From the Guidelines
Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment for adults with chronic insomnia disorder. This approach includes a combination of treatments such as cognitive therapy around sleep, behavioral interventions (like sleep restriction and stimulus control), and education (such as sleep hygiene) 1. The most recent and highest quality study supports the use of CBT-I as the primary treatment for insomnia, citing its effectiveness in improving global outcomes, sleep onset latency, and wake after sleep onset, as well as its durability beyond the end of treatment 2.
Some key components of CBT-I include:
- Establishing a consistent sleep schedule
- Creating a comfortable sleep environment
- Avoiding caffeine and alcohol before bedtime
- Limiting screen time before bed
- Implementing relaxation techniques and sleep restriction therapy
For patients who do not respond to CBT-I alone, a shared decision-making approach can be used to consider adding pharmacological therapy, weighing the benefits, harms, and costs of short-term medication use 1. Medication options may include over-the-counter supplements like melatonin or prescription medications such as zolpidem, eszopiclone, or trazodone, which should generally be used for a limited duration to prevent dependence. It's essential to address underlying conditions that may contribute to sleep difficulties, such as sleep apnea, depression, anxiety, or pain, and to discuss potential side effects and interactions with a healthcare provider.
The benefits of CBT-I are well-documented, with moderate-quality evidence showing improved sleep outcomes and reduced symptoms of insomnia in both the general population and older adults 1. Additionally, CBT-I has been shown to be effective in various delivery methods, including in-person, group, telephone-, or Web-based modules, making it a versatile treatment option 1, 2.
In selecting appropriate treatments, clinicians should consider comorbid medical and psychiatric conditions that may change the balance of benefits vs harms, and help set realistic expectations for patients undergoing psychological and behavioral insomnia therapies, which typically produce gradual improvements in insomnia symptoms 2.
From the FDA Drug Label
BELSOMRA® (suvorexant) is indicated for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance. 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
- Treatment Options: Zolpidem, suvorexant, and ramelteon are indicated for the treatment of insomnia.
- Key Considerations: + Zolpidem is effective for both transient and chronic insomnia. + Suvorexant is indicated for insomnia characterized by difficulties with sleep onset and/or sleep maintenance. + Ramelteon is indicated for insomnia characterized by difficulty with sleep onset. 3, 4, 5
From the Research
Treatment Options for Insomnia
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep, delivered over six to eight sessions 6.
- CBT-I has been shown to be effective in reducing insomnia severity and improving mental health in patients with comorbid mental disorders, such as depression, post-traumatic stress disorder (PTSD), and alcohol dependency 7.
- Pharmacological interventions for insomnia, including gamma-aminobutyric acid (GABA)A receptor agonists, melatonergic receptors agonists, and dual orexin receptors antagonists (DORA), have also been found to be effective in improving insomnia and comorbid mood disorders 8.
Barriers to Treatment
- Despite its effectiveness, CBT-I is underutilized due to barriers such as limited access to trained practitioners, lack of knowledge among primary care providers, and patient misconceptions about the treatment 9, 10.
- System barriers, including limited access to CBT-I and behavioral sleep medicine (BSM) providers, also contribute to the underutilization of CBT-I 9.
Key Components of CBT-I
- Sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques are the five key components of CBT-I 10.
- These components work together to help patients learn how to support and promote their body's natural sleep mechanism, leading to long-term improvements in sleep quality 10.