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, with medications considered as second-line options when non-pharmacological approaches are insufficient. 1

Treatment Algorithm

First-Line Treatment: Non-Pharmacological Approaches

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

   • Superior efficacy and safety compared to medications 1
   • Components include:
     • Sleep restriction
     • Stimulus control
     • Cognitive restructuring
     • Relaxation techniques
   • Effective for 70-80% of patients 2
   • Produces sustained benefits without risk of tolerance or adverse effects 3

2. Other Non-Pharmacological Options

   • Sleep hygiene education
   • Progressive muscle relaxation
   • Regular exercise
   • Mindfulness techniques 1, 4

Second-Line Treatment: Pharmacological Options

When non-pharmacological approaches are insufficient, medications may be considered based on insomnia type:

For Sleep Onset Insomnia:

• Ramelteon (8mg): No abuse potential, safe for patients with substance abuse history 1, 5
• Zolpidem (10mg for adults, 5mg for elderly): Effective for reducing sleep latency 1, 6
• Zaleplon (10mg) 1

For Sleep Maintenance Insomnia:

• Doxepin (3-6mg): Particularly suitable for elderly patients due to fewer anticholinergic effects 1
• Eszopiclone (2-3mg) 1
• Suvorexant (10-20mg) 1
• Temazepam (15mg) 1

For Comorbid Conditions:

• Depression/Anxiety: Consider trazodone (25-100mg) or mirtazapine (7.5-30mg) 1
• PTSD-related insomnia: Prazosin (first-line), clonidine, gabapentin, or topiramate 1

Special Considerations

Elderly Patients

• Prefer low-dose doxepin (3-6mg) 1
• For zolpidem, use reduced dose of 5mg 1, 6
• Consider ramelteon 4-8mg which has shown efficacy in this population 5

Patients with Substance Abuse History

• Ramelteon is preferred due to lack of abuse potential 1, 5
• Avoid benzodiazepines 1

Medications to Avoid

• Benzodiazepines for long-term use: Risk of dependency, cognitive impairment, falls, and respiratory depression 1
• Antihistamines: Antimuscarinic effects and rapid development of tolerance 1
• Antipsychotics (including quetiapine): Limited evidence, significant harms including increased mortality risk in elderly 1
• Alcohol: Short duration of action, adverse effects on sleep, exacerbation of sleep apnea 1

Monitoring and Follow-up

• Assess response to treatment within 2-4 weeks of initiation 1
• Monitor for side effects:
  • Daytime sedation
  • Orthostatic hypotension
  • Cognitive changes
  • Falls 1
• For pharmacological treatments, regularly reassess need and consider tapering 1

Common Pitfalls to Avoid

• Overreliance on medications: Despite their immediate effects, medications should not replace CBT-I as first-line treatment 1, 7
• Prolonged use of hypnotics: Can lead to tolerance, dependence, and rebound insomnia 1
• Inadequate dosing: Using higher than recommended doses increases risk of side effects without improving efficacy 1, 6
• Ignoring comorbidities: Untreated medical or psychiatric conditions can perpetuate insomnia 1, 8
• Anterograde amnesia: Can occur with zolpidem, particularly at doses above 10mg 6

Evidence Quality and Considerations

The recommendations from the American Academy of Sleep Medicine and American College of Physicians provide strong evidence for CBT-I as first-line treatment 1. Clinical trials support the efficacy of zolpidem and ramelteon for specific insomnia types 6, 5. Meta-analyses confirm CBT-I produces clinically meaningful improvements in sleep parameters 3. The evidence consistently shows that non-pharmacological approaches should be prioritized before medications due to their sustained benefits and lack of adverse effects 7, 4, 2, 8.