What are the treatment options for insomnia?

From the Guidelines

Insomnia can be effectively treated through a combination of behavioral changes and, when necessary, medication, with Cognitive Behavioral Therapy for Insomnia (CBT-I) being a highly effective treatment option. The most recent and highest quality study, published in 2021 1, supports the use of CBT-I as a first-line treatment for insomnia disorder. This study found that CBT-I improves most outcomes compared to inactive controls, and multicomponent behavioral therapy and stimulus control may also improve some sleep outcomes.

Behavioral Changes

To manage insomnia, it is essential to start with good sleep hygiene practices, including:

• Maintaining a consistent sleep schedule
• Creating a relaxing bedtime routine
• Avoiding screens 1-2 hours before bed
• Keeping the bedroom dark and cool (65-68°F)
• Limiting caffeine and alcohol

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is a highly effective treatment for insomnia and includes techniques such as:

• Stimulus control: associating the bed with sleep and establishing a consistent sleep schedule
• Sleep restriction: limiting time in bed to the amount of time spent sleeping
• Relaxation training: using techniques such as progressive muscle relaxation and deep breathing to reduce stress and anxiety
• Cognitive therapy: identifying and challenging negative thoughts and beliefs about sleep

Medication Options

For short-term medication options, consider:

• Over-the-counter melatonin (0.5-5mg taken 1-2 hours before bedtime)
• Prescription medications like zolpidem (Ambien, 5-10mg), eszopiclone (Lunesta, 1-3mg), or trazodone (50-100mg) These medications should generally be used for less than 2-4 weeks to avoid dependence. For chronic insomnia, low-dose doxepin (3-6mg) or ramelteon (8mg) may be safer for longer use.

Important Considerations

Always start with the lowest effective dose and consult a healthcare provider before beginning any medication regimen, especially if you have other health conditions or take other medications. It is also essential to consider the potential risks and benefits of medication and to weigh these against the benefits of behavioral therapies like CBT-I.

From the FDA Drug Label

Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) Insomnia Treatment Options:

• Zolpidem: indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation 2
• Ramelteon: indicated for the treatment of insomnia characterized by difficulty with sleep onset 3 Key Considerations:
• Zolpidem has been shown to decrease sleep latency for up to 35 days in controlled clinical studies 4
• Ramelteon clinical trials were up to six months in duration 3

From the Research

Insomnia Treatment Options

• Non-pharmacologic approaches are generally considered first-line treatment for insomnia, as they have been shown to be effective in managing the condition without the potential adverse effects of commonly used drugs 5, 6, 7.
• Cognitive Behavioral Therapy for Insomnia (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 6.
• CBT-I has been shown to be effective in managing insomnia in a wide range of populations, including those with primary insomnia and those with insomnia comorbid with other psychiatric and medical conditions 6, 7.
• Other non-pharmacologic treatment options include exercise, relaxation techniques, light therapy, aromatherapy, music therapy, and herbal medicine 5, 7, 8.
• Pharmacologic interventions, such as benzodiazepines and hypnotic benzodiazepine receptor agonists, melatonin and melatonin receptor agonists, sedating antidepressants, antipsychotics and antihistamines, and orexin receptor antagonists, can be considered if non-pharmacologic approaches are not available or effective 9, 8.

Considerations for Treatment

• Patient-specific criteria, such as age, medical history, and other drug use, should be considered when recommending treatment for insomnia 8.
• The underlying cause of the sleep disturbance should also be taken into account when selecting a treatment option 8.
• Pharmacotherapy should be used with appropriate caution, at minimum effective doses, and for minimum duration of time 8.