How should I evaluate and manage an adult with insomnia, including sleep‑hygiene measures, appropriate use of short‑acting hypnotics (e.g., zolpidem dosing for women/elderly) or low‑dose trazodone, and indications for referral to CBT‑I?

Evaluation and Management of Adult Insomnia

Initial Evaluation

Begin with a focused clinical assessment using three essential tools: a general medical/psychiatric questionnaire, the Epworth Sleepiness Scale to screen for other sleep disorders, and a mandatory two-week sleep diary documenting bedtime, wake times, sleep latency, awakenings, total sleep time, and naps. 1

Key History Components

• Document the specific insomnia pattern (difficulty falling asleep, staying asleep, or early-morning awakening), pre-sleep conditions (bedroom environment, screen use, mental state), and daytime consequences (fatigue, irritability, cognitive difficulties, quality-of-life impairment). 1
• Screen for psychiatric comorbidities because 40–50% of chronic insomnia cases involve depression or anxiety; the relationship is bidirectional. 1, 2
• Review all medications and substances including SSRIs/SNRIs (commonly cause insomnia), stimulants, β-blockers, theophylline, caffeine timing/quantity, alcohol (causes fragmentation despite initial sedation), and nicotine. 1, 2
• Assess for medical conditions that worsen insomnia: cardiovascular disease, chronic pain, GERD, asthma/COPD, neurological disorders, hyperthyroidism. 1, 2

When to Order Testing

Polysomnography and multiple sleep latency testing are NOT indicated for routine insomnia evaluation; reserve them for suspected sleep apnea, periodic limb movement disorder, narcolepsy, or when treatment fails. 1

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First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

Initiate CBT-I immediately for all patients with chronic insomnia (≥3 nights/week for ≥3 months) before or alongside any medication; it provides superior long-term efficacy with sustained benefits after discontinuation, whereas medication effects cease when stopped. 1, 2, 3

Core CBT-I Components

• Stimulus control therapy: Use the bed only for sleep; leave the bed if unable to fall asleep within 20 minutes. 2
• Sleep restriction therapy: Limit time in bed to approximate actual sleep time plus 30 minutes. 2
• Relaxation techniques: Progressive muscle relaxation, guided imagery, breathing exercises. 2
• Cognitive restructuring: Modify negative beliefs about sleep and reduce anxiety about insomnia. 2
• Sleep hygiene education (insufficient alone but essential): Avoid caffeine ≥6 hours before bedtime, maintain consistent sleep-wake times (including weekends), limit daytime naps to ≤30 minutes before 2 PM, eliminate screens ≥1 hour before bed, optimize bedroom environment (dark, quiet, comfortable temperature). 1, 2

CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show comparable effectiveness. 2, 3

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Pharmacotherapy (Add Only After CBT-I Initiation)

If CBT-I alone is insufficient after 4–8 weeks, add pharmacotherapy as a supplement—not a replacement—while continuing behavioral interventions. 2, 3

First-Line Pharmacologic Options

For Sleep-Onset Insomnia

• Zolpidem 10 mg (5 mg for women and adults ≥65 years): Reduces sleep latency by ~25 minutes and increases total sleep time by ~29 minutes; take within 30 minutes of bedtime with ≥7 hours remaining before awakening. 2, 3, 4, 5
• Zaleplon 10 mg (5 mg for adults ≥65 years): Ultrashort half-life (~1 hour) provides rapid sleep initiation with minimal next-day sedation; can be used middle-of-night when ≥4 hours remain. 2, 3
• Ramelteon 8 mg: Melatonin-receptor agonist with zero abuse potential, no DEA scheduling, no withdrawal symptoms; preferred for patients with substance-use history. 2, 3

For Sleep-Maintenance Insomnia

• Low-dose doxepin 3–6 mg: Reduces wake after sleep onset by 22–23 minutes via selective H₁-histamine antagonism; minimal anticholinergic effects at hypnotic doses, no abuse potential. 2, 3
• Suvorexant 10 mg: Orexin-receptor antagonist reduces wake after sleep onset by 16–28 minutes; lower risk of cognitive/psychomotor impairment than benzodiazepine-type agents. 2, 3

For Combined Sleep-Onset and Maintenance Insomnia

• Eszopiclone 2–3 mg (1 mg for adults ≥65 years or hepatic impairment): Increases total sleep time by 28–57 minutes with moderate-to-large improvements in subjective sleep quality; take within 30 minutes of bedtime with ≥7 hours remaining. 2, 3

