From the Guidelines
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for patients with sleep disturbances, as it has the most evidence available in the literature and is considered the treatment of choice 1.
Non-Pharmacological Approaches
Non-pharmacological approaches should be the initial focus for patients with sleep disturbances. These include:
- Sleep hygiene practices such as maintaining a consistent sleep schedule, creating a comfortable sleep environment, avoiding caffeine and alcohol before bedtime, limiting screen time, and engaging in relaxation techniques like meditation or deep breathing exercises.
- CBT-I, which is typically delivered over 6-8 weekly sessions, addressing negative thoughts about sleep and teaching stimulus control techniques.
Pharmacological Management
For short-term pharmacological management, medications may include:
- Benzodiazepines like temazepam (15-30mg) or non-benzodiazepine hypnotics like zolpidem (5-10mg) or eszopiclone (1-3mg), typically limited to 2-4 weeks to prevent dependence.
- Melatonin (1-5mg) may help with circadian rhythm disorders.
- Sedating low-dose antidepressants like trazodone (25-100mg) or mirtazapine (7.5-15mg) can be considered for sleep maintenance issues, although evidence for their efficacy when used alone is relatively weak 1.
Individualized Treatment
Treatment should be individualized based on the specific sleep disorder, patient characteristics, and underlying causes, with the goal of addressing the root cause rather than merely masking symptoms. Some of the challenges patients face when undergoing psychological treatments include the ability to attend sessions and adhere to treatment recommendations, and clinicians should discuss different treatment modalities with their patients and align the delivery modality based on availability, affordability, treatment format, duration, and the patient’s preferences and values 1.
Key Considerations
Key considerations in selecting appropriate treatments include comorbid medical and psychiatric conditions that may change the balance of benefits vs harms, and the potential adverse effects of treatment-induced sleep deprivation on seizure disorder or bipolar disorder 1. The principles of sleep hygiene are now widely available to patients as general health information, and clinician time should be allocated to delivery of interventions with the best evidence, rather than providing sleep hygiene alone 1.
Recent Guidelines
Recent guidelines suggest that clinicians use suvorexant, eszopiclone, zaleplon, zolpidem, triazolam, temazepam, ramelteon, or doxepin as a treatment for sleep onset and/or sleep maintenance insomnia in adults, while trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, and valerian are not recommended as a treatment for sleep onset or sleep maintenance insomnia in adults 1.
From the FDA Drug Label
14.1 Transient Insomnia Normal adults experiencing transient insomnia (n=462) during the first night in a sleep laboratory were evaluated in a double-blind, parallel group, single-night trial comparing two doses of zolpidem (7. 5 and 10 mg) and placebo. 14. 2 Chronic Insomnia 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) 5. 1 CNS Depressant Effects and Next-Day Impairment Eszopiclone is a central nervous system (CNS) depressant and can impair daytime function in some patients at the higher doses (2 mg or 3 mg), even when used as prescribed
The recommended treatments for patients with sleep disturbances are:
- Zolpidem: for transient and chronic insomnia, with doses of 7.5 and 10 mg compared to placebo.
- Eszopiclone: a CNS depressant that can impair daytime function, with recommended doses of 2 mg or 3 mg. Key considerations:
- Evaluate patients for comorbid diagnoses before initiating treatment.
- Monitor for excess depressant effects and next-day impairment.
- Use the lowest possible effective dose, especially in the elderly.
- Discontinue treatment if complex sleep behaviors or severe anaphylactic reactions occur 2, 2, 3.
From the Research
Recommended Treatments for Sleep Disturbances
The following are recommended treatments for patients with sleep disturbances:
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep 4
- Non-pharmacological interventions such as Resistance Training, Yoga, Cognitive Behavioral Therapy, Music, and Light therapy have been shown to improve sleep quality in individuals with sleep disturbances 5
- CBT-I is an effective treatment for patients with insomnia and a comorbid mental disorder, especially depression, PTSD, and alcohol dependency 6
Medication for Sleep
In some cases, medication may be used in conjunction with non-pharmacological interventions:
- Trazodone, a sedative antidepressant, has been shown to improve the results of CBT for primary insomnia in non-depressed patients 7
- However, the use of medication should be considered carefully, as it can have side effects and may not be suitable for all patients
Alternative Therapies
Alternative therapies such as: