What are the treatment guidelines for insomnia?

Treatment Guidelines for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adults with chronic insomnia due to its proven efficacy, sustained benefits, and lack of adverse effects compared to pharmacological options. 1, 2

Initial Treatment Approach

First-Line Treatment: CBT-I

• The American Academy of Sleep Medicine strongly recommends multicomponent CBT-I as the primary treatment for chronic insomnia disorder 2
• CBT-I components include:
  • Stimulus control therapy (recommended as effective single-component therapy) 2
  • Sleep restriction therapy (recommended as effective single-component therapy) 2
  • Cognitive therapy (addresses unhelpful sleep-related beliefs)
  • Relaxation techniques (recommended as effective single-component therapy) 2
  • Sleep hygiene education (not effective as standalone therapy) 2, 1

CBT-I Delivery Methods

• Multiple effective delivery formats:
  • In-person individual therapy (most studied and most effective) 1, 3
  • Group therapy
  • Telehealth/telemedicine
  • Internet-based modules
  • Self-help books
  • Brief therapies for insomnia (BTIs) 2

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
3. For severe or refractory insomnia 2

Recommended Medication Sequence 2:

1. First options:

   • Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon
   • Examples: zolpidem, eszopiclone, zaleplon, temazepam

2. If first option unsuccessful:

   • Try alternate short-intermediate acting BzRAs or ramelteon

3. Next options:

   • Sedating antidepressants (especially with comorbid depression/anxiety)
   • Examples: trazodone, amitriptyline, doxepin, mirtazapine

4. Combined approaches:

   • BzRA or ramelteon plus sedating antidepressant

5. Other sedating agents (primarily for comorbid conditions):

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

Important Medication Considerations:

• Start with lowest effective dose, especially in elderly patients 1
• Use for shortest duration necessary (ideally ≤4 weeks) 1, 4
• Triazolam should only be prescribed for short-term use (7-10 days) 4
• Monitor for adverse effects including daytime impairment, "sleep driving," and behavioral abnormalities 1
• Avoid over-the-counter antihistamines, herbal supplements, barbiturates, and older sedative-hypnotics 2, 1
• Avoid benzodiazepines in elderly patients due to fall risk and cognitive impairment 1

Treatment Monitoring and Follow-up

• Follow patients regularly (every few weeks initially) to assess effectiveness, side effects, and need for ongoing medication 2
• Use sleep diary data and validated instruments to monitor response 1
• Employ lowest effective maintenance dosage and taper medication when conditions allow 2
• CBT-I facilitates medication tapering and discontinuation 2
• Long-term hypnotic medication may be indicated for severe or refractory insomnia, but should be accompanied by consistent follow-up 2

Special Considerations

• Older adults: More likely to have sleep maintenance problems; use lower medication doses; avoid benzodiazepines 1
• Comorbid conditions: CBT-I is effective for insomnia with psychiatric and medical comorbidities 1
• Lactating mothers: Low-dose doxepin (3-6mg) is recommended as a safe option 1

Common Pitfalls to Avoid

1. Using sleep hygiene alone: Not effective as a standalone treatment 2, 1, 5
2. Overlooking underlying conditions: Failure of insomnia to remit after 7-10 days may indicate primary psychiatric/medical illness 4
3. Prolonged medication use: Hypnotics should generally be limited to short-term use 4
4. Neglecting follow-up: Regular assessment is essential, especially with pharmacotherapy 2
5. Ignoring relaxation components: Recent evidence suggests relaxation procedures may be counterproductive in some CBT-I packages 3
6. Overlooking cognitive components: Cognitive restructuring appears to be a critical component of effective CBT-I 3

By following these evidence-based guidelines and prioritizing CBT-I as first-line treatment, clinicians can effectively manage insomnia while minimizing risks associated with pharmacological interventions.