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 has been shown to improve global outcomes, including increased remission and treatment response, and reduced insomnia severity index (ISI) and Pittsburgh Sleep Quality Index (PSQI) scores compared to controls 1. CBT-I is a combination of treatments that include cognitive therapy around sleep, behavioral interventions, and education, and can be performed in primary care.
Causes of Insomnia
Insomnia can result from various underlying factors, including:
- Stress
- Anxiety
- Depression
- Medical conditions
- Poor sleep hygiene practices, such as inconsistent sleep schedules, exposure to screens before bed, and consumption of caffeine and alcohol
Treatment Options
For short-term insomnia, over-the-counter options like melatonin (0.5-5mg taken 30-60 minutes before bedtime) may help. If insomnia persists, prescription medications such as zolpidem (Ambien, 5-10mg), eszopiclone (Lunesta, 1-3mg), or trazodone (50-100mg) might be prescribed for short-term use, typically 2-4 weeks 1. However, pharmacological therapy should only be considered after CBT-I has been tried, as the benefits and harms of medication are not well established, and there is a risk of cognitive and behavioral changes, including driving impairment 1.
Key Considerations
- Insomnia is a common sleep disorder that can have significant impacts on quality of life and overall health
- CBT-I is a highly effective treatment for chronic insomnia disorder, and should be considered the first-line treatment
- Pharmacological therapy should only be used after CBT-I has been tried, and under the guidance of a healthcare provider
- Addressing underlying factors, such as stress, anxiety, and depression, is essential for lasting improvement in insomnia symptoms.
From the FDA Drug Label
Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. 2 3
- Causes of insomnia: may be due to a physical and/or psychiatric disorder.
- Treatments of insomnia:
- Symptomatic treatment should be initiated only after a careful evaluation of the patient.
- The smallest possible effective dose of sedative-hypnotics should be used, especially in the elderly.
- Discontinuation of sedative-hypnotics should be strongly considered for patients who report complex behaviors such as sleep-driving.
- Evaluation: The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated.
From the Research
Causes of Insomnia
- Insomnia can be classified as idiopathic or comorbid, with comorbid insomnias associated with psychiatric disorders, medical disorders, substance abuse, and specific sleep disorders 4
- Idiopathic insomnia is essentially a diagnosis of exclusion 4
- Insomnia can be acute, lasting from one night to a few weeks, or chronic, lasting at least three nights weekly for at least one month 4
Treatments for Insomnia
- Non-pharmacologic interventions for insomnia include:
- Pharmacologic therapies for insomnia include:
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep 7
- CBT-I has been found to be an effective alternative to pharmacotherapy in individuals with insomnia 6