What are the treatment guidelines for insomnia?

Treatment Guidelines for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for chronic insomnia disorder in adults due to its effectiveness in improving sleep quality with equivalent results to medication but without side effects. 1, 2

First-Line Treatment: Non-Pharmacological Approaches

Recommended Behavioral and Psychological Treatments:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I)

   • Strong recommendation by the American Academy of Sleep Medicine 1
   • Produces sustained benefits without risks of tolerance or adverse effects 3
   • Effective for both primary and secondary insomnia 4

2. Single-Component Therapies (if full CBT-I is not available):

   • Stimulus Control Therapy - Conditional recommendation 1
   • Sleep Restriction Therapy - Conditional recommendation 1
   • Relaxation Therapy - Conditional recommendation 1
   • Multicomponent Brief Therapies - Conditional recommendation 1

3. Not Recommended as Single-Component Therapy:

   • Sleep Hygiene alone - Conditional recommendation against 1
   • Should be incorporated as part of comprehensive treatment but not used alone

Second-Line Treatment: Pharmacological Options

When patients cannot participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I, medication may be considered 1:

For Sleep Onset Insomnia:

• Zolpidem: 10mg for adults, 5mg for elderly 2, 5

  • FDA-approved for short-term treatment of difficulties with sleep initiation
  • Decreases sleep latency for up to 35 days in controlled studies

• Ramelteon: 8mg 2, 6

  • FDA-approved for treatment of insomnia characterized by difficulty with sleep onset
  • Reduces sleep onset latency by approximately 10 minutes in older adults
  • Favorable safety profile with no evidence of cognitive impairment, rebound insomnia, or withdrawal effects

For Sleep Maintenance Insomnia:

• Eszopiclone: 2-3mg for adults, 1mg for elderly 2, 7

  • FDA-approved for treatment of insomnia
  • Decreases sleep latency and improves sleep maintenance

• Suvorexant: 10-20mg 2

  • Moderate evidence supporting effectiveness

• Low-dose doxepin: 3-6mg 2

  • Moderate evidence supporting effectiveness

Treatment Algorithm

1. Initial Assessment:

   • Establish diagnosis using ICSD-3 or DSM-5 criteria
   • Use a 2-week sleep diary to document patterns
   • Identify specific insomnia type (onset vs. maintenance)

2. First-Line Treatment:

   • Implement full CBT-I when available
   • If full CBT-I is not accessible, use single-component therapies (stimulus control, sleep restriction, or relaxation therapy)

3. If Inadequate Response to Non-Pharmacological Treatment:

   • For sleep onset insomnia: Consider zolpidem or ramelteon
   • For sleep maintenance insomnia: Consider eszopiclone, suvorexant, or low-dose doxepin

4. Monitoring and Follow-up:

   • Schedule follow-up within 7-10 days of initiating treatment
   • Use standardized assessment tools like Insomnia Severity Index
   • Evaluate treatment response after 4-6 weeks
   • Consider medication adjustment or switching if ineffective

5. Long-Term Management:

   • Aim to taper and discontinue medications when possible
   • Continue behavioral strategies indefinitely
   • Gradually taper medications to prevent withdrawal symptoms

Important Considerations and Pitfalls

• Avoid Common Pitfalls:

  • Do not rely solely on sleep hygiene as treatment 1
  • Avoid routine use of over-the-counter antihistamines 8
  • Do not use alcohol as a sleep aid due to abuse potential 8
  • Be cautious with long-term benzodiazepine use due to adverse effects and withdrawal phenomena 8

• Special Populations:

  • For older adults: Use lower doses of medications and prefer non-benzodiazepines 2
  • For patients with comorbid depression: Consider mirtazapine 2
  • For patients with chronic pain and insomnia: Opiates may be valuable 8

• Safety Monitoring:

  • Monitor for weight gain with medications like mirtazapine
  • Be aware that multiple sedating medications increase fall risk, especially in older adults
  • Consider the potential for medication interactions

The newer-generation non-benzodiazepines (zolpidem, zaleplon, eszopiclone, and ramelteon) have better safety profiles than benzodiazepines, making them preferred choices for pharmacological treatment when needed 8.