From the Guidelines
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for insomnia, as it has been shown to be effective in improving sleep outcomes and reducing symptoms of insomnia. According to the American Academy of Sleep Medicine clinical practice guideline published in 2021 1, CBT-I is a multicomponent intervention that includes techniques such as stimulus control, sleep restriction, relaxation training, and cognitive restructuring to address unhelpful thoughts about sleep.
Some key points to consider when implementing CBT-I include:
- It is typically provided by a trained therapist, but can also be delivered through online programs or self-help books
- It usually consists of 4-8 sessions, and patients may experience gradual improvements in insomnia symptoms over time
- CBT-I has been shown to be effective in improving sleep outcomes, including reduced sleep onset latency and wake after sleep onset, and improved sleep efficiency and sleep quality
- It is considered a safe and effective treatment option, with minimal undesirable effects
In addition to CBT-I, other non-medication approaches such as good sleep hygiene practices, including maintaining a consistent sleep schedule, creating a comfortable sleep environment, avoiding caffeine and alcohol before bedtime, limiting screen time, and establishing a relaxing bedtime routine, can also be helpful in managing insomnia.
For short-term medication options, prescription medications such as zolpidem (Ambien, 5-10mg), eszopiclone (Lunesta, 1-3mg), or temazepam (Restoril, 7.5-30mg) may be considered for 2-4 weeks maximum to avoid dependence, as suggested by the American Academy of Sleep Medicine clinical practice guideline published in 2017 1. However, medication should only be used under the guidance of a healthcare provider, as they can help determine the most appropriate treatment based on the patient's specific situation, medical history, and underlying causes of insomnia.
It's also important to note that some medications, such as trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, and valerian, are not recommended as treatments for insomnia due to lack of evidence or potential harms, as stated in the American Academy of Sleep Medicine clinical practice guideline published in 2017 1.
Overall, the most effective treatment approach for insomnia will depend on the individual patient's needs and circumstances, and may involve a combination of non-medication and medication approaches. CBT-I is the recommended first-line treatment, and medication should only be used under the guidance of a healthcare provider.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. The clinical trials performed in support of efficacy were up to six months in duration. 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™)
The recommended treatments for insomnia include:
- Ramelteon: indicated for the treatment of insomnia characterized by difficulty with sleep onset.
- Zolpidem: evaluated in two controlled studies for the treatment of patients with chronic insomnia. Key points to consider when treating insomnia:
- Ramelteon has been shown to reduce sleep latency in clinical trials 2, 2.
- Zolpidem has been shown to be effective in reducing sleep latency and improving sleep quality in patients with chronic insomnia 3.
From the Research
Insomnia Treatment Options
Insomnia is a common condition that can have significant clinical and economic consequences. Fortunately, there are various treatment options available to help manage insomnia.
- Nonpharmacologic options include:
- Stimulus control
- Sleep hygiene education
- Sleep restriction
- Paradoxical intention
- Relaxation therapy
- Biofeedback
- Cognitive behavioral therapy (CBT) 4
- Pharmacologic options include:
- Benzodiazepine and nonbenzodiazepine sedative-hypnotic agents
- Ramelteon, a melatonin receptor agonist
- Trazodone
- Sedating antihistamines 4
- Herbal and alternative preparations include:
- Melatonin
- Valerian 4
Cognitive Behavioral Therapy for Insomnia
Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective nonpharmacologic treatment for insomnia. It has been shown to be equivalent to sleep medication in terms of efficacy, with no side effects and fewer episodes of relapse 5. The five key components of CBT-I are:
- Sleep consolidation
- Stimulus control
- Cognitive restructuring
- Sleep hygiene
- Relaxation techniques 5
Efficacy of CBT-I
Studies have demonstrated the efficacy of CBT-I in improving insomnia symptoms and sleep parameters, including sleep efficiency, sleep onset latency, and wake after sleep onset 6. CBT-I has also been shown to be effective in patients with comorbid insomnia and psychiatric or medical conditions, with a small to medium positive effect on comorbid outcomes 6.
Other Non-Pharmacological Approaches
Other non-pharmacological approaches, such as relaxation therapy and biofeedback, may also be effective in managing insomnia 7. Additionally, complementary alternative medicine, such as melatonin and valerian, may be used as adjunctive treatments for insomnia 7. However, more research is needed to fully understand the efficacy and safety of these approaches 7.
Considerations for Treatment
When recommending treatment for insomnia, clinicians should consider patient-specific criteria, such as age, medical history, and other drug use, as well as the underlying cause of the sleep disturbance 4. All pharmacotherapy should be used with appropriate caution, at minimum effective doses, and for minimum duration of time 4.