Treatment of Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adults with chronic insomnia disorder due to its proven efficacy, long-term benefits, and minimal side effects. 1
First-Line Treatment: CBT-I
CBT-I is strongly recommended as the initial treatment approach for chronic insomnia based on moderate-quality evidence. It consists of multiple components:
- Stimulus control therapy: Creating a strong association between the bed and sleeping
- Sleep restriction therapy: Limiting time in bed to increase sleep efficiency
- Cognitive therapy: Addressing dysfunctional beliefs about sleep
- Relaxation techniques: Reducing physiological and cognitive arousal
- Sleep hygiene education: As part of a comprehensive approach, not as standalone therapy
CBT-I has been shown to improve:
- Sleep onset latency (time to fall asleep)
- Wake time after sleep onset
- Sleep efficiency
- Overall sleep quality
- Insomnia severity scores 1
Delivery Methods
CBT-I can be delivered through:
- In-person individual sessions
- Group therapy
- Telephone-based programs
- Web-based modules
- Self-help books 1
Alternative Behavioral Treatments
When CBT-I is not available or appropriate, consider these single-component therapies:
- Brief behavioral therapy for insomnia (BBT)
- Sleep restriction therapy
- Stimulus control therapy
- Relaxation therapy 1
Pharmacological Treatment
Medication should be considered only after CBT-I has been tried or alongside behavioral interventions, not as first-line therapy. 1
When pharmacotherapy is necessary, follow this recommended sequence:
Short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon:
- Examples: zolpidem, eszopiclone, zaleplon, temazepam
- Ramelteon is specifically indicated for sleep onset difficulties 2
- Consider patient-specific factors: symptom pattern, past response, comorbidities
Try alternative BzRA or ramelteon if first agent is unsuccessful
Sedating antidepressants (especially with comorbid depression/anxiety):
- Examples: trazodone, amitriptyline, doxepin, mirtazapine
Combined BzRA/ramelteon plus sedating antidepressant
Other sedating agents (for specific comorbidities):
- Anti-epilepsy medications (gabapentin, tiagabine)
- Atypical antipsychotics (quetiapine, olanzapine) 1
Important Considerations for Pharmacotherapy
- Short-term use: FDA approval for most sleep medications is limited to 4-5 weeks
- Lowest effective dose: Particularly important for older adults
- Regular follow-up: Every few weeks initially to assess effectiveness and side effects
- Patient education about:
- Treatment goals and expectations
- Safety concerns and potential side effects
- Drug interactions
- Potential for tolerance or dependence
- Rebound insomnia 1
Treatments to Avoid
- Sleep hygiene alone is insufficient for treating chronic insomnia
- Over-the-counter antihistamines or "sleep aids" are not recommended
- Herbal supplements (valerian, melatonin) lack sufficient efficacy and safety data
- Older medications like barbiturates and chloral hydrate are not recommended 1
Combined Treatment Approach
When using both CBT-I and medication:
- Short-term medication may help with immediate symptom relief
- CBT-I provides long-term sustainable benefits
- Consider tapering medication as CBT-I takes effect
- CBT-I can facilitate medication discontinuation 1, 3
Monitoring and Follow-up
- Collect sleep diary data before and during treatment
- Reassess every few weeks during initial treatment
- Continue follow-up every 6 months after improvement (high relapse rate)
- Monitor for treatment effectiveness and side effects
- Consider alternative or additional treatments if initial approach is ineffective 1
Special Considerations
- CBT-I is effective for adults of all ages, including older adults
- CBT-I is effective for patients with comorbid medical and psychiatric conditions 4
- Benefits of CBT-I persist beyond the end of treatment, unlike medication effects 5
- Initial side effects of CBT-I (sleepiness, fatigue) are typically mild and resolve quickly 1
The evidence clearly demonstrates that CBT-I should be the cornerstone of insomnia treatment, with medications serving as adjunctive therapy when necessary.