What are the recommended treatments for insomnia, specifically regarding the use of sleeping tablets?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for chronic insomnia, with pharmacological options considered only for patients who cannot participate in CBT-I, who continue to have symptoms despite CBT-I, or as a temporary adjunct to CBT-I. 1

Non-Pharmacological Treatments

First-Line Treatment: CBT-I

• CBT-I is the standard of care with the most favorable benefit-to-risk ratio 1, 2
• Components include:
  • Sleep restriction therapy (limiting time in bed)
  • Stimulus control (associating bed with sleep only)
  • Cognitive restructuring (addressing negative thoughts about sleep)
  • Relaxation techniques
  • Sleep hygiene education (as an adjunct, not standalone treatment) 2
• Produces results equivalent to medication with no side effects, fewer relapses, and continued improvement after treatment ends 3

Other Non-Pharmacological Options

• Exercise has shown effectiveness comparable to benzodiazepines in some studies 4
• Mindfulness and acupuncture may provide benefit 5

Pharmacological Treatment Algorithm

When to Consider Medication

Only consider medications when:

1. Patient cannot participate in CBT-I
2. Patient continues to have symptoms despite CBT-I
3. As a temporary adjunct to CBT-I 1

First-Line Pharmacological Options

For sleep onset insomnia (difficulty falling asleep):

• Suvorexant (dual orexin receptor antagonist) 1, 5
• Eszopiclone (non-benzodiazepine) 1
• Zaleplon (non-benzodiazepine) 1
• Zolpidem (non-benzodiazepine) - indicated specifically for short-term treatment of sleep initiation difficulties 1, 6
• Ramelteon (melatonin receptor agonist) - specifically indicated for sleep onset insomnia 1, 7
• Triazolam (benzodiazepine) 1

For sleep maintenance insomnia (difficulty staying asleep):

• Suvorexant 1, 5
• Eszopiclone 1
• Zolpidem 1
• Temazepam (benzodiazepine) 1
• Doxepin (low-dose) 1

Medications to Avoid

The following are explicitly not recommended for insomnia:

• Trazodone 1
• Tiagabine 1
• Diphenhydramine and other antihistamines 1
• Melatonin (not prescription ramelteon) 1
• Tryptophan 1
• Valerian 1

Medication Selection Considerations

When selecting a medication:

1. Match the drug to the specific sleep complaint (onset vs. maintenance)
2. Use the lowest effective dose for the shortest period possible 1
3. Consider:
   • Patient's age (avoid long-acting benzodiazepines in older adults) 1
   • Comorbid conditions
   • Potential drug interactions
   • Side effect profile
   • Risk of dependence

Important Cautions

• Zolpidem and other sedative-hypnotics can cause complex sleep behaviors (sleep-driving, sleep-eating, etc.) that may lead to serious injury 6
• Benzodiazepines should be used short-term only, as long-term use may lead to adverse effects and withdrawal phenomena 4
• Patients should be able to dedicate 7-8 hours to sleep when taking sleep medications 6
• Alcohol should never be used as a sleep aid and should not be combined with sleep medications 6, 4
• Newer non-benzodiazepines (zolpidem, zaleplon, eszopiclone) have better safety profiles than traditional benzodiazepines for long-term use 4

Follow-Up and Monitoring

• Assess effectiveness of treatment within 7-10 days
• If insomnia worsens or doesn't improve within this timeframe, reevaluate for underlying conditions 6
• For pharmacotherapy, regularly reassess the need for continued treatment
• Monitor for side effects, especially with long-term use of benzodiazepines and non-benzodiazepines

By following this evidence-based approach to insomnia treatment, prioritizing CBT-I and carefully selecting appropriate pharmacotherapy when necessary, clinicians can effectively address insomnia while minimizing risks and optimizing patient outcomes.