From the Guidelines
Managing insomnia effectively requires a combination of behavioral changes and possibly medication, with cognitive behavioral therapy for insomnia (CBT-I) being a highly effective treatment option that should be considered before long-term medication use. To manage insomnia, start by establishing a consistent sleep schedule, going to bed and waking up at the same time every day, even on weekends 1. Create a relaxing bedtime routine that might include reading, taking a warm bath, or practicing relaxation techniques like deep breathing or meditation. Make your bedroom comfortable, dark, quiet, and cool. Limit screen time before bed as blue light can interfere with melatonin production. Avoid caffeine, alcohol, and large meals close to bedtime. Regular exercise during the day can help, but avoid vigorous activity within a few hours of sleep.
Some key behavioral therapies for insomnia include:
- Stimulus control, which involves removing yourself from bed if you're unable to fall asleep within 20 minutes and engaging in relaxing activities until drowsy 1
- Relaxation training, such as progressive muscle relaxation, to lower somatic and cognitive arousal states that interfere with sleep 1
- Sleep restriction, which initially limits the time in bed to the total sleep time, as derived from baseline sleep logs, to achieve a high sleep efficiency 1
If these lifestyle changes don't help, short-term use of medications may be considered. Over-the-counter options include melatonin (typically 1-5mg taken 30-60 minutes before bed) or diphenhydramine (25-50mg) 1. Prescription medications like zolpidem (5-10mg), eszopiclone (1-3mg), or trazodone (25-100mg) may be prescribed for short periods 1. However, the choice of medication should be based on the patient's response to the first medication, with consideration of factors such as treatment history, coexisting conditions, and specific side effect profiles 1.
It's essential to note that persistent insomnia may indicate an underlying health condition, so consulting a healthcare provider is crucial if sleep problems continue despite these interventions 1. Additionally, CBT-I has been shown to be highly effective in managing insomnia, and its use should be considered before resorting to long-term medication use 1.
From the FDA Drug Label
Sleep disturbance may be the presenting manifestation of an underlying physical and/or psychiatric disorder Consequently, a decision to initiate symptomatic treatment of insomnia should only be made after the patient has been carefully evaluated. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated Because some of the important adverse effects appear to be dose-related, it is important to use the lowest possible effective dose, especially in the elderly
To manage insomnia, careful evaluation of the patient is necessary to rule out underlying physical and/or psychiatric disorders.
- Initiate symptomatic treatment only after evaluation.
- Monitor for excess depressant effects and impairment.
- Use the lowest possible effective dose, especially in the elderly.
- Re-evaluate if insomnia does not remit after 7 to 10 days of treatment. 2 3
From the Research
Managing Insomnia
To manage insomnia, several approaches can be taken, including:
- Cognitive Behavioral Therapy for Insomnia (CBT-i): a non-pharmacological treatment that has been shown to be effective in improving sleep quality 4, 5, 6
- Sleep hygiene practices: establishing a consistent sleep schedule, creating a relaxing sleep environment, and avoiding stimulating activities before bedtime 4, 7
- Relaxation techniques: such as deep breathing, progressive muscle relaxation, and mindfulness meditation 4, 8
- Stimulus control: associating the bed with sleep and removing distractions from the sleep environment 4, 5
Cognitive Behavioral Therapy for Insomnia (CBT-i)
CBT-i is a multi-component treatment that targets the perpetuating factors that contribute to the development of chronic insomnia 6. The core components of CBT-i include:
- Sleep Restriction Therapy: limiting the amount of time spent in bed to improve sleep efficiency 5, 6
- Stimulus Control Therapy: associating the bed with sleep and removing distractions from the sleep environment 4, 5
- Sleep Hygiene: establishing a consistent sleep schedule, creating a relaxing sleep environment, and avoiding stimulating activities before bedtime 4, 7
- Cognitive Therapy: identifying and challenging negative thoughts and beliefs that contribute to insomnia 4, 8
Pharmacological Treatments
While pharmacological treatments are available for insomnia, they are generally recommended as a last resort due to the risk of side effects and dependence 7, 8. Non-benzodiazepine receptor agonists (non-BzRAs) and benzodiazepines are commonly used, but their use is limited by their potential for adverse effects, such as dementia, serious injury, and fractures 7. Ramelteon and suvorexant are alternative options that have been shown to be effective in improving sleep quality with minimal adverse effects 7.