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?