What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for chronic insomnia in adults, as it is more effective than pharmacotherapy for both short-term and long-term outcomes. 1

Treatment Algorithm

First-Line Treatment: Non-Pharmacological Approaches

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)
   • Most effective non-pharmacological intervention with level I evidence 1
   • Components include:
     • Sleep restriction therapy
     • Stimulus control therapy
     • Sleep hygiene education
     • Cognitive restructuring
     • Relaxation techniques
   • Effective for 70-80% of patients 2
   • Produces sustainable improvements with no side effects 3

Second-Line Treatment: Pharmacological Options

If CBT-I is insufficient or unavailable, consider pharmacotherapy based on insomnia type:

For Sleep Onset Insomnia:

• Ramelteon 8mg - FDA-approved for sleep onset difficulties with favorable safety profile 4
• Zolpidem 10mg (5mg in elderly) - Effective for reducing sleep latency 1, 5
• Zaleplon 10mg - Short half-life, good for sleep initiation 1

For Sleep Maintenance Insomnia:

• Doxepin 3-6mg - Low-dose option with minimal side effects 1
• Eszopiclone 2-3mg - Effective for maintaining sleep 1
• Suvorexant 10-20mg - Orexin receptor antagonist 1
• Temazepam 15mg - Benzodiazepine option 1

Alternative Option:

• Melatonin 1-3mg (1-2 hours before bedtime) - Safer alternative with modest effects on sleep latency 1

Special Population Considerations

Elderly Patients

• Use lower doses of all medications
• Avoid benzodiazepines due to fall risk
• Preferred options: ramelteon or low-dose doxepin 1

Patients with Substance Use History

• Prefer non-scheduled medications like ramelteon or doxepin 1

Patients with Respiratory Conditions

• Use caution with sedating medications
• Consider lower doses: zolpidem 5mg, doxepin 3mg 1

Medication Evidence and Considerations

Ramelteon

• Reduces latency to persistent sleep compared to placebo 4
• No evidence of abuse potential even at 20 times therapeutic dose 4
• 8mg dose is effective; 16mg confers no additional benefit 4

Zolpidem

• Superior to placebo for sleep latency and efficiency 5
• Potential side effects include next-day residual effects and anterograde amnesia, particularly at doses above 10mg 5
• Effective for both transient and chronic insomnia 5

Monitoring and Follow-up

• Assess improvement in sleep parameters within 2-4 weeks of starting treatment 1
• Monitor for side effects, particularly:
  • Daytime sedation
  • Falls
  • Cognitive changes
• Consider referral to sleep specialist if insomnia persists or sleep-disordered breathing is suspected 1

Common Pitfalls to Avoid

1. Overreliance on medication - Despite the effectiveness of CBT-I, patients and providers often default to pharmacological options first 3

2. Prolonged use of hypnotics - Benzodiazepines and non-benzodiazepine hypnotics can cause dependence, tolerance, and withdrawal when used long-term 1

3. Ignoring comorbid conditions - Insomnia often co-occurs with psychiatric and medical conditions that may require specific management 6

4. Inadequate dose adjustment for vulnerable populations - Elderly patients and those with respiratory conditions require lower doses to avoid adverse effects 1

5. Failure to address perpetuating factors - Even when insomnia begins due to a specific cause, it is often perpetuated by learned behaviors and cognitions that foster sleeplessness 2