher incidences of fatigue, headache, and next-day somnolence 4

Treatment of Underlying Conditions

If screening reveals specific disorders:

• For RLS with low ferritin: Treat with dopamine agonists, benzodiazepines, gabapentin, and/or opioids; refer to sleep specialist 1
• For OSA: Treat with continuous positive airway pressure, surgery, or oral appliances; recommend weight loss and exercise; refer to sleep specialist 1

Common Pitfalls to Avoid

• Do not assume medications are first-line: Despite being commonly prescribed, pharmacotherapy should follow or accompany non-pharmacologic interventions 5, 6
• Do not overlook medication-induced insomnia: SSRIs (including fluoxetine), β-blockers, and diuretics are well-documented causes that require medication adjustment rather than adding sleep aids 2
• Do not ignore comorbid conditions: Treatment of comorbid conditions alone may not resolve insomnia, but untreated conditions will undermine sleep interventions 7
• Avoid excessive time in bed: This maladaptive behavior perpetuates insomnia and should be addressed through sleep restriction therapy 1

Referral Considerations

Refer to a sleep medicine specialist when 1:

• Sleep disturbances persist despite adequate disease control and initial interventions
• Suspected OSA, narcolepsy, or other primary sleep disorders require formal sleep studies
• Complex cases with multiple comorbidities
• Patient requires specialized behavioral interventions not available in primary care