What can I add to my treatment for insomnia?

Treatment Options for Insomnia

For insomnia treatment, cognitive behavioral therapy for insomnia (CBT-I) should be initiated as first-line therapy, with medications such as low-dose doxepin (3-6mg) or ramelteon (8mg) added if CBT-I is insufficient, as these options have minimal addiction potential and favorable safety profiles. 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as the initial approach for treating insomnia with high-quality evidence supporting its effectiveness 1. CBT-I components include:

• Sleep Restriction Therapy: Limit time in bed to match actual sleep time based on 2-week sleep logs, gradually increasing time in bed by 15-20 minutes every 5 days as sleep efficiency improves
• Stimulus Control: Associate bedroom only with sleep and sex, leave bedroom if unable to fall asleep within 15-20 minutes, return only when sleepy
• Sleep Hygiene Education: Maintain consistent sleep-wake schedule, limit daytime naps to 30 minutes before 2 PM, avoid caffeine/alcohol/nicotine in evening
• Relaxation Techniques: Progressive muscle relaxation, guided imagery, diaphragmatic breathing, meditation

Second-Line Treatment: Medication Options

If CBT-I alone is insufficient after 4-6 weeks of consistent implementation, consider adding medication based on specific insomnia type:

For Sleep Onset Insomnia:

1. Ramelteon (8mg): A melatonin receptor agonist with no abuse potential, well-tolerated with minimal side effects 1, 2
2. Zolpidem (10mg adults, 5mg elderly): Effective for decreasing sleep latency but has risks of tolerance and dependence 1, 3

For Sleep Maintenance Insomnia:

1. Low-dose Doxepin (3-6mg): Effective for sleep maintenance with minimal addiction potential 1
2. Eszopiclone (2-3mg, 1mg for elderly): Effective for sleep maintenance but use with caution due to risk of cognitive impairment and falls 1

Medication Efficacy Comparison

Medication	Sleep Onset	Sleep Maintenance	Sleep Quality
Ramelteon	Significant improvement	Limited effect	Not well-reported
Doxepin (3-6mg)	Modest (22%) improvement	Effective	Improved
Eszopiclone	Moderate improvement	10-14 min improvement	Moderate-to-Large improvement
Zolpidem	Moderate improvement	25 min improvement	Moderate improvement

Important Considerations and Cautions

• Benzodiazepines should be avoided as first-line agents due to risks of tolerance, dependence, withdrawal seizures, and cognitive impairment 1
• Z-drugs (zolpidem, eszopiclone) should be prescribed with caution due to risks of cognitive impairment and falls 1
• For elderly patients, use lower doses of medications (zolpidem 5mg, eszopiclone 1mg) and avoid benzodiazepines 1, 3
• Zolpidem should not be taken with or immediately after meals as food decreases absorption and delays onset of action 3
• Regular physical activity like walking and Tai Chi can improve sleep quality in older adults, with benefits comparable to medication 1

Monitoring and Follow-up

• Use standardized measures like the Insomnia Severity Index (ISI) to track progress
• Schedule follow-up within 7-10 days of initiating treatment
• Monitor for treatment response after 4-6 weeks of therapy
• If initial treatment is ineffective after 4-6 weeks, consider switching medications or augmentation strategies
• Implement gradual tapering when discontinuing medications to prevent withdrawal symptoms 1

Alternative Options

• Melatonin: May be considered at doses of 1-5mg for adults, with evidence showing it can reduce sleep latency with minimal side effects 4, 5
• Mirtazapine: Consider for patients with comorbid depression and insomnia (7.5-15mg), with lower doses having more pronounced sedative effects 1
• Trazodone: May be considered for patients with comorbid depression and insomnia, but use with caution in patients with cardiac conditions due to potential QT prolongation 1

Remember that insomnia medications should be used for the shortest duration possible, with the goal of addressing the underlying causes of sleep disturbance while implementing sustainable behavioral changes through CBT-I.