What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for chronic insomnia, followed by pharmacological options when necessary. 1, 2

Non-Pharmacological Treatments

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• Recommended as the initial treatment for all patients with chronic insomnia 1, 2
• Components include:
  • Sleep restriction/consolidation
  • Stimulus control
  • Cognitive restructuring
  • Sleep hygiene education
  • Relaxation techniques
• Implementation typically requires 4-8 weeks 2
• Produces sustained benefits without risk of tolerance or adverse effects 3
• 36% of patients achieve remission from insomnia with CBT-I compared to 16.9% with control conditions 4
• Effective for both primary insomnia and insomnia comorbid with medical or psychiatric conditions 4

Sleep Hygiene Education

• Regular sleep-wake schedule
• Comfortable sleep environment
• Avoiding caffeine and alcohol
• Regular physical activity (but not within 2 hours of bedtime) 2

Pharmacological Treatments

When CBT-I is insufficient or while waiting for CBT-I to take effect, medications may be considered:

First-Line Medications

1. For Sleep Onset Insomnia:

   • Ramelteon (8mg): Non-scheduled medication with no abuse potential and minimal morning sedation 2, 5
   • Zolpidem (10mg adults, 5mg elderly): FDA-approved for sleep onset difficulties 2, 6
   • Zaleplon (10mg): Short-acting agent for sleep initiation 2

2. For Sleep Maintenance Insomnia:

   • Doxepin (3-6mg): Particularly suitable for elderly patients with lower risk of falls 2
   • Eszopiclone (2-3mg, 1mg in elderly): Effective for both sleep onset and maintenance 2
   • Suvorexant (10-20mg): Orexin receptor antagonist for sleep maintenance 2

Special Considerations for Elderly Patients

• Use lower doses: zolpidem 5mg, doxepin 3mg, eszopiclone 1mg 2
• Avoid benzodiazepines due to increased risk of falls, confusion, and dependence 2
• Consider low-dose doxepin due to favorable safety profile 2

Alternative Options

• Low-dose melatonin (1-3mg) 1-2 hours before bedtime: Safer alternative with consistent effects on sleep latency 2
• Mirtazapine (7.5-15mg) or Nortriptyline (starting at 10mg): May be considered for patients with comorbid depression and insomnia 2

Treatment Algorithm

1. Initial Approach:

   • Start with CBT-I for all patients with chronic insomnia
   • Implement sleep hygiene education concurrently

2. If inadequate response after 4-8 weeks of CBT-I:

   • Identify specific insomnia type (onset vs. maintenance)
   • For sleep onset: Consider ramelteon or low-dose zolpidem
   • For sleep maintenance: Consider low-dose doxepin or eszopiclone
   • For elderly patients: Prefer doxepin or ramelteon

3. Monitoring and Follow-up:

   • Assess improvement within 2-4 weeks of starting any treatment
   • Monitor for side effects, particularly daytime sedation and falls
   • Use medications at lowest effective dose for shortest duration necessary
   • Reassess every few weeks until insomnia stabilizes, then every 6 months 2

Important Caveats

• Long-term use of sleep medications is generally not recommended 2
• Patients with history of substance use should prefer non-scheduled options like ramelteon or doxepin 2
• Consider periodic medication-free intervals to assess continued need for sleep aids 2
• Benzodiazepines should be avoided in elderly patients or those with cognitive impairment 2
• Consider referral to a sleep specialist if insomnia persists despite treatment or if sleep-disordered breathing is suspected 2