What are the recommended management strategies for insomnia?

Management of Chronic Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be recommended as the first-line treatment for all adults with chronic insomnia disorder due to its proven efficacy and safety profile. 1

First-Line Treatment: Psychological and Behavioral Interventions

CBT-I Components

CBT-I is a multimodal intervention that includes:

• Cognitive therapy: Addresses maladaptive thoughts and beliefs about sleep
• Behavioral components:
  • Sleep restriction therapy: Limiting time in bed to match actual sleep time
  • Stimulus control: Strengthening association between bed and sleep
  • Relaxation techniques: Managing physiological arousal
• Educational component: Sleep hygiene education

CBT-I has demonstrated strong effectiveness with moderate-quality evidence showing improvements in:

• Global outcomes (remission rates, treatment response)
• Sleep onset latency
• Wake time after sleep onset
• Sleep efficiency
• Sleep quality 1

Delivery Methods

CBT-I can be effectively delivered through:

• Individual face-to-face sessions
• Group therapy
• Telephone-based sessions
• Web-based modules
• Self-help books 1

Important: While sleep hygiene education is a component of CBT-I, it should not be used alone as it has insufficient evidence for effectiveness as monotherapy. 1

Second-Line Treatment: Pharmacological Interventions

If CBT-I alone is unsuccessful, pharmacological therapy may be considered using a shared decision-making approach that discusses benefits, harms, and costs 1.

Recommended Medication Sequence:

1. Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon:

   • Examples: zolpidem, eszopiclone, zaleplon, temazepam
   • Evidence shows these improve sleep onset latency, total sleep time, and wake after sleep onset 1

2. Alternative BzRA or ramelteon if initial agent unsuccessful

3. Sedating antidepressants (especially with comorbid depression/anxiety):

   • Examples: trazodone, amitriptyline, doxepin, mirtazapine

4. Combined BzRA/ramelteon with sedating antidepressant

5. Other sedating agents (for specific comorbidities):

   • Anti-epilepsy medications (gabapentin, tiagabine)
   • Atypical antipsychotics (quetiapine, olanzapine) 1

Important Medication Considerations:

• Safety warnings: Medications like eszopiclone and zolpidem carry FDA warnings about complex sleep behaviors (sleep-walking, sleep-driving) and next-day impairment 2, 3
• Duration: Pharmacotherapy should be short-term and supplemented with behavioral therapies when possible 1
• Monitoring: Patients should be followed regularly (every few weeks initially) to assess effectiveness, side effects, and need for continued medication 1
• Avoid: Over-the-counter antihistamines, barbiturates, and chloral hydrate are not recommended due to lack of efficacy data and safety concerns 1

Treatment Algorithm

1. Initial Assessment:

   • Confirm chronic insomnia diagnosis (symptoms ≥3 nights/week for ≥3 months)
   • Rule out other sleep, medical, or psychiatric disorders
   • Collect sleep diary data

2. First-Line Treatment:

   • Implement CBT-I with at least one behavioral component (stimulus control or relaxation)
   • Full CBT-I preferred when available

3. Monitoring:

   • Reassess every few weeks initially
   • Use sleep diaries and validated questionnaires (ISI, PSQI)

4. If Inadequate Response:

   • Try alternative behavioral approaches or combination therapies
   • Consider pharmacological therapy if CBT-I alone unsuccessful
   • Select medication based on symptom pattern, treatment goals, and patient factors

5. Long-term Follow-up:

   • Continue monitoring every 6 months due to high relapse rate 1
   • Gradually taper medications while maintaining behavioral strategies

Special Considerations

• Older adults: Often present with sleep maintenance rather than sleep initiation problems; CBT-I remains effective in this population 1
• Comorbid conditions: May require specific medication selection or combination therapy 1
• Medication risks: Increased risk of falls, cognitive impairment, and dependence, particularly in older adults 1, 2

By following this evidence-based approach to insomnia management, clinicians can help patients achieve sustainable improvements in sleep quality and quantity while minimizing risks associated with long-term medication use.