Treatment
- First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I).
- Stimulus control: Bed only for sleep/sex; leave bed after 20 min if unable to sleep; consistent wake time.
- Sleep restriction: Restrict time in bed to match actual sleep time.
- Sleep hygiene: Avoid caffeine/screens/alcohol prior to bedtime; keep room dark, cool, and quiet.
- Second-Line:
- Principle: Use lowest effective dose for shortest possible duration (≤2–4 weeks); avoid routine chronic use.
- Non-Benzodiazepine GABA-A Receptor Agonists (“Z-drugs”): Zolpidem, eszopiclone (risk of complex sleep behaviors, falls).
- Melatonin receptor agonist: Ramelteon (preferred in elderly or history of substance use disorder; no abuse potential).
- Dual orexin receptor antagonists (DORAs): Suvorexant, lemborexant.
- Sedating antidepressants: Low-dose doxepin, trazodone, or mirtazapine (best if comorbid MDD/anxiety).
- Avoid: Benzodiazepines and OTC antihistamines in elderly (Beers criteria: delirium, falls, fractures).
- Refractory: Overnight PSG (evaluate occult OSA/PLMD); referral to a sleep specialist.