Maintenance Insomnia Treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated as first-line treatment for all adults with chronic maintenance insomnia before considering any pharmacotherapy. 1, 2, 3
First-Line Treatment: CBT-I
CBT-I is the standard of care with a strong recommendation from both the American Academy of Sleep Medicine and the American College of Physicians, demonstrating superior long-term efficacy that persists for up to 2 years after treatment ends—unlike medications, which show degradation of benefit after discontinuation. 1, 2, 3, 4
Core CBT-I Components for Maintenance Insomnia
Sleep restriction therapy: Calculate the patient's current total sleep time from sleep logs and restrict time in bed to match actual sleep time (minimum 5 hours), creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 2, 3
Stimulus control therapy: Use the bed only for sleep—no reading or watching TV in bed; if unable to fall asleep within approximately 20 minutes, leave the bed and engage in relaxing activity until drowsy, then return and repeat as necessary. 2, 3
Set consistent bedtime and wake time to achieve >85% sleep efficiency, adjusting time in bed weekly based on sleep efficiency. 2
Cognitive restructuring: Target maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments. 3
Implementation
In-person, therapist-led CBT-I is most beneficial; digital CBT-I is effective when in-person is unavailable. 2
Treatment typically requires 4-8 sessions over 6 weeks. 2, 5
Counsel patients that improvements are gradual but sustained—initial mild sleepiness and fatigue typically resolve quickly. 2
Pharmacotherapy (Only After CBT-I Initiation)
Pharmacotherapy should only be added after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 1, 2, 3
First-Line Pharmacologic Options for Maintenance Insomnia
Low-dose doxepin 3-6 mg at bedtime is the preferred first-line hypnotic for sleep maintenance insomnia, reducing wake after sleep onset by 22-23 minutes with minimal anticholinergic effects at hypnotic doses and no abuse potential. 1, 6
Suvorexant 10 mg (orexin receptor antagonist) reduces wake after sleep onset by 16-28 minutes through a mechanism distinct from benzodiazepine-type agents, with lower risk of cognitive and psychomotor impairment. 1, 6
Eszopiclone 2-3 mg (1 mg for adults ≥65 years) addresses both sleep onset and maintenance, increasing total sleep time by 28-57 minutes with moderate-to-large improvements in subjective sleep quality. 1, 6, 7
Zolpidem 10 mg (5 mg for adults ≥65 years) improves both sleep onset and maintenance, reducing sleep latency by 25 minutes and adding 29 minutes to total sleep time. 1, 6
Dosing Algorithm for Maintenance Insomnia
Start with low-dose doxepin 3 mg at bedtime; if insufficient after 1-2 weeks, increase to 6 mg. 6
If doxepin fails or is contraindicated, switch to suvorexant 10 mg. 6
If both fail, consider eszopiclone 2 mg (1 mg if ≥65 years), titrating to 3 mg (maximum 2 mg if ≥65 years) if needed after 1-2 weeks. 6, 7
Critical Safety Considerations
All hypnotics carry risks: driving impairment, complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating), falls, fractures, cognitive impairment, and possible associations with dementia. 1, 6, 2
FDA labeling recommends short-term use (≤4 weeks) for acute insomnia; evidence beyond 4 weeks is limited. 1, 6
Discontinue immediately if complex sleep behaviors occur; patients should be warned about these potentially life-threatening risks. 6
Elderly patients (≥65 years) require dose reductions: eszopiclone maximum 2 mg, zolpidem maximum 5 mg, doxepin maximum 6 mg. 1, 6
Reassess after 1-2 weeks for changes in wake after sleep onset, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects. 6
Medications Explicitly NOT Recommended
Trazodone yields only ~10 minutes reduction in sleep latency and ~8 minutes reduction in wake after sleep onset, with no improvement in subjective sleep quality; harms outweigh minimal benefits. 1, 6
Over-the-counter antihistamines (diphenhydramine, doxylamine) lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation), and develop tolerance within 3-4 days. 1, 6
Traditional benzodiazepines (lorazepam, clonazepam, diazepam) have long half-lives leading to drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, and associations with dementia and fractures. 6
Melatonin supplements produce only ~9 minutes reduction in sleep latency with insufficient efficacy data. 1, 6
Herbal supplements (valerian, L-tryptophan) have insufficient evidence to support use for primary insomnia. 1, 6
Common Pitfalls to Avoid
Do NOT prescribe medications before attempting CBT-I—this is the most common error and leads to less durable benefit. 6, 2
Do NOT rely on sleep hygiene education alone—it lacks efficacy as a single intervention and must be integrated into comprehensive CBT-I. 2, 5
Do NOT use adult dosing in older adults—age-adjusted dosing is essential to reduce fall risk. 6
Do NOT combine multiple sedative agents—this markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 6
Do NOT continue pharmacotherapy long-term without periodic reassessment every 2-4 weeks to evaluate efficacy, side effects, and plan tapering. 6