From the Guidelines
Medical management of insomnia should begin with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, which addresses sleep habits and anxiety about sleep. This approach is supported by the American College of Physicians guideline, which recommends CBT-I as the initial treatment for chronic insomnia disorder, with a strong recommendation based on moderate-quality evidence 1.
Key Components of CBT-I
- Cognitive therapy around sleep
- Behavioral interventions, such as sleep restriction and stimulus control
- Education on sleep hygiene
Medication Management
For short-term medication management, consider benzodiazepine receptor agonists like zolpidem (5-10mg), eszopiclone (1-3mg), or zaleplon (5-20mg) taken 30 minutes before bedtime for 2-4 weeks maximum to avoid dependence. Alternatively, sedating antidepressants such as trazodone (25-100mg) or doxepin (3-6mg) may be used, particularly for patients with comorbid depression. Melatonin (1-5mg) or ramelteon (8mg) can help regulate sleep-wake cycles with fewer side effects. Over-the-counter antihistamines like diphenhydramine should be used cautiously due to anticholinergic effects, especially in older adults.
Sleep Hygiene Practices
All medications should be combined with sleep hygiene practices, including:
- Maintaining regular sleep schedules
- Avoiding caffeine and alcohol before bedtime
- Creating a comfortable sleep environment
- Limiting screen time before sleep
Monitoring and Tapering
Medication should be tapered rather than abruptly discontinued, and patients should be monitored for side effects including daytime drowsiness, cognitive impairment, and risk of falls. The goal is to use medications judiciously while addressing underlying causes of insomnia rather than indefinite pharmacological treatment, as supported by the American Academy of Sleep Medicine clinical practice guideline 1.
From the FDA Drug Label
Eszopiclone tablets are used in adults for the treatment of a sleep problem called insomnia. Symptoms of insomnia include: trouble falling asleep, waking up often during the night Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo.
The medical management of insomnia may involve the use of sedative-hypnotic medicines such as eszopiclone or ramelteon.
- Eszopiclone is used in adults for the treatment of insomnia, and is taken right before bed, with the ability to get a full night's sleep.
- Ramelteon has been shown to reduce latency to persistent sleep in clinical trials, and is taken as a single, nightly dose. It is essential to follow the prescribed dosage and instructions for use, as well as to be aware of potential side effects and interactions with other medicines 2 3.
From the Research
Medical Management of Insomnia
The medical management of insomnia involves a range of treatments, including cognitive behavioral therapy for insomnia (CBT-I) and pharmacotherapy.
- CBT-I is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep and is delivered over the course of six to eight sessions 4.
- The primary focus of CBT-I is to address the perpetuating factors that contribute to the development of chronic insomnia, which is the most prevalent sleep disorder, occurring in approximately 6-10% of the population 4.
- CBT-I is now commonly recommended as first-line treatment for chronic insomnia due to its sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches 5.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes 5.
- Approaches to CBT-I incorporate at least three of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation 5.
- CBT-I has been shown to improve sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency, with changes seeming to be sustained at later time points 5.
- CBT-I is also an effective treatment for patients with insomnia and a comorbid mental disorder, especially depression, PTSD, and alcohol dependency 6.
Pharmacotherapy for Insomnia
Pharmacotherapy, such as newer generation nonbenzodiazepines (e.g., zolpidem, zaleplon), is used as first-line treatment for chronic insomnia 7.
- However, CBT-I is considered a safer and more effective approach, with the key challenge being the lack of clinicians to implement it 7.
- Newer drugs active on targets other than the gamma-aminobutyric acid receptor are now available, but clear treatment guidelines are needed 7.
Long-term Effects of CBT-I
CBT-I produces clinically significant effects that last up to a year after therapy, with moderate to large effects on insomnia severity, sleep onset latency, and sleep efficiency 8.
- Although effects decline over time, CBT-I has been shown to be effective at 3-, 6-, and 12-month follow-ups compared to non-active controls 8.