What are the first-line treatments for insomnia?

First-Line Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia, not sleep hygiene education or pharmacotherapy. 1, 2

Evidence-Based Treatment Approach

First-Line Treatment: CBT-I

• CBT-I is a multicomponent therapy that includes:

  • Sleep restriction therapy (limiting time in bed to sleep time)
  • Stimulus control (strengthening association between sleep environment and sleep)
  • Cognitive therapy (targeting maladaptive thoughts about sleep)
  • Relaxation techniques (counterarousal strategies)
  • Sleep hygiene education (as a component, not standalone)

• CBT-I has demonstrated superior efficacy compared to:

  • Sleep hygiene education alone 1
  • Pharmacotherapy in long-term outcomes 1
  • Placebo in multiple clinical trials 2

• CBT-I delivery formats:

  • In-person individual therapy (most effective format) 2, 3
  • Group therapy
  • Telehealth/telemedicine
  • Internet-based modules
  • Self-help books 2

Second-Line Treatments

Medications should be considered only when:

• Patients are unable to participate in CBT-I
• Patients still have symptoms despite CBT-I
• As a temporary adjunct to CBT-I 1

Recommended pharmacological options:

• For sleep onset insomnia:

  • Zolpidem 10mg (5mg in elderly) 2, 4
  • Eszopiclone 2-3mg (1-2mg in elderly) 2
  • Ramelteon 8mg 2, 5

• For sleep maintenance insomnia:

  • Eszopiclone 2-3mg 2
  • Suvorexant 10-20mg 2
  • Low-dose doxepin (3-6mg) 2

Common Pitfalls and Caveats

Avoid These Common Mistakes:

1. Using sleep hygiene education alone

   • Sleep hygiene education as monotherapy is ineffective and potentially harmful 1
   • May make patients less receptive to effective treatments like CBT-I 1

2. Starting with pharmacotherapy

   • Most medications have limited long-term safety data 2
   • Risk of dependence, tolerance, and rebound insomnia with some agents
   • FDA approvals for most hypnotics are for short-term use only 5, 4

3. Overlooking underlying sleep disorders

   • Always assess for obstructive sleep apnea, restless legs syndrome, and circadian rhythm disorders before treatment 2

4. Inadequate CBT-I implementation

   • Critical components include cognitive restructuring, sleep restriction, and stimulus control 3
   • Relaxation procedures alone may be counterproductive 3

Special Considerations

• Older adults: CBT-I remains first-line; if medication is needed, use lower doses 2
• Comorbid conditions: CBT-I is effective for insomnia comorbid with psychiatric and medical conditions 2
• Menopausal women: Consider hormone therapy only when insomnia is related to vasomotor symptoms 2

Treatment Algorithm

1. Start with CBT-I as the primary intervention
2. If CBT-I access is limited, consider digital CBT-I (dCBT) or brief behavioral treatment for insomnia (BBT-I) 1, 6
3. If response is inadequate after 4-6 weeks or patient cannot engage in CBT-I, consider adding short-term pharmacotherapy
4. When using medications, employ the lowest effective dose for the shortest duration possible
5. Continue CBT-I during medication tapering to prevent relapse 7

The evidence clearly demonstrates that CBT-I should be the cornerstone of insomnia treatment, with medications reserved for specific situations when CBT-I is insufficient or inaccessible.