Dosing for Special Populations

For women and elderly (≥65 years): Reduce zolpidem to maximum 5 mg, eszopiclone to maximum 2 mg, zaleplon to maximum 5 mg due to increased sensitivity, fall risk, and prolonged drug clearance. 2, 3, 4

For hepatic impairment: Limit eszopiclone to 2 mg maximum, zaleplon to 5 mg maximum. 2, 3

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Medications to EXPLICITLY AVOID

Trazodone

The American Academy of Sleep Medicine recommends AGAINST trazodone for insomnia because it yields only ~10 minutes reduction in sleep latency and ~8 minutes reduction in wake after sleep onset, with NO improvement in subjective sleep quality; adverse events occur in ~75% of older adults (headache, somnolence), and harms outweigh minimal benefits. 2, 3, 6

Over-the-Counter Antihistamines

Do NOT use diphenhydramine or doxylamine due to lack of efficacy data, strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation, delirium in elderly), and tolerance development within 3–4 days. 2, 3

Traditional Benzodiazepines

Avoid lorazepam, temazepam, clonazepam, diazepam as first-line treatment due to long half-lives causing drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, dependence potential, and associations with dementia and fractures. 2, 3

Antipsychotics

Do NOT use quetiapine or olanzapine for primary insomnia due to weak evidence for benefit and significant risks: weight gain, metabolic syndrome, extrapyramidal symptoms, increased mortality in elderly with dementia. 2, 3

Herbal Supplements

Melatonin supplements produce only ~9 minutes reduction in sleep latency with insufficient evidence; valerian and L-tryptophan lack adequate efficacy data. 2, 3

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Treatment Duration and Safety Monitoring

FDA labeling indicates hypnotics are intended for short-term use (≤4 weeks) for acute insomnia; evidence beyond 4 weeks is limited. 2, 3, 4

Reassessment Schedule

Evaluate patients after 1–2 weeks to assess changes in sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects (morning sedation, cognitive impairment, complex sleep behaviors). 2, 3

Critical Safety Warnings

All benzodiazepine-receptor agonists (zolpidem, eszopiclone, zaleplon) carry FDA warnings for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating); discontinue immediately if these occur and counsel patients to avoid alcohol while on these agents. 2, 3, 4

Monitor for increased fall and fracture risk, daytime impairment, driving impairment, and cognitive decline, especially in adults ≥65 years. 2, 3

If insomnia persists beyond 7–10 days despite appropriate treatment, evaluate for comorbid sleep disorders (sleep apnea, restless-legs syndrome, periodic limb movement disorder, circadian-rhythm disorders). 2, 3

Tapering Strategy

Use the lowest effective dose for the shortest duration; taper gradually when discontinuing to avoid rebound insomnia, maintaining CBT-I support throughout. 2, 3

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Treatment Algorithm

1. Initiate CBT-I immediately for all patients with chronic insomnia (stimulus control, sleep restriction, relaxation, cognitive restructuring, sleep hygiene). 2, 3

2. Add first-line pharmacotherapy if CBT-I alone is insufficient after 4–8 weeks:

   • Sleep-onset difficulty → zaleplon, ramelteon, or zolpidem (age-adjusted dosing)
   • Sleep-maintenance difficulty → low-dose doxepin or suvorexant
   • Combined difficulty → eszopiclone 2, 3

3. If the chosen first-line agent fails after 1–2 weeks, switch to an alternative agent within the same class (e.g., zaleplon → zolpidem for onset; doxepin → suvorexant for maintenance). 2, 3

4. If multiple first-line agents are ineffective, consider sedating antidepressants (low-dose doxepin, mirtazapine) especially when comorbid depression/anxiety is present. 2, 3

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Common Pitfalls to Avoid

• Initiating pharmacotherapy without first implementing CBT-I leads to less durable benefit and contravenes guideline recommendations. 2, 3
• Using adult dosing in older adults; age-adjusted dosing (zolpidem ≤5 mg, eszopiclone ≤2 mg for ≥65 years) is essential to reduce fall risk. 2, 3
• Combining multiple sedative agents markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 2, 3
• Failing to reassess pharmacotherapy regularly (every 2–4 weeks) to evaluate efficacy, side effects, and plan tapering. 2, 3
• Prescribing trazodone, OTC antihistamines, antipsychotics, or traditional benzodiazepines for primary insomnia despite lack of efficacy and significant safety concerns. 2, 3
• Continuing hypnotic therapy long-term without periodic reassessment; routine use beyond 4 weeks is not supported by evidence. 2, 3, 4