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3yr
Addressing the nighttime and daytime effects of insomnia

A 56-year-old woman presents with difficulty sleeping for the past 9 months, along with complaints of daytime sleepiness and fatigue. She claims to get ~4.5 hours of sleep each night despite spending adequate time in bed and implementing recommended sleep hygiene. She reports having difficulty falling asleep and experiences nighttime/early morning awakenings with difficulty falling back to sleep.



The woman appears agitated and distressed by the sleep disturbance and says it is negatively impacting her work, home, and social life. Other than sleep disturbance, the patient is in good health, with no history of cardiometabolic disease, psychiatric illness, substance misuse, or sleep apnea. Her specialist previously prescribed zolpidem but it became less effective after a few weeks. The patient found trazadone intolerable due to excessive daytime drowsiness and impaired daytime functioning. She doesn’t want to take benzodiazepines for insomnia due to concerns about dependence.



Considering the effects of her insomnia both at nighttime and during the day, as well as previous attempts to treat the condition with other drugs, how would you treat this patient’s condition? What medication would you try next and for how long?


  • 3yr
    Consider depression, if negative psychiatric w/u , would start melatonin, consider belsomra, dayvigo
  • 3yr
    thorough evaluation and review of systems for current physical and mental health symptoms. I wonder about anxiety and any recent changes/grief/loss. Also, any other changes in memory, functioning, motivation. A sleep study would also be very valuable. I would think about CBT-I and also exercise and early daytime light exposure. Medications - probably next would move to Belsomra or Dayvigo as examples.
  • 3yr
    Complete history, physical and psychiatric interview is needed
  • 3yr
    Need details physical, psychiatric/ social history , medical and medications intake /daily routine/ caffeine/ stimulant/SUD history. Need sleep study to rule dyssomnia and parasomnia , also need r/o psychiatric problems including depression, or other physical problems which can affects sleep. Before considering any sleep meds
  • 3yr
    Agree with posts would include a good psychiatric interview medication review etc if a sleep study showed reason for excessive daytime sleepiness consider dopamine agonits on contrary trouble with sleep and history of SUD. Orexin antagonist are a great option
  • 3yr
    It is important to rule out a sleep disorder.
  • 3yr
    I would first have to rule out any type of sleep related breathing disorder. A home sleep test would be sufficient. Her frequent nocturnal awakenings are certainly suspicious for something like this or some thing like a periodic limb movement disorder. In regards to treatment, certainly cognitive behavioral therapy seems warranted. It does sound like the patient may be experiencing some additional behavioral trouble and potentially mental health instability that is likely contributing to some of her symptoms. Cognitive behavioral therapy is most appropriate in the situation. Utilizing a medication such as gabapentin to increase fatigue levels and increased slow wave sleep can also be helpful. Bed restriction therapy is also some thing considering the patient reports that she only gets 4.5 hours of sleep. I typically ask Patience to wear some type of sleep monitoring device to actually confirm their information is correct. Usually patients have a very poor perception of how much they actually sleep.
  • 3yr
    I would also like to obtain an inpatient sleep study, and considering orexin receptor antagonists after the patient failed several lines of therapy. Currently, three orexin antagonists-suvorexant (Belsomra), lemborexant (Dayvigo) and daridorexant (Quviviq)- are FDA approved for treatment of insomnia. Among them, Dayvigo seems to be most consistently effective treatment for fall asleep and stay asleep.
  • 3yr
    I think she is the perfect patient for Quviviq from what I read so far. Unfortunately in real clinical practice, I’m afraid that there may be only a small subset of patients might qualify and benefit from this new medication. I hope I am wrong.
  • 3yr
    while emphasizing concurrent proper sleep hygiene, I would also consider trials of doxepin, hydroxyzine, or if patient able to withstand possible weight gain mirtazapine, initially to be taken nightly and overtime may reduce to prn.
  • 3yr
    Ruling out other medical and mental health causes is imperative, I would also check hormone levels. Belaomra, Rozerum, or Dayvigo would be good trials.
  • 3yr
    Needpt chdeck sleep study, to check for sleep abnormalities.
  • 3yr
