What are the first line treatments for insomnia?

First-Line Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia in adults. 1, 2

Evidence-Based Treatment Algorithm

Step 1: Non-Pharmacological Interventions (First-Line)

CBT-I is the gold standard first-line treatment and consists of several components:

• Stimulus Control Therapy

  • Go to bed only when sleepy
  • Use bed only for sleep and sex
  • Leave bed if unable to sleep within 15-20 minutes
  • Maintain regular wake-up time regardless of sleep duration 2

• Sleep Restriction Therapy

  • Limit time in bed to match actual sleep time
  • Gradually increase time in bed as sleep efficiency improves
  • Target sleep efficiency >85% 2

• Cognitive Therapy

  • Addresses maladaptive thoughts and beliefs about sleep 1

• Relaxation Training

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

• Sleep Hygiene Education (as part of CBT-I, not as standalone therapy)

  • Information about caffeine, alcohol, and nicotine use
  • Exercise recommendations
  • Sleep environment optimization
  • Sleep-wake regularity and nap avoidance
  • Stress management 1

Step 2: Delivery Methods for CBT-I

Multiple effective delivery options exist:

• Traditional face-to-face individual sessions
• Group therapy
• Telehealth platforms
• Self-directed internet-based programs 1, 2, 3

Step 3: Pharmacological Options (Second-Line)

If CBT-I is unsuccessful or unavailable, consider pharmacotherapy 1:

For sleep onset insomnia:

• Ramelteon 8mg (preferred in elderly due to lower risk profile) 2, 4
• Zolpidem 10mg (5mg in elderly) 2
• Zaleplon 10mg 2

For sleep maintenance insomnia:

• Doxepin 3-6mg (preferred in elderly due to lower risk profile) 2
• Eszopiclone 2-3mg 2
• Temazepam 15mg 2
• Suvorexant 10-20mg 2

Important Clinical Considerations

1. Sleep Hygiene Alone Is Insufficient

   • Sleep hygiene education should not be used as a standalone treatment for chronic insomnia 1, 5
   • May be harmful if it delays referral for effective treatments like CBT-I 1

2. Pharmacotherapy Concerns

   • Short-term efficacy similar to CBT-I but inferior long-term outcomes 1
   • Associated with potential risks including:
     • Dementia
     • Fractures
     • Major injuries
     • Daytime memory and psychomotor impairment
     • Abnormal thinking and behavioral changes 2

3. Treatment Monitoring

   • Follow-up within 2-4 weeks to assess effectiveness and side effects 2
   • For medications, start with lower doses in elderly patients or those with liver impairment 2
   • When discontinuing medications, implement gradual tapering to prevent withdrawal symptoms 2

4. Efficacy of CBT-I

   • Improves sleep onset latency by approximately 19 minutes 6
   • Improves wake after sleep onset by approximately 26 minutes 6
   • Improves sleep efficiency by approximately 9.9% 6
   • Benefits are typically sustained long-term 6

CBT-I represents a safe, effective approach with durable benefits and no significant adverse effects, making it clearly superior to pharmacological options for long-term management of chronic insomnia.