From the Guidelines
Chronic insomnia is best treated with Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment, which involves sleep restriction, stimulus control, relaxation techniques, and addressing unhelpful thoughts about sleep. This approach is supported by the American Academy of Sleep Medicine clinical practice guideline 1, which recommends CBT-I as the treatment of choice for chronic insomnia disorder in adults. The guideline suggests that CBT-I is a multicomponent intervention that can be delivered in various formats, including in-person, group, or internet-based programs.
Some key components of CBT-I include:
- Sleep restriction therapy: limiting time in bed to sleep time, followed by a gradual increase in time in bed as sleep efficiency improves
- Stimulus control therapy: strengthening the association between the sleep environment and sleep, and establishing consistent sleep patterns
- Relaxation therapy: techniques such as progressive muscle relaxation, mindfulness, or meditation to reduce stress and anxiety
- Cognitive therapy: addressing maladaptive thoughts and beliefs about sleep
In addition to CBT-I, lifestyle modifications are crucial for managing chronic insomnia, including:
- Maintaining consistent sleep-wake times
- Avoiding caffeine after noon
- Limiting alcohol
- Exercising regularly, but not close to bedtime
- Creating a dark, cool sleeping environment
- Avoiding screens before bed
Medications may be considered as a temporary measure to help with sleep, but they should be used under the guidance of a healthcare professional and in conjunction with behavioral therapies. Some medication options include:
- Non-benzodiazepine hypnotics like zolpidem (5-10mg), eszopiclone (1-3mg), or zaleplon (5-20mg) at bedtime
- Low-dose doxepin (3-6mg) for sleep maintenance
- Melatonin (0.5-5mg) taken 1-2 hours before bedtime to regulate sleep cycles
- Trazodone (25-100mg) used off-label for sleep
It's essential to note that treatment should be individualized, and medication should be used temporarily while behavioral strategies are developed for long-term management. The American College of Physicians guideline 1 also recommends CBT-I as the first-line treatment for chronic insomnia disorder in adults, and suggests that medication should be used as a shared decision-making approach with patients.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™)
The treatment options for chronic insomnia include:
- Ramelteon (PO): indicated for the treatment of insomnia characterized by difficulty with sleep onset 2, 2
- Zolpidem (PO): evaluated in two controlled studies for the treatment of patients with chronic insomnia 3 Key points:
- Ramelteon reduces sleep latency at each time point when compared to placebo 2
- Zolpidem 10 mg was superior to placebo on a subjective measure of sleep latency for all 4 weeks, and on subjective measures of total sleep time, number of awakenings, and sleep quality for the first treatment week 3
From the Research
Treatment Options for Chronic Insomnia
The following treatment options are available for chronic insomnia:
- Cognitive-behavioral therapy for insomnia (CBT-i) 4, 5, 6, 7
- Stimulus control therapy 4
- Relaxation training 4
- Sleep restriction therapy 4
- Multicomponent therapy (without cognitive therapy) 4
- Biofeedback 4
- Paradoxical intention 4
- Sleep hygiene education 8, 6, 7
- Progressive muscle relaxation 8
- Physical exercise practices 8
Non-Pharmacological Treatment Approaches
Non-pharmacological treatment approaches are effective in the treatment of chronic insomnia, including:
- Behavioral approaches 8
- Cognitive approaches 5, 6, 7
- Complementary and alternative medicine (CAM) approaches 5
Effectiveness of Treatment Options
The effectiveness of these treatment options is well established, with cognitive-behavioral therapies comparing favorably to pharmacologic approaches 5, 6, 7. CBT-i is considered an evidence-based treatment for insomnia, with results equivalent to sleep medication and no side effects 7.