What are the treatment options for insomnia?

Treatment Options for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all patients with insomnia due to its sustained benefits without risk of tolerance or adverse effects. 1

First-Line Treatment: CBT-I

CBT-I is a multicomponent therapy that includes:

• Sleep restriction therapy: Limiting time in bed to match actual sleep time
• Stimulus control: Creating a positive association between bed and sleep
• Cognitive therapy: Addressing unhelpful beliefs about sleep
• Relaxation techniques: Reducing physiological and mental arousal
• Sleep hygiene education: As an adjunct, not standalone treatment

CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users 2. It produces clinically meaningful improvements in sleep onset latency, wake time after sleep onset, and sleep efficiency 3.

CBT-I Delivery Options:

• Traditional face-to-face CBT-I (8-12 sessions)
• Digital CBT-I applications
• Brief Behavioral Treatment for Insomnia (BBT-I)
• Self-help CBT-I materials (books, online resources) 1

Important caveat: While sleep hygiene is commonly recommended, it is insufficient as a standalone treatment and should always be combined with other therapies 2, 4.

Pharmacological Options (When Needed)

If CBT-I is unsuccessful after 4-6 weeks or as a temporary adjunct, consider medication 1:

For Sleep Onset Insomnia:

1. Zolpidem (10mg, 5mg for elderly) - Reduces sleep latency 1, 5
2. Zaleplon (10mg) - Very short half-life, specifically targets sleep onset 1
3. Ramelteon (8mg) - Non-scheduled melatonin receptor agonist, good for patients with substance use history 1

For Sleep Maintenance Insomnia:

1. Eszopiclone (2-3mg) - Effective for both sleep onset and maintenance 1, 6
2. Suvorexant (10-20mg) - Orexin receptor antagonist 1
3. Doxepin (3-6mg) - Low-dose option with minimal side effects 1

Second-Line Options:

• Sedating antidepressants (trazodone, mirtazapine) - Especially when comorbid depression/anxiety exists 2
• Other sedating agents (gabapentin, quetiapine, olanzapine) 2

Treatment Algorithm

1. Start with CBT-I for all patients (4-8 weeks)
2. If inadequate response after 4-6 weeks:
   • Add appropriate pharmacotherapy based on insomnia type
   • Continue CBT-I alongside medication
3. If first medication unsuccessful:
   • Try alternative agent from same class
   • Consider adding sedating antidepressant if appropriate
4. Reassess every few weeks until insomnia stabilizes, then every 6 months 2

Special Considerations

• Elderly patients: Use lower doses of medications (e.g., zolpidem 5mg) 1
• Substance use history: Consider non-scheduled options like ramelteon 1
• Medication precautions:
  • Use lowest effective dose for shortest period possible
  • Avoid antihistamines (diphenhydramine) and herbal supplements due to lack of efficacy data 1
  • Be aware of potential side effects: residual sedation, memory impairment, falls, and sleep behaviors (sleepwalking, sleep-eating) 1

Monitoring and Follow-up

• Collect sleep diary data before and during treatment 2
• Screen for other sleep disorders (obstructive sleep apnea, restless legs syndrome) 1
• For pharmacotherapy, employ lowest effective maintenance dosage and taper when conditions allow 1
• Be aware that relapse rates for insomnia are high, requiring ongoing monitoring 2

CBT-I remains the gold standard treatment with the strongest evidence base and should be prioritized whenever possible due to its durable benefits without the risks associated with pharmacotherapy 7, 3.