What are the recommended management strategies for insomnia?

Management of Insomnia: Evidence-Based Approaches

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, sustained benefits, and lack of adverse effects compared to pharmacological options. 1

First-Line Treatment: CBT-I

CBT-I is a multimodal intervention that includes:

• Stimulus control therapy: Strengthening the association between the bedroom environment and sleep
• Sleep restriction therapy: Limiting time in bed to actual sleep time, then gradually increasing as sleep efficiency improves
• Cognitive therapy: Targeting maladaptive thoughts and beliefs about sleep
• Relaxation techniques: Reducing physiological and mental arousal
• Sleep hygiene education: As a component of CBT-I, not as standalone therapy

Moderate-quality evidence shows that CBT-I improves:

• Global sleep outcomes (increased remission and treatment response)
• Reduced Insomnia Severity Index (ISI) scores
• Reduced sleep onset latency
• Reduced wake after sleep onset
• Improved sleep efficiency and quality 1

CBT-I Delivery Methods

CBT-I can be effectively delivered through multiple formats:

• In-person individual therapy
• Group therapy
• Telehealth/telemedicine
• Internet-based modules
• Self-help books 1, 2

While in-person CBT-I has been most studied, other delivery methods have also shown effectiveness, which can increase accessibility 1, 3.

Important Caution: Sleep Hygiene Alone Is Insufficient

Sleep hygiene education alone should NOT be used as a standalone treatment for chronic insomnia 1. The VA/DoD clinical practice guidelines specifically warn that sleep hygiene education alone may be not only ineffectual but potentially harmful if it prevents patients from seeking effective treatments like CBT-I 1.

Pharmacological Treatment (Second-Line)

Pharmacotherapy should only be considered when:

1. CBT-I alone has been unsuccessful
2. As a short-term adjunct to CBT-I 1, 2

When medication is necessary, a shared decision-making approach should be used, discussing benefits, harms, and costs of short-term medication use 1.

Recommended Medication Sequence:

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

   • For sleep onset insomnia: Zolpidem 10mg (5mg in elderly) or eszopiclone 2-3mg (1-2mg in elderly)
   • For sleep maintenance insomnia: Eszopiclone 2-3mg or suvorexant 10-20mg 1, 2

2. Alternative options if initial agent unsuccessful:

   • Try alternate BzRA or ramelteon
   • For sleep onset insomnia: Zaleplon 10mg or ramelteon 8mg 1, 2

3. For comorbid conditions:

   • Sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine) especially with comorbid depression/anxiety
   • Combined BzRA/ramelteon with sedating antidepressant 1

Medication Safety Considerations:

• Start with lowest effective dose, especially in elderly patients
• Use for shortest duration necessary (ideally ≤4 weeks)
• Monitor for adverse effects including daytime impairment, "sleep driving," and behavioral abnormalities
• Be aware of serious potential adverse effects including dementia, injury, and fractures, particularly in older adults 1, 2

Medications to Avoid:

• Over-the-counter antihistamines (diphenhydramine)
• Herbal supplements (valerian, melatonin)
• Barbiturates and older sedative-hypnotics
• Benzodiazepines in elderly patients due to fall risk, cognitive impairment, and dependence potential 1, 2

Treatment Algorithm:

1. Initial assessment: Evaluate for chronic insomnia disorder (symptoms ≥3 nights/week for ≥3 months causing distress/dysfunction)
2. First-line: Implement CBT-I through available delivery method
3. Monitor response: Use sleep diary data and validated instruments (ISI, PSQI)
4. If inadequate response: Consider alternative CBT-I delivery method or components
5. If still inadequate: Consider short-term pharmacotherapy while continuing CBT-I
6. Regular follow-up: Every few weeks initially, then every 6 months due to high relapse rate 1

Special Considerations:

• Older adults: More likely to have sleep maintenance problems rather than sleep onset difficulties; use lower medication doses and avoid benzodiazepines 1, 2
• Comorbid conditions: CBT-I is effective for insomnia comorbid with psychiatric and medical conditions, with larger effects on psychiatric conditions 4
• Lactating mothers: Low-dose doxepin (3-6mg) is recommended if medication is necessary 2

By following this evidence-based approach prioritizing CBT-I as first-line treatment, clinicians can effectively manage insomnia while minimizing the risks associated with pharmacotherapy.