What are the recommendations for managing insomnia?

Management of Insomnia

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for chronic insomnia due to its proven efficacy, safety, and long-term benefits. 1

Non-Pharmacological Approaches

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I combines multiple behavioral treatments and has been shown to be highly effective in treating insomnia in all age groups, with effects sustained for up to 2 years 1. It includes:

• Sleep restriction/compression therapy:

  • Limit time in bed to match actual sleep time
  • Gradually increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 1

• Stimulus control:

  • Go to bed only when sleepy
  • Use bedroom only for sleep and sex
  • Leave bedroom if unable to fall asleep
  • Maintain consistent wake times 1

• Sleep hygiene practices:

  • Develop a sleep ritual (30-minute relaxation before bed)
  • Make bedroom comfortable and restful
  • Avoid heavy exercise within 2 hours of bedtime
  • Avoid caffeine, nicotine, and alcohol
  • Maintain stable bed and wake times
  • Limit daytime napping to 30 minutes before 2 PM 1

• Relaxation techniques:

  • Progressive muscle relaxation
  • Guided imagery
  • Diaphragmatic breathing
  • Meditation 1

Other Non-Pharmacological Options

• Exercise: Regular physical activity, particularly walking, Tai Chi, and weight training may improve sleep 1
• Mindfulness practices 2
• Acupuncture may be beneficial for some individuals 2

Pharmacological Approaches (When CBT-I Is Insufficient)

When non-pharmacological approaches are insufficient, a shared decision-making approach should be used to determine whether pharmacotherapy is appropriate 1.

FDA-Approved Medications for Insomnia:

1. Short-acting benzodiazepines:

   • Should be used for short periods (7-10 days) 3
   • For elderly or debilitated patients, start with lower doses (7.5 mg for temazepam) 3
   • Use with caution due to risks of dependence, withdrawal, and side effects 3
   • Avoid in older patients and those with cognitive impairment 4

2. Non-benzodiazepine hypnotics (Z-drugs):

   • Zolpidem: Use lower doses (5mg immediate-release or 6.25mg extended-release) 4
   • Use with caution due to risk of next-morning impairment 4

3. Orexin receptor antagonists:

   • Effective for sleep maintenance insomnia and difficulty with sleep onset 2

4. Melatonin receptor agonists:

   • Ramelteon
   • Safer and well-tolerated but with limited effectiveness 2
   • For older adults (>55 years), prolonged-release melatonin is recommended as a first-line pharmacological option 1

5. Low-dose doxepin 1

Other Pharmacological Options:

• Sedating antidepressants (trazodone, mirtazapine):

  • May be effective, particularly in patients with comorbid depression 4
  • Limited evidence for efficacy specifically for insomnia 1

• Melatonin:

  • May be used at 3mg 30-60 minutes before bedtime, can be titrated up to 5mg if needed 4

Important Considerations and Cautions

• Avoid long-term use of benzodiazepines and Z-drugs due to risks of dependence, withdrawal reactions, and side effects including cognitive impairment 3

• Taper medications gradually when discontinuing to reduce withdrawal reactions 3

• Monitor for complex behaviors such as sleep-driving, which can occur with sedative-hypnotics, particularly when combined with alcohol or other CNS depressants 3

• Antihistamines have limited evidence for efficacy in treating insomnia, though doxylamine may be effective for up to four weeks 2

• Evaluate for underlying conditions that may cause or exacerbate insomnia, such as sleep apnea, restless legs syndrome, or psychiatric disorders 1

When to Refer to a Sleep Specialist

Consider referral when:

• Symptoms persist despite appropriate treatment
• There are signs of primary sleep disorders requiring polysomnography
• Severe anxiety or panic attacks are not responding to first-line treatment 4
• Patient has a suboptimal response to treatment 5

By implementing these evidence-based strategies in a stepwise approach, most patients with insomnia can achieve significant improvement in sleep quality and daytime functioning.