Medications for Insomnia and Sleep Disorders
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia, with pharmacological options including zolpidem, zaleplon, ramelteon, doxepin, eszopiclone, and suvorexant as second-line therapies for specific insomnia patterns. 1
First-Line Treatment
CBT-I is recommended as the initial treatment for chronic insomnia by the American Academy of Sleep Medicine due to its proven efficacy and minimal side effects 1. CBT-I components include:
- Stimulus control therapy
- Sleep restriction therapy
- Relaxation training
- Cognitive restructuring
- Sleep hygiene education
Pharmacological Options
When medication is necessary, selection should be based on the specific insomnia pattern:
For Sleep Onset Insomnia:
Zolpidem: 10mg for adults, 5mg for elderly 1, 2
- FDA-approved for short-term treatment of insomnia with difficulties in sleep initiation
- Shown to decrease sleep latency for up to 35 days in controlled studies 2
Zaleplon: 10mg 1
- Short half-life makes it ideal for sleep initiation without morning hangover
For Sleep Maintenance Insomnia:
Doxepin: 3-6mg 1
- Particularly effective for sleep maintenance with minimal anticholinergic effects at low doses
Temazepam: 15mg 1
- Benzodiazepine with intermediate half-life
- Caution: Avoid in elderly due to fall risk and cognitive impairment
Suvorexant: 10-20mg 1
- Orexin receptor antagonist
- Particularly effective for sleep maintenance
Medication Efficacy Comparison
| Medication | Sleep Onset Improvement | Sleep Maintenance Improvement | Quality of Sleep Improvement |
|---|---|---|---|
| Ramelteon | Significant reduction in sleep latency | Limited effect | Not reported |
| Doxepin (3-6mg) | Modest (22%) improvement | Effective | Improved |
| Eszopiclone | Moderate | 10-14 min improvement | Moderate-to-Large |
| Suvorexant | Limited | 16-28 min improvement | Not reported |
| Zolpidem | Moderate | 25 min improvement | Moderate |
Special Populations
Elderly Patients:
- Start with lower medication doses (zolpidem 5mg, doxepin 3mg)
- Avoid benzodiazepines due to increased risk of falls and cognitive impairment 1
- Eszopiclone 2mg has shown benefits in both sleep induction and maintenance with improved daytime functioning 4
Patients with Comorbidities:
- With Depression: Consider mirtazapine (15-30mg) or trazodone (50-100mg for sleep; 150-300mg for antidepressant effect) 1
- With Seizure Disorders: Melatonin or ramelteon are safer options with minimal drug interactions 1
Important Precautions
- Avoid benzodiazepines when possible due to high risk of falls, cognitive impairment, and dependency 1
- Avoid quetiapine for insomnia treatment due to significant safety concerns 1
- Monitor for next-day residual effects, particularly with higher doses of zolpidem (>10mg) 2
- Anterograde amnesia can occur with zolpidem, predominantly at doses above 10mg 2
- Schedule follow-up within 2-4 weeks to assess medication effectiveness and side effects 1
Medication Administration Guidelines
- Administer sleep medications 30-60 minutes before desired sleep time 1
- Start with the lowest effective dose, especially in elderly patients or those with liver impairment 1
- For chronic insomnia, newer generation non-benzodiazepines (zolpidem, zaleplon) are considered first-line pharmacotherapy 5
Common Pitfalls to Avoid
- Using medications as first-line treatment instead of CBT-I
- Prescribing benzodiazepines for elderly patients
- Continuing hypnotic medications beyond recommended short-term use without reassessment
- Failing to address underlying medical or psychiatric conditions contributing to insomnia
- Not considering potential drug interactions with existing medications
Remember that pharmacotherapy should be initiated only in patients with inadequate response to CBT-I and should be tailored to specific insomnia patterns and comorbidities 6.