From the Guidelines
Cognitive behavioral therapy for insomnia (CBT-I) should be considered first-line treatment for adults with chronic insomnia disorder. This approach addresses underlying thought patterns and behaviors that contribute to sleep problems and has been shown to be highly effective in improving sleep outcomes, including increased remission and treatment response, and reduced symptoms of insomnia 1.
Non-Medication Approaches
In addition to CBT-I, other non-medication approaches can be beneficial, including:
- Maintaining a consistent sleep schedule
- Creating a relaxing bedtime routine
- Limiting screen time before bed
- Avoiding caffeine and alcohol near bedtime
- Ensuring the bedroom is dark, quiet, and cool
Medication Options
For short-term medication options, over-the-counter sleep aids containing diphenhydramine (25-50mg) or doxylamine (25mg) can be used occasionally. Prescription medications include:
- Benzodiazepines like temazepam (15-30mg)
- Non-benzodiazepine "Z-drugs" like zolpidem (5-10mg), eszopiclone (1-3mg), or zaleplon (5-20mg)
- Melatonin receptor agonists like ramelteon (8mg)
- Orexin receptor antagonists like suvorexant (10-20mg)
- Certain antidepressants like trazodone (25-100mg)
Important Considerations
Prescription medications should generally be used at the lowest effective dose for the shortest duration possible (ideally less than 2-4 weeks) due to potential side effects and risk of dependence 1. The selection of a particular drug should rest on the evidence summarized, as well as additional patient-level factors, such as the optimal pharmacokinetic profile, assessments of benefits versus harms, and past treatment history.
Key Recommendations
- CBT-I is recommended as the first-line treatment for chronic insomnia disorder 1.
- Medications should be used judiciously and with careful consideration of their potential benefits and risks 1.
From the FDA Drug Label
- 1 Controlled Clinical Trials Chronic Insomnia Three randomized, doubleblind trials in subjects with chronic insomnia employing polysomnography (PSG) were provided as objective support of ramelteon's effectiveness in sleep initiation 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.
The recommended treatments for insomnia include:
- Ramelteon (PO): effective in reducing sleep latency in patients with chronic insomnia 2
- Zolpidem (PO): effective in reducing sleep latency and improving sleep quality in patients with transient and chronic insomnia 3 Key points:
- Ramelteon is effective in reducing sleep latency in patients with chronic insomnia
- Zolpidem is effective in reducing sleep latency and improving sleep quality in patients with transient and chronic insomnia
- Both medications have been shown to be effective in clinical trials, but may have different side effect profiles and dosing recommendations.
From the Research
Recommended Treatments for Insomnia
The following are recommended treatments for insomnia:
- Non-pharmacologic approaches, which should be preferred in most cases due to the possible adverse effects of commonly used drugs to promote sleep 4
- Cognitive Behavioral Therapy for Insomnia (CBT-I), a multi-component treatment that targets difficulties with initiating and/or maintaining sleep 5, 6, 7, 8
- Exercise and relaxation techniques, which can be used in conjunction with CBT-I 4
- Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine 4, 7
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is a highly effective treatment for chronic insomnia, with clinically meaningful effect sizes 6
- The primary goal of CBT-I is to address the perpetuating factors that contribute to the development of chronic insomnia 5
- Core components of CBT-I include:
- Sleep Restriction Therapy
- Stimulus Control Therapy
- Sleep Hygiene
- Cognitive Therapy 5
- CBT-I can be delivered over the course of six to eight sessions, with a session-by-session outline provided 5
Non-Pharmacological Approaches
Non-pharmacological approaches, including CBT-I, are recommended as first-line treatment for insomnia due to their efficacy and lack of adverse effects 4, 7, 8
- These approaches can be used to manage insomnia in a wide range of populations, including those with comorbid psychiatric and medical conditions 7
- Non-pharmacological approaches can be implemented across different age groups, with some initial evidence on the sequential combination of insomnia treatments 7