    The newer orexin agents would be a great option, or a trial on Rozerem is warranted given the fact that her insomnia is impacting her daily life. That said, I would still do a complete medical work up and wonder if Hypothyroidism or iron deficiency anemia as possible medical causes
  • 3yr
    I would first exercise some healthy skepticism about all the things that have allegedly been ruled out bc a large proportion of community diagnoses of primary (idiopathic) insomnia turn out to be primary psychiatric disorders when SCID is administered. Similarly numerous good suggestions have been made by my colleagues above re chronic pain, RLS, narcolepsy, and so forth. If however it all checks out and she truly does have primary insomnia I think the orexin antagonists are the way to go for long term management. Each has a different half life but Quiviviq has the shortest so I would start there.
  • 3yr
    In keeping with the above suggestions, a sleep study seems appropriate to rule out sleep apnea and parasomnias. I would make certain that there is no other psychiatric condition (depression, PTSD) pain or bladder condition as well exacerbating the insomnia. I would first offer a trial of CBT-I which is the first line recommended treatment for insomnia. Should the patient not find this helpful, then there are several options, some on-label, most off label. An antihistamine such as hydroxyzine is one option, but care is needed for this given some cognitive issues next day that could occur. Off label use of Mirtazipine could be valuable despite weight gain risk, Silenor (doxepin) would be another on label option.
  • 3yr
    I would order an inpatient sleep
    Study to rule out sleep apnea and periodic limb movement disorder. Will also prove home much sleep she is getting or not getting. Is she has true insomnia … would try lunesta.
  • 3yr
    Sleep study first, preferably inpatient instead of home study. Discuss sleep hygiene again - I tell my patients that "the bedroom is for sleep and sex" - no other activities should occur there including phone use, TV, reading. Depending on other conditions could try amitriptyline since she does not want benzo. No strenuous exercise or caffeine intake 2 hours prior to bedtime. Keep regular schedule.
  • 3yr
    Following clearance from Neurology, I would recommend trial of low dose Doxepin or Seroquel for few weeks. Also, obtain Family History & continue Sleep Hygiene.
  • 3yr
    Sleep study would be helpful. Further inquires as to caffeine intake especially in evenings. Has she tried melatonin or other more homeopathic measures
  • 3yr
    Medications like Monoxodil or some of the ADHD medications such as Vyvanse are helpful with daytime sleepiness. This patient needs to be tested for narcolepsy.
  • 3yr
    would get polysomnography and probably MSLT to screen for sleep disorders
    Belsomra would be ok while I am awaiting test results
  • 3yr
    Obtain more info, review previous also study, consider a sleep study. What's the dose of Zolpidem? Therapy.
  • 3yr
    needs a sleep study. if osa found then cpap. if normal the patient may require a mild sedative to assist with sleep
  • 3yr
    If OSA has been ruled out, then remeron can be considered.
    Trazodone left resudual day time sedation, so would try either lower doses or remeron.
    Hydroxyzine could be tried as may have anxiety contributing to insomnia.
    Melatonin could be tried as well.
    Sleep hygiene, CBT for insomnia also considerations
  • 3yr
    trial of antihistamine, needs to review social/diet profile, psych causes, full labs
  • 3yr
    Would order a sleep study, recommend CBT (where they would more deeply evaluate sleep hygiene), and if a med was needed try an orexin antagonist like Belsomra
  • 3yr
    Check TSH, ferritin, sleep study and try Belsomra.
  • 4yr
    I would start with a sleep study, then try CBT along with Ambien or trazodone
  • 4yr
    Consider belsomra. In addition melatinin 3-6 mg every night
  • 4yr
    consider sleep study, reinforce sleep hygiene, check about menopausal symptoms, check tsh , cbc
  • 4yr
    sleep test is the key.
  • 4yr
    Reiterate sleep hygiene. Avoid excess fluids and caffeine in the evening. Consider OTC melatonin . If not acceptable Belsomra is a good option. Ambien CR is an option if not tried. Can b used few days a week with drug holidays to prevent dependence. Sleep study is an option.
  • 4yr
    Sleep study, labs for metabolic disturbance like TSH and CBC. Could have iron deficiency causing RLS.
  • 4yr
    I concur — if medication is considered to treat her insomnia, it should be a sleep maintainance product, not a sleep inducer. Belsomra or a newer drug in the same class should be tried. She should be carefully screened for a mixed anxiety/depression syndrome, possibly independent of her sleep problem
  • 4yr
    sleeo test, review caffein and otc drug use,, rx Belsomora or Dayvigo

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