What are the treatment options for insomnia?

Treatment Options for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adult patients with chronic insomnia disorder due to its proven efficacy, long-term benefits, and lack of side effects. 1

First-Line Treatment: Psychological and Behavioral Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is a multicomponent therapy that includes cognitive therapy, stimulus control, sleep restriction, with or without relaxation therapy 1
• CBT-I has strong evidence supporting its effectiveness for both primary and secondary (comorbid) insomnia 1
• CBT-I can be delivered through various modalities including in-person individual or group therapy, telephone or web-based modules, and self-help books 1
• CBT-I produces results equivalent to sleep medication but with no side effects, fewer relapses, and continued improvement after treatment ends 2

Other Effective Behavioral Interventions

• Stimulus control therapy (establishing a clear association between bed and sleep) is effective as a standalone treatment 1, 3
• Sleep restriction therapy (limiting time in bed to increase sleep efficiency) is recommended for chronic insomnia 1
• Relaxation techniques (progressive muscle relaxation, deep breathing) are effective individual therapies 1, 3
• Multicomponent behavioral therapy without cognitive components is also effective 1
• Biofeedback therapy and paradoxical intention can be used as alternative approaches 1, 3

Sleep Hygiene Considerations

• Sleep hygiene alone is insufficient for treating chronic insomnia but should be used in combination with other therapies 1, 4
• Sleep diary data should be collected before and during treatment to track progress 1
• Clinical reassessment should occur every few weeks until insomnia stabilizes, then every 6 months due to high relapse rates 1

Second-Line Treatment: Pharmacological Options

When CBT-I alone is unsuccessful, pharmacological therapy may be considered using a shared decision-making approach that discusses benefits, harms, and costs 1:

Recommended Medication Sequence

1. Short to intermediate-acting benzodiazepine receptor agonists or ramelteon:

   • Non-benzodiazepines (zolpidem, eszopiclone, zaleplon) are preferred first-line medications 1, 5
   • Zolpidem is FDA-approved for short-term treatment of insomnia characterized by difficulties with sleep initiation 6
   • Ramelteon is indicated for insomnia characterized by difficulty with sleep onset 7

2. If initial agent unsuccessful, try alternative short-intermediate acting BzRAs or ramelteon 1

3. Sedating antidepressants (especially when comorbid depression/anxiety exists):

   • Options include trazodone, amitriptyline, doxepin, and mirtazapine 1

4. Combined BzRA or ramelteon with sedating antidepressant 1

5. Other sedating agents such as anti-epilepsy medications (gabapentin, tiagabine) or atypical antipsychotics (quetiapine, olanzapine) - these should be reserved for patients with comorbidities who may benefit from the primary action of these drugs 1

Important Medication Considerations

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies 1, 8
• Over-the-counter antihistamines and herbal/nutritional supplements (valerian, melatonin) are not recommended due to lack of efficacy and safety data 1
• Older drugs like barbiturates and chloral hydrate are not recommended 1
• Medication selection should consider symptom pattern, treatment goals, past responses, patient preference, cost, comorbidities, contraindications, and potential drug interactions 1

Treatment Monitoring and Follow-up

• Evaluate treatment efficacy using measures of wake time after sleep onset (WASO), sleep onset latency (SOL), number of awakenings, sleep efficiency, and improvement of sleep-related psychological distress 1
• If a single treatment is ineffective, consider other behavioral therapies, pharmacological options, combined approaches, or reevaluation for occult comorbid disorders 1
• Regular follow-up is essential - every few weeks initially, then monthly until insomnia resolves, followed by biannual check-ins 1

Special Considerations

• Psychological and behavioral treatments are effective for adults of all ages, including older adults and chronic hypnotic users 1, 3
• Older adults more commonly report problems with maintaining sleep rather than falling asleep 1
• Pharmacological treatment carries higher risks in older adults, making behavioral approaches particularly important in this population 1, 5
• Despite its effectiveness, CBT-I remains underutilized due to limited availability of trained practitioners and greater awareness of medication options 2