What are the recommended treatments for insomnia, including medications like zolpidem (non-benzodiazepine) and ramelteon (melatonin receptor agonist)?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be offered as first-line treatment for chronic insomnia disorder before pharmacological interventions. 1, 2

Non-Pharmacological Approaches

First-Line Treatment

• CBT-I: Strongly recommended as initial therapy for chronic insomnia
  • Effective for both standalone insomnia and insomnia comorbid with psychiatric disorders 1
  • Produces equivalent results to medication with no side effects and fewer relapses 3
  • Key components: sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques

Other Non-Pharmacological Options

• Auricular acupuncture with seed and pellet is suggested for chronic insomnia disorder 1
• NOT recommended as standalone treatments:
  • Sleep hygiene education alone (weak recommendation against) 1
  • Cranial electrical stimulation (weak recommendation against) 1

Pharmacological Options

Recommended Short-Course Medications

1. Low-dose doxepin (3-6mg):

   • Suggested for sleep maintenance insomnia 1, 2
   • Improves wake after sleep onset and total sleep time 2

2. Non-benzodiazepine receptor agonists:

   • Zolpidem (5-10mg):
     • Effective for sleep onset insomnia 2, 4
     • FDA-approved for both transient and chronic insomnia 4
     • Demonstrated superiority over placebo in objective measures of sleep latency and efficiency 4
   • Eszopiclone (2-3mg): Effective for sleep maintenance insomnia 2
   • Zaleplon (10mg): Useful for sleep onset insomnia 2

3. Ramelteon (8mg):

   • FDA-approved for insomnia characterized by difficulty with sleep onset 5
   • Reduces latency to persistent sleep compared to placebo in both adults and elderly 5
   • Minimal side effect profile compared to other sleep medications 6

Medications NOT Recommended

• Benzodiazepines (weak recommendation against) 1, 6
• Diphenhydramine (weak recommendation against) 1
• Melatonin (weak recommendation against) 1
• Valerian and chamomile (weak recommendation against) 1
• Kava (strong recommendation against) 1
• Antipsychotic drugs (weak recommendation against) 1
• Trazodone (weak recommendation against) 1

Treatment Algorithm

1. Start with CBT-I as first-line therapy

   • If unavailable or inadequate response after 4-6 weeks, proceed to medication

2. For pharmacological treatment, match medication to insomnia type:

   • Sleep onset difficulty: Ramelteon (8mg) or Zolpidem (5-10mg)
   • Sleep maintenance difficulty: Low-dose doxepin (3-6mg) or Suvorexant (10-20mg)
   • Both onset and maintenance: Eszopiclone (2-3mg) or extended-release zolpidem 2

3. Special considerations for elderly patients:

   • Use lower doses (zolpidem 5mg, eszopiclone 1mg)
   • Ramelteon has a particularly favorable safety profile in older adults 6

4. Medication duration:

   • Use for shortest duration possible (typically 2-4 weeks)
   • Re-evaluate efficacy after 4-6 weeks 2
   • If ineffective, consider switching medications rather than continuing ineffective therapy

Monitoring and Follow-up

• Schedule follow-up within 7-10 days of initiating treatment
• Monitor for side effects:
  • Zolpidem: potential for next-day residual effects, anterograde amnesia (particularly at doses >10mg) 4
  • Non-benzodiazepines: potential for cognitive impairment, falls (especially in elderly) 6
• Use standardized measures like Insomnia Severity Index to track progress 2

Important Caveats

• Avoid combining sedative medications due to increased risk of excessive sedation and cognitive impairment 2
• Avoid alcohol consumption with any sleep medication 2
• When discontinuing medications, use gradual tapering to prevent withdrawal symptoms and rebound insomnia 2
• Non-benzodiazepine agents (zolpidem, zaleplon) have better safety profiles than benzodiazepines but still carry risks of adverse effects 7