What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adult patients with chronic insomnia disorder. 1 This recommendation is based on moderate-quality evidence showing that CBT-I improves global sleep outcomes without the risks associated with pharmacological interventions.

First-Line Treatment: CBT-I

CBT-I consists of several components:

• Cognitive therapy: Addresses misconceptions and worries about sleep
• Stimulus control: Associates the bed with sleep rather than wakefulness
• Sleep restriction: Limits time in bed to increase sleep efficiency
• Sleep hygiene education: Promotes habits conducive to sleep
• Relaxation techniques: Reduces physical and mental tension

CBT-I has demonstrated significant benefits:

• Improves sleep onset latency by 19 minutes 2
• Improves wake after sleep onset by 26 minutes 2
• Increases sleep efficiency by 9.91% 2
• Effects are sustained long-term 2, 3
• Works for both primary insomnia and insomnia comorbid with medical or psychiatric conditions 4

CBT-I can be delivered through:

• Individual therapy
• Group therapy 5
• Telephone or web-based modules
• Self-help books

Pharmacological Options (When CBT-I Alone Is Unsuccessful)

If CBT-I is unsuccessful, pharmacological therapy may be considered using a shared decision-making approach 1. The following medications have evidence supporting their use:

For Sleep Onset Insomnia:

1. Ramelteon (weak recommendation) 1, 6

   • FDA-approved for insomnia characterized by difficulty with sleep onset
   • Reduced latency to persistent sleep in clinical trials
   • Lower risk of next-day impairment compared to other sleep medications

2. Suvorexant 7

   • FDA-approved for difficulties with sleep onset and/or maintenance

3. Zolpidem (weak recommendation) 1

   • Effective for sleep onset insomnia
   • Use with caution: risk of next-morning impairment
   • Lower doses recommended for women and older adults (5mg immediate-release or 6.25mg extended-release) 8

4. Triazolam (weak recommendation) 1

   • Short-acting benzodiazepine effective for sleep onset insomnia

For Sleep Maintenance Insomnia:

1. Doxepin (weak recommendation) 1

   • Particularly effective for sleep maintenance insomnia

2. Eszopiclone (weak recommendation) 1

   • Improves both sleep onset and maintenance

3. Temazepam (weak recommendation) 1

   • Effective for both sleep onset and maintenance insomnia

Medications NOT Recommended:

The following medications are explicitly not recommended for insomnia treatment 1:

• Trazodone (weak recommendation against use)
• Tiagabine (weak recommendation against use)
• Diphenhydramine (weak recommendation against use)
• Melatonin (weak recommendation against use for general adult population)
• Tryptophan (weak recommendation against use)
• Valerian (weak recommendation against use)

Special Considerations

Older Adults and Those with Cognitive Impairment:

• Avoid benzodiazepines due to risk of decreased cognitive performance 8
• Use zolpidem with caution due to risk of next-morning impairment 8
• Consider melatonin as a safer option in older adults with Alzheimer's disease 8

Patients with Comorbid Conditions:

• For patients with depression and insomnia, sedating antidepressants like mirtazapine may be considered 8
• For excessive daytime sleepiness, modafinil may be appropriate 8

Important Safety Considerations

• FDA warnings exist for cognitive and behavioral changes with hypnotic drugs, including potential driving impairment 1
• Lower doses of benzodiazepines and non-benzodiazepine hypnotics are recommended for women and older adults 1
• Short-term use is recommended, though many patients continue use for extended periods 1
• Adverse effects such as dementia and fractures may be associated with hypnotic drugs 1

Treatment Algorithm

1. Start with CBT-I for all patients with chronic insomnia
2. Assess response after 4-6 weeks of CBT-I
3. If inadequate response to CBT-I:
   • For sleep onset insomnia: Consider ramelteon (first choice due to safety profile) or low-dose zolpidem
   • For sleep maintenance insomnia: Consider doxepin
   • For both onset and maintenance: Consider eszopiclone or temazepam
4. Follow up within 2-4 weeks of any intervention to assess efficacy and side effects
5. Reassess periodically to determine if continued pharmacotherapy is necessary

Remember that even when medications are used, CBT-I should be continued as the foundation of treatment to achieve long-term improvement in sleep patterns.