What are the management options for insomnia?

From the Guidelines

Insomnia management involves a multi-faceted approach, including behavioral therapies and pharmacological interventions.

Behavioral Therapies

For patients with chronic insomnia, cognitive-behavioral therapy for insomnia (CBT-I) is the preferred treatment 1, with adjunctive use of other therapies such as:

• Stimulus control: designed to extinguish the negative association between the bed and undesirable outcomes such as wakefulness, frustration, and worry 1
• Relaxation training: designed to lower somatic and cognitive arousal states which interfere with sleep 1
• Sleep restriction: initially limits the time in bed to the total sleep time, as derived from baseline sleep logs 1

Pharmacological Interventions

For patients who do not respond to behavioral therapies, pharmacological interventions may be considered, including:

• Non-benzodiazepine hypnotics such as zolpidem (5-10mg) or eszopiclone (1-3mg) for short-term use 1
• Sedating antidepressants like trazodone (25-50mg) or melatonin receptor agonists like ramelteon (8mg) for 3-6 months 1
• Benzodiazepines may be considered for short-term use, but with caution due to the risk of dependence and adverse effects 1 It is essential to note that the choice of pharmacological intervention should be based on the patient's response to the first treatment, and factors such as treatment history, coexisting conditions, and specific side effect profile should guide the selection of a specific agent 1.

From the FDA Drug Label

Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. The management options for insomnia include:

• Ramelteon (PO): indicated for the treatment of insomnia characterized by difficulty with sleep onset 2
• Eszopiclone (PO): used in adults for the treatment of insomnia, symptoms of which include trouble falling asleep and waking up often during the night 3 Key considerations:
• Take the medication exactly as prescribed
• Do not take more than the prescribed dose
• Do not take the medication unless you are able to stay in bed for a full night (7 to 8 hours) before you must be active again
• Be aware of the potential for serious side effects, such as sleepiness during the day, not thinking clearly, and abnormal thoughts and behavior

From the Research

Management Options for Insomnia

The management of insomnia can involve various approaches, including:

• Cognitive and behavioral therapy for insomnia (CBTi) to increase acceptance and use of continuous positive airway pressure (CPAP) therapy in patients with co-morbid insomnia and sleep apnea (COMISA) 4
• Insomnia-specific therapy for improved management of depressed patients with comorbid insomnia 5
• Multi-faceted treatment approaches provided by multi-disciplinary teams of psychologists and physicians for COMISA 4
• Treatment of underlying sleep disorders, such as sleep apnea, to alleviate insomnia symptoms 6
• Pharmacological interventions, such as antidepressants, to manage insomnia and depression 7
• Nonpharmacological interventions, such as environmental modifications and sleep-promoting techniques, to improve sleep quality in various settings, including intensive care units (ICUs) 8

Treatment Considerations

When managing insomnia, it is essential to consider the following:

• The complex diagnostic and treatment decisions for clinicians, particularly in cases of COMISA 4, 6
• The bi-directional relationships between insomnia and other sleep disorders, such as sleep apnea, and their impact on treatment outcomes 6
• The importance of measuring and managing insomnia symptoms in the presence of other sleep disorders or mental health conditions, such as depression 5, 7
• The need for personalized diagnostic and treatment approaches, taking into account the individual patient's needs and circumstances 4, 6