What are the recommended management strategies for insomnia?

Management of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered the first-line treatment for chronic insomnia due to its proven efficacy, long-term benefits, and minimal side effects. 1, 2

First-Line Treatment: CBT-I

CBT-I is a multicomponent treatment that includes:

• Stimulus Control Therapy:

  • Going to bed only when sleepy
  • Using bed only for sleep and sex
  • Leaving bed if unable to sleep within 15-20 minutes
  • Maintaining regular wake-up time regardless of sleep duration 2

• Sleep Restriction Therapy:

  • Limiting time in bed to match actual sleep time
  • Gradually increasing time in bed as sleep efficiency improves
  • Targeting sleep efficiency >85% 1, 2

• Cognitive Therapy:

  • Targeting maladaptive thoughts and beliefs about sleep 1

• Relaxation Training:

  • Progressive muscle relaxation
  • Deep breathing exercises
  • Meditation techniques 2

Evidence strongly supports CBT-I's effectiveness, with improvements in insomnia severity, sleep efficiency, sleep quality, and reduced wake time after sleep onset 1. CBT-I has been shown to be more effective than several pharmacotherapies, with equivalent short-term results (2-4 weeks) but superior long-term outcomes 1.

Pharmacological Interventions (Second-Line)

When CBT-I is not immediately available or for short-term management, the following medications may be considered:

For Sleep Onset Insomnia:

• Ramelteon 8mg
• Zolpidem 10mg (5mg for elderly)
• Zaleplon 10mg 2, 3

For Sleep Maintenance Insomnia:

• Doxepin 3-6mg
• Eszopiclone 2-3mg
• Suvorexant 10-20mg 2

Ramelteon has been shown to reduce latency to persistent sleep compared to placebo in clinical trials, though the 16mg dose confers no additional benefit for sleep initiation 3.

Important Considerations and Pitfalls

1. Avoid Sleep Hygiene Education Alone:

   • Sleep hygiene education should not be considered a first-line therapy for chronic insomnia 1, 4
   • It may be ineffectual as standalone treatment and potentially harmful if it delays referral for effective treatments like CBT-I 1
   • Should be considered an adjunct to other empirically supported treatments 4

2. Special Considerations for Elderly Patients:

   • Start with lower medication doses
   • Avoid benzodiazepines due to increased risk of falls and cognitive impairment 2

3. Medication Cautions:

   • Hypnotic medications should be considered short-term solutions only
   • There is a lack of clear harms data for pharmacologic treatments beyond brief treatment periods 1
   • Monitor for side effects, particularly with higher doses

4. Treatment Delivery Options:

   • Traditional face-to-face CBT-I
   • Telehealth delivery platforms
   • Self-directed Internet-based programs
   • Group delivery of CBT-I 1

Treatment Algorithm

1. Initial Approach: Begin with CBT-I as first-line treatment
2. If CBT-I is not immediately available: Consider brief behavioral treatment for insomnia (BBT-I) focusing on behavioral components only
3. For acute/short-term management: Consider appropriate pharmacotherapy based on insomnia type (onset vs. maintenance)
4. For patients with comorbidities: CBT-I remains effective for insomnia comorbid with psychiatric and medical conditions 2
5. Follow-up: Schedule within 2-4 weeks to assess effectiveness and side effects 2

CBT-I has been shown to be effective in 70-80% of patients with chronic insomnia 5, making it the clear first choice for management. While pharmacotherapy may provide immediate relief, the potential benefits of CBT-I outweigh the potential harms and burden of medication, especially considering the long-term outcomes.