What are the treatment options for insomnia?

Treatment Options for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered the first-line treatment for chronic insomnia, with pharmacological interventions reserved for specific situations or as adjunctive therapy. 1

Non-Pharmacological Interventions

First-Line Treatment: CBT-I

• CBT-I is a comprehensive approach combining sleep hygiene education, stimulus control, sleep restriction, and cognitive restructuring
• Effects are sustained for up to 2 years 2
• Typically delivered in 4-10 weekly or biweekly sessions 3
• Targets maladaptive cognitions, behaviors, and arousal that perpetuate insomnia
• Multiple delivery modalities can be effective, including internet-based CBT-I 1

Other Evidence-Based Behavioral Treatments

1. Stimulus Control Therapy - Strongest evidence for efficacy as a single component (treatment standard) 1
2. Relaxation Training - Strong evidence for efficacy (guideline level) 1
3. Sleep Restriction Therapy - Effective as individual therapy 1
4. Mindfulness-Based Treatments - Emerging evidence for efficacy 1

Practical Sleep Hygiene Measures

• Regular sleep-wake schedule
• Avoiding caffeine, alcohol, and nicotine
• Creating a comfortable sleep environment
• Limiting daytime napping
• Developing a relaxing bedtime routine
• Morning light exposure to regulate circadian rhythms
• Regular daytime exercise (avoiding exercise within 3 hours of bedtime) 2

Important Note: Sleep hygiene alone is not effective as a single-component therapy and should be considered an adjunct to other empirically supported treatments 1, 3

Pharmacological Interventions

When to Consider Medication

• When CBT-I is not immediately available
• For short-term management of acute insomnia
• As adjunctive therapy with behavioral interventions
• When non-pharmacological approaches have failed

FDA-Approved Medications for Insomnia

For Sleep Onset Insomnia:

1. Zolpidem (10mg adults, 5mg elderly)

   • Decreases sleep latency for up to 35 days in controlled studies 4
   • Superior to placebo on objective measures of sleep latency and sleep efficiency 4

2. Ramelteon (8mg)

   • Effective for sleep onset with minimal next-day effects 2

3. Zaleplon (10mg) - Effective for sleep onset insomnia 2

For Sleep Maintenance Insomnia:

1. Eszopiclone

   • Improves sleep maintenance in controlled studies up to 6 months 5
   • Moderate improvement in sleep quality 2

2. Doxepin (3-6mg)

   • Effective for sleep maintenance with minimal next-day effects 2

3. Suvorexant (10-20mg)

   • 16-28 minute improvement in sleep maintenance 2

4. Temazepam (15mg) - Effective for sleep maintenance 2

Special Considerations for Medication Use

• Start with lowest effective dose, especially in elderly patients
• Use for shortest duration possible
• Monitor for side effects including:
  • Next-day residual effects (decreased performance on cognitive tests) 4
  • Potential for anterograde amnesia, particularly at higher doses 4
  • Risk of falls, especially in older adults 2
• Avoid benzodiazepines and medications with strong anticholinergic properties in patients with cognitive impairment 2

Treatment Algorithm

1. Initial Approach:

   • Begin with comprehensive CBT-I as first-line treatment
   • Include stimulus control, sleep restriction, and cognitive therapy components

2. If CBT-I is not immediately available or insufficient:

   • For sleep onset problems: Consider ramelteon (8mg) or zolpidem (10mg, 5mg in elderly)
   • For sleep maintenance problems: Consider low-dose doxepin (3-6mg) or eszopiclone (2-3mg)

3. For combined sleep onset and maintenance issues:

   • Consider eszopiclone or suvorexant

4. Follow-up within 2-4 weeks to assess effectiveness and adjust treatment as needed 2

Common Pitfalls to Avoid

1. Relying solely on sleep hygiene - While important, sleep hygiene alone is insufficient for treating chronic insomnia 3

2. Prolonged use of hypnotics - Can lead to tolerance, dependence, and rebound insomnia

3. Inadequate assessment - Failing to identify specific insomnia type (onset vs. maintenance) or underlying medical conditions

4. Overlooking comorbidities - Insomnia often coexists with psychiatric or medical disorders that require specific management

5. Ignoring drug interactions - Particularly important with sedating medications that may have additive effects

By following this evidence-based approach, clinicians can effectively manage insomnia while minimizing risks and maximizing benefits for patients.