From the Guidelines
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for chronic insomnia disorder, as it has been shown to be highly effective in improving sleep quality and reducing symptoms of insomnia. This recommendation is based on the American College of Physicians' clinical practice guideline, which states that CBT-I is a strong recommendation with moderate-quality evidence 1. The guideline emphasizes the importance of using a shared decision-making approach when considering pharmacological therapy, taking into account the benefits, harms, and costs of short-term medication use 1.
Key Components of CBT-I
- Establishing a consistent sleep schedule
- Creating a relaxing bedtime routine
- Avoiding screens 1-2 hours before bed
- Keeping the bedroom dark and cool
- Limiting caffeine and alcohol
Pharmacological Therapy
If CBT-I is unsuccessful, pharmacological therapy may be considered, with a focus on short-term use to minimize the risk of dependence. The American Academy of Sleep Medicine's clinical practice guideline provides recommendations for the use of prescription and non-prescription medications for insomnia, including melatonin, zolpidem, eszopiclone, and trazodone 1. However, it is essential to weigh the benefits and harms of medication use and to consider individual patient factors, such as medical history, medication use, and patient preferences.
Addressing Underlying Causes
Insomnia often stems from underlying causes, such as stress, anxiety, depression, or pain conditions. Addressing these underlying causes is crucial for long-term improvement in sleep quality. A comprehensive evaluation, including a detailed history of sleep complaints, medical and psychiatric history, and medication/substance use, is necessary to identify and address these underlying causes 1.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation.
Treatment Options for Insomnia:
- Ramelteon (PO) is indicated for the treatment of insomnia characterized by difficulty with sleep onset 2.
- Zolpidem (PO) is indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation 3.
From the Research
Definition and Prevalence of Insomnia
- Insomnia is a complaint of patients seen in many medical settings, particularly prevalent in patients who present to mental health practitioners 4.
- The prevalence of insomnia is higher in females and increases with higher age 5.
Non-Pharmacologic Treatments for Insomnia
- Non-pharmacologic interventions for insomnia have been found to have evidence to support their use in achieving sustained improvements in sleep parameters over time 4.
- Methods such as cognitive-behavioral therapy, stimulus-control therapy, relaxation, paradoxical intention, and sleep restriction are efficacious treatments for insomnia 4.
- Cognitive-behavioral therapy for insomnia (CBT-I) is a highly effective treatment for insomnia, producing results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment 6.
- CBT-I has been shown to have long-term effects, with clinically significant effects that last up to a year after therapy 7.
Recommendations for Treatment
- A non-pharmacologic approach should be preferred in most cases of insomnia, considering the possible adverse effects of commonly used drugs to promote sleep 5.
- Primary care physicians may use pharmacologic and non-pharmacologic approaches, while the latter should be generally considered first-line treatment 5.
- Cognitive-behavioral therapy for insomnia, exercise, and relaxation techniques are recommended as first-line treatments for insomnia 5, 8.
- Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine, may also be considered 5, 8.