Best Treatment for Interrupted Sleep (Sleep-Maintenance Insomnia) in Adults
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated as first-line treatment for all adults with sleep-maintenance insomnia before any medication is prescribed, and if pharmacotherapy is needed, low-dose doxepin 3–6 mg at bedtime is the preferred first-line agent. 1, 2, 3
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (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 because it provides superior long-term efficacy compared to medications, with sustained benefits for up to 2 years after treatment ends. 1, 2, 3 Unlike pharmacotherapy, whose effects cease when stopped, CBT-I maintains sleep improvements after discontinuation. 2, 3
Core Components of CBT-I (All Must Be Implemented)
Sleep restriction therapy – Limit time in bed to match actual total sleep time (minimum 5 hours) to increase homeostatic sleep drive; adjust weekly based on sleep efficiency (total sleep time ÷ time in bed × 100%). 2, 3
Stimulus control therapy – Use the bed only for sleep and sex; if unable to fall asleep within ~20 minutes, leave the bed and return only when sleepy; maintain consistent sleep-wake times every day. 2, 3
Cognitive restructuring – Address maladaptive beliefs about sleep (e.g., "I can't function without 8 hours" or "I must sleep perfectly") through psychoeducation and behavioral experiments. 2, 3
Relaxation techniques – Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to lower physiological arousal before sleep. 2, 3
Sleep hygiene education – Maintain consistent sleep-wake schedule, avoid caffeine ≥6 hours before bedtime, eliminate screens ≥1 hour before sleep, keep bedroom cool/dark/quiet. 2, 3 Sleep hygiene alone is insufficient as monotherapy and must be combined with the other CBT-I components. 2, 3
CBT-I can be delivered via individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show comparable effectiveness. 2, 3
First-Line Pharmacotherapy (Only After CBT-I Initiation)
Low-Dose Doxepin (3–6 mg)
Low-dose doxepin is the preferred first-line medication for sleep-maintenance insomnia because it reduces wake after sleep onset by 22–23 minutes, has minimal anticholinergic effects at hypnotic doses, and carries no abuse potential. 2, 3
Dosing algorithm:
- Start doxepin 3 mg at bedtime. 2, 3
- If insufficient improvement after 1–2 weeks, increase to 6 mg. 2, 3
- Reassess sleep parameters (wake after sleep onset, total sleep time, nocturnal awakenings, daytime functioning) and adverse effects after 1–2 weeks. 2, 3
Doxepin maintains efficacy for up to 12 weeks without tolerance or dependence, and adverse-event rates are comparable to placebo. 2, 3
Second-Line Pharmacotherapy (If Doxepin Fails or Is Contraindicated)
Suvorexant (10 mg)
Suvorexant is an orexin-receptor antagonist that reduces wake after sleep onset by 16–28 minutes and carries a lower risk of cognitive and psychomotor impairment than benzodiazepine-type agents. 2, 3 It has no abuse potential and works through a completely different mechanism than benzodiazepine receptor agonists. 2
Eszopiclone (2–3 mg; 1 mg if age ≥65 years)
Eszopiclone is effective for both sleep-onset and sleep-maintenance insomnia, increasing total sleep time by 28–57 minutes and producing moderate-to-large improvements in subjective sleep quality. 2, 3, 4 However, it carries higher risks of complex sleep behaviors (sleep-driving, sleep-walking), falls, and cognitive impairment compared to doxepin. 2, 3
Dosing for elderly patients: Start at 1 mg and do not exceed 2 mg due to increased sensitivity and fall risk. 2, 3
Zolpidem (10 mg; 5 mg if age ≥65 years)
Zolpidem reduces sleep-onset latency by ~25 minutes and increases total sleep time by ~29 minutes, but it is more appropriate for combined sleep-onset and maintenance problems rather than pure maintenance insomnia. 2, 5 Age-adjusted dosing is mandatory in older adults to reduce fall risk. 2, 3
Medications Explicitly NOT Recommended
Trazodone
The American Academy of Sleep Medicine explicitly recommends against trazodone because it yields only a ~10-minute 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. 2, 3
Benzodiazepines (Lorazepam, Temazepam, Clonazepam, Diazepam)
Traditional benzodiazepines are contraindicated due to long half-lives leading to drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, and associations with dementia and fractures. 2, 3
Over-the-Counter Antihistamines (Diphenhydramine, Doxylamine)
Antihistamines are not recommended due to lack of efficacy data, strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation, delirium), and rapid tolerance development within 3–4 days. 2, 3
Antipsychotics (Quetiapine, Olanzapine)
Antipsychotics must not be used for insomnia because evidence of benefit is weak and they carry significant risks including weight gain, metabolic syndrome, extrapyramidal symptoms, and increased mortality in elderly patients. 2, 3
Melatonin Supplements
Melatonin is not recommended for chronic insomnia because it produces only a ~9-minute reduction in sleep latency with insufficient supporting evidence. 2, 3
Safety Considerations and Monitoring
All hypnotics carry risks of driving impairment, complex sleep behaviors, falls, fractures, cognitive decline, and possible association with dementia. 2, 3
FDA labeling limits hypnotic use to ≤4 weeks for acute insomnia; evidence for longer durations is limited. 1, 2, 3
Reassess after 1–2 weeks to evaluate wake after sleep onset, total sleep time, nocturnal awakenings, and daytime functioning; monitor for adverse effects such as morning sedation or cognitive impairment. 2, 3
If insomnia persists beyond 7–10 days despite treatment, evaluate for underlying sleep disorders such as sleep apnea, restless-legs syndrome, or circadian-rhythm disorders. 2
Use the lowest effective dose for the shortest necessary duration, and taper gradually when discontinuing to avoid rebound insomnia, using CBT-I to support cessation. 2, 3
Common Pitfalls to Avoid
Do not prescribe hypnotic medication before attempting CBT-I—this violates strong guideline recommendations and results in less durable benefit. 2, 3
Do not rely on sleep-hygiene education alone—it is ineffective as a solitary intervention and must be combined with stimulus control and sleep restriction. 2, 3
Do not use adult dosing in older adults—age-adjusted dosing (e.g., eszopiclone ≤2 mg, zolpidem ≤5 mg) is essential to reduce fall risk. 2, 3
Do not combine multiple sedative agents (e.g., adding a benzodiazepine to doxepin)—this markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 2, 3
Do not continue pharmacotherapy long-term without periodic reassessment (every 2–4 weeks) to evaluate efficacy, side effects, and plan tapering. 2, 3
Do not prescribe trazodone, OTC antihistamines, benzodiazepines, or antipsychotics—these agents lack efficacy for primary insomnia and carry significant safety concerns. 2, 3