Treatments for Initiation of Sleep
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be recommended as the first-line treatment for sleep initiation problems, with pharmacological options considered only when CBT-I is unsuccessful or unavailable. 1
Non-Pharmacological Treatments
First-Line Treatment: CBT-I
CBT-I is the most evidence-based treatment for sleep initiation difficulties with a strong recommendation from clinical guidelines. It includes:
Stimulus Control Therapy: Instructions to:
- Use the bed only for sleep and sex
- Go to bed only when sleepy
- Leave the bed if unable to fall asleep within 15-20 minutes
- Return only when sleepy
- Maintain a consistent wake time
Sleep Restriction Therapy: Limiting time in bed to match actual sleep time, gradually increasing as sleep efficiency improves
Cognitive Therapy: Addressing unhelpful beliefs and attitudes about sleep
Relaxation Techniques: Progressive muscle relaxation, deep breathing exercises
CBT-I can be delivered through various modalities:
- Individual in-person sessions
- Group therapy
- Internet-based programs
- Self-help books
Other Behavioral Treatments
When full CBT-I is not available, the following single-component therapies have conditional recommendations 1:
- Brief Behavioral Therapy for Insomnia (BBT-I): Simplified version of CBT-I
- Sleep Restriction Therapy: Used alone
- Stimulus Control: Used alone
- Relaxation Therapy: Used alone
Treatments with Insufficient Evidence
The following have insufficient evidence when used alone 1:
- Paradoxical intention
- Intensive sleep retraining
- Biofeedback
- Cognitive therapy alone
- Mindfulness
Pharmacological Treatments
Pharmacological options should only be considered when CBT-I is unsuccessful or unavailable 1. All medications for sleep initiation have weak recommendations.
FDA-Approved Medications for Sleep Onset Insomnia:
Non-Benzodiazepine Receptor Agonists (Z-drugs):
Benzodiazepines:
Melatonin Receptor Agonists:
- Ramelteon (8mg): Specifically for sleep onset 1
Orexin Receptor Antagonists:
Not Recommended for Sleep Onset:
The following are not recommended for sleep onset insomnia 1:
- Trazodone
- Tiagabine
- Diphenhydramine
- Melatonin
- Tryptophan
- Valerian
Treatment Algorithm
Start with CBT-I as first-line treatment
- Allow 4-8 weeks for full effect
- Can be delivered in various formats based on availability
If CBT-I is unavailable or unsuccessful:
- Consider single-component behavioral treatments (stimulus control, sleep restriction)
If non-pharmacological approaches are insufficient:
- For younger adults without comorbidities: Consider Z-drugs (zolpidem, zaleplon, eszopiclone)
- For older adults or those with risk of falls/cognitive impairment: Consider ramelteon (lowest risk profile)
- For those with depression: Consider low-dose doxepin
Important cautions with medications:
- Use lowest effective dose
- Prescribe for short-term use (generally 2-4 weeks)
- Monitor for side effects, especially daytime sedation and cognitive impairment
- Avoid in older adults when possible due to increased risk of falls and cognitive impairment
Special Considerations
- Older adults: Higher risk of adverse effects with sedative-hypnotics; prefer non-pharmacological approaches
- Comorbid conditions: Address underlying conditions that may contribute to insomnia
- Pregnancy: Non-pharmacological approaches strongly preferred
- Substance use: Assess for alcohol or substance use that may affect sleep
Remember that sleep hygiene education alone is not effective for treating chronic insomnia but should be incorporated as part of a comprehensive treatment approach 1.