What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all patients with insomnia, due to its long-term efficacy, lack of side effects, and sustained benefits after treatment completion. 1, 2

First-Line Treatment: CBT-I

CBT-I is a multimodal therapy that includes several components:

• Sleep restriction: Limiting time in bed to match actual sleep time
• Stimulus control: Associating the bed with sleep only
• Cognitive restructuring: Addressing unhelpful beliefs about sleep
• Sleep hygiene education: Promoting habits that facilitate sleep
• Relaxation techniques: Methods to reduce physiological arousal

CBT-I can be delivered through various methods including:

• In-person individual or group therapy
• Telephone or web-based modules
• Self-help books
• Trained clinicians or mental health professionals 2

CBT-I has demonstrated superior long-term outcomes compared to medications, with continued improvement even after treatment ends 3. It achieves remission in 36% of patients compared to 16.9% in control conditions 4.

Second-Line Treatment: Pharmacologic Options

If CBT-I is insufficient or while waiting for CBT-I to take effect (typically 4-8 weeks), medications may be considered:

For Sleep Onset Insomnia:

• Ramelteon (8mg): FDA-approved for sleep onset difficulties with minimal side effects and no abuse potential 5
• Zolpidem (10mg adults, 5mg elderly): Effective for reducing sleep latency but has potential for tolerance 1, 6
• Zaleplon (10mg): Short-acting agent for sleep initiation 1

For Sleep Maintenance Insomnia:

• Doxepin (3-6mg): Low-dose for sleep maintenance with minimal side effects 1
• Eszopiclone (2-3mg, 1mg for elderly): Effective for sleep maintenance 1
• Suvorexant (10-20mg): Orexin receptor antagonist for sleep maintenance 1

Important Medication Considerations:

• Benzodiazepines (triazolam, estazolam, temazepam, flurazepam, quazepam) should be avoided as first-line agents due to risks of tolerance, dependence, withdrawal seizures, and cognitive impairment 2, 1
• Z-drugs (zolpidem, zaleplon, eszopiclone) should be prescribed with caution due to risks of cognitive impairment and falls 1
• Elderly patients should receive lower doses of medications and avoid benzodiazepines 1
• Medications should generally be prescribed for short periods only 7

Treatment Algorithm

1. Begin with CBT-I for all patients with insomnia

   • Allow 4-8 weeks for full effect
   • Continue CBT-I even if medications are added

2. If CBT-I is insufficient after adequate trial:

   • For sleep onset difficulties: Add ramelteon 8mg
   • For sleep maintenance issues: Add doxepin 3-6mg

3. For patients with specific comorbidities:

   • Depression and insomnia: Consider mirtazapine 7.5-15mg or trazodone
   • Elderly patients with fall risk: Low-dose eszopiclone (1mg)
   • Cardiovascular disease: Avoid benzodiazepines and tricyclic antidepressants

4. Monitor treatment effectiveness:

   • Use standardized measures like the Insomnia Severity Index (ISI)
   • Schedule follow-up within 7-10 days of initiating treatment
   • Consider referral to sleep specialist if insomnia persists despite multiple interventions

Special Considerations

• Older adults more commonly report problems with sleep maintenance rather than sleep onset 2
• Avoid routine use of over-the-counter antihistamines and alcohol as sleep aids 7
• Exercise has been shown to improve sleep as effectively as benzodiazepines in some studies 7
• Complementary approaches such as acupuncture and herbal medicine have been used but have less robust evidence 2

Despite being the most effective treatment, CBT-I remains underutilized due to limited availability of trained practitioners and greater awareness of pharmacological options through advertising 3. Healthcare providers should prioritize educating patients about CBT-I as the first-line treatment for chronic insomnia.