From the Guidelines
Insomnia can be effectively treated with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, which has shown better long-term outcomes than medications. For mild to moderate insomnia, start with behavioral and lifestyle changes including:
- Practicing good sleep hygiene (maintaining a consistent sleep schedule, creating a comfortable sleep environment, avoiding screens before bed)
- Cognitive behavioral therapy for insomnia (CBT-I)
- Relaxation techniques
- Regular exercise
If these approaches are insufficient, short-term medication options can be considered, including:
- Over-the-counter sleep aids containing diphenhydramine or doxylamine
- Prescription medications such as benzodiazepines (like temazepam 15-30mg), non-benzodiazepine hypnotics (like zolpidem 5-10mg, eszopiclone 1-3mg), melatonin receptor agonists (ramelteon 8mg), orexin receptor antagonists (suvorexant 10-20mg), or sedating antidepressants (trazodone 25-100mg) 1.
Prescription medications should generally be used for short periods (2-4 weeks) to avoid dependence and tolerance. Underlying conditions contributing to insomnia, such as depression, anxiety, sleep apnea, or restless leg syndrome, should also be addressed. These treatments work by either promoting relaxation, resetting disrupted sleep-wake cycles, or targeting specific brain receptors involved in sleep regulation.
Key considerations for treatment include:
- Patient preference and values
- Availability and cost of treatment options
- Potential benefits and harms of each treatment
- Presence of comorbid medical or psychiatric conditions
It is essential to note that CBT-I has been shown to be effective in improving sleep outcomes and reducing symptoms of insomnia, and should be considered as the first-line treatment for chronic insomnia 1.
From the FDA Drug Label
Zolpidem Tartrate Tablets USP are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. 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 treatment options for insomnia include zolpidem tartrate for the short-term treatment of insomnia characterized by difficulties with sleep initiation, as evidenced by decreased sleep latency in clinical studies 2 2.
- Zolpidem has been shown to be effective in both transient and chronic insomnia.
- The recommended use is for short-term treatment, with clinical trials performed in support of efficacy being 4 to 5 weeks in duration.
From the Research
Treatment Options for Insomnia
The treatment options for insomnia can be categorized into pharmacologic and nonpharmacologic therapies.
- Pharmacologic Therapies:
- Benzodiazepines and nonbenzodiazepine benzodiazepine receptor agonists are commonly used to treat insomnia 3, 4.
- Melatonin receptor agonists have also been approved for the treatment of insomnia 3, 5.
- Antidepressants and antipsychotics are sometimes prescribed off-label for insomnia, but they have side effects that can be severe 3, 4.
- Orexin antagonists, such as daridorexant, are a new class of hypnotics that have recently been introduced to the market 5.
- Nonpharmacologic Therapies:
- Cognitive-behavioral therapy (CBT) is a highly effective treatment for chronic insomnia, with benefits that can be sustained over time 6, 7.
- Sleep hygiene education, stimulus-control therapy, relaxation therapy, and sleep-restriction therapy are other nonpharmacologic interventions that can help patients with insomnia 4.
- CBT can be administered in various forms, including face-to-face, bibliotherapy, phone psychotherapy, brief behavioral therapy, and online-CBT 7.
Considerations for Treatment
When selecting a treatment option for insomnia, patient-specific factors should be taken into account, such as age, proposed length of treatment, primary sleep complaint, history of drug or alcohol abuse, and cost 4. Additionally, the potential risks and benefits of each treatment option should be considered, including the risk of adverse effects, withdrawal syndrome, and abuse potential 5.