What is the best approach to start treating a patient complaining of insomnia?

Treatment Approach for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for patients with insomnia, with pharmacological interventions reserved for cases where CBT-I is ineffective or unavailable. 1

Non-Pharmacological Interventions (First-Line)

Sleep Hygiene Education

• Maintain stable bed times and rising times; arise at the same time each morning regardless of sleep obtained 1
• Avoid daytime napping (if necessary, limit to 30 minutes before 2 PM) 1
• Avoid heavy exercise within 2 hours of bedtime 1
• Avoid sleep-fragmenting substances (caffeine, nicotine, alcohol) 1
• Use bedroom only for sleep and sex; avoid watching TV or working in bed 1
• Leave the bedroom if unable to fall asleep and return only when sleepy 1

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• The American Academy of Sleep Medicine strongly recommends CBT-I as initial treatment based on moderate quality evidence 1

• Components include:

  • Cognitive therapy (identifying and challenging dysfunctional beliefs about sleep)
  • Stimulus control (associating bedroom with sleep only)
  • Sleep restriction (limiting time in bed to maximize sleep efficiency)
  • Relaxation techniques (progressive muscle relaxation, guided imagery, diaphragmatic breathing)
  • Paradoxical intention (removing fear of sleep by advising to remain awake)

• CBT-I typically involves 4-8 weekly sessions of 60-90 minutes each 2

• Studies show 70-80% of patients benefit from these interventions with sustained improvements for at least 6 months 3

Pharmacological Interventions (Second-Line)

If CBT-I is ineffective, unavailable, or if rapid symptom relief is needed while waiting for CBT-I to take effect:

First-Line Medications

• Non-benzodiazepine receptor agonists (e.g., eszopiclone): Start at lowest available dose 1

  • Monitor for CNS depressant effects and next-day impairment 4
  • Caution patients about driving or hazardous activities the day after use 4

• Melatonin receptor agonist: Consider for older adults (>55 years) 1

  • Has not demonstrated significant potential for abuse or motor/cognitive impairment 1

Second-Line Medications

• Benzodiazepines (e.g., temazepam): Use with caution due to risk of dependence 1, 5
  • Start at lowest available dose 1
  • Prescribe for short-term use only 1
  • Monitor for abuse, misuse, addiction, and withdrawal reactions 5
  • Elderly patients are at higher risk for adverse effects including falls 5

Important Considerations

• Evaluate for underlying conditions: Persistent insomnia (>7-10 days) may indicate an underlying physical or psychiatric disorder 5, 4

• Monitor for behavioral changes: Sedative-hypnotics can cause abnormal thinking and behavioral changes including decreased inhibition, aggressiveness, hallucinations, and complex behaviors like "sleep-driving" 5, 4

• Risk assessment: Before prescribing any benzodiazepine, assess patient's risk for abuse, misuse, and addiction 5

• Discontinuation: Use a gradual taper when discontinuing benzodiazepines to reduce withdrawal risk 5

• Combination therapy: When pharmacotherapy is necessary, it should ideally be accompanied by cognitive-behavioral therapies 1

Treatment Algorithm

1. Start with CBT-I and sleep hygiene education
2. If inadequate response after 4-6 weeks or CBT-I unavailable:
   • For adults <55 years: Consider non-benzodiazepine receptor agonist at lowest effective dose
   • For adults >55 years: Consider melatonin receptor agonist
3. Reserve benzodiazepines for short-term use when other options have failed
4. Reassess regularly for efficacy, side effects, and continued need for medication