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 adults with chronic insomnia disorder due to its proven effectiveness and lack of side effects. 1

First-Line Treatment: Psychological and Behavioral Interventions

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is strongly recommended as the initial treatment for chronic insomnia based on moderate-quality evidence 1
• CBT-I is effective for both primary and comorbid (secondary) insomnia 1
• CBT-I typically includes multiple components: cognitive therapy, stimulus control, sleep restriction, with or without relaxation therapy 1
• CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users 1, 2
• CBT-I produces results equivalent to sleep medication but with no side effects, fewer relapses, and continued improvement after treatment ends 3

Other Effective Behavioral Interventions

• Stimulus control therapy (establishing a positive association between bed and sleep) is an effective individual therapy 1, 2
• Relaxation therapy is effective as a standalone treatment for chronic insomnia 1, 2
• Sleep restriction therapy is recommended for chronic insomnia 1
• Brief Behavioral Interventions (BBIs) are potentially useful with minimal undesirable effects 1
• Multicomponent therapy (without cognitive therapy) is effective and recommended 1

Sleep Hygiene Considerations

• Sleep hygiene alone is insufficient for treating chronic insomnia 1, 4
• Sleep hygiene should be used in combination with other therapies, not as a standalone treatment 1, 4
• All patients with chronic insomnia should adhere to rules of good sleep hygiene as part of a comprehensive treatment plan 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 of short-term medication use 1.

Recommended Medication Sequence

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

   • Non-benzodiazepines (zolpidem, eszopiclone, zaleplon) 1, 5
   • Benzodiazepines (temazepam) 1
   • Ramelteon for insomnia characterized by difficulty with sleep onset 6

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

3. Sedating antidepressants (especially with comorbid depression/anxiety) 1

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

4. Combined BzRA or ramelteon with sedating antidepressant 1

5. Other sedating agents 1

   • Anti-epilepsy medications (gabapentin, tiagabine) 1
   • Atypical antipsychotics (quetiapine, olanzapine) - only suitable for patients with comorbid conditions who may benefit from primary action of these drugs 1

Important Medication Considerations

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible 1
• Over-the-counter antihistamines and herbal/nutritional substances (valerian, melatonin) are not recommended due to lack of efficacy and safety data 1
• Barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended 1
• Zolpidem is FDA-approved for short-term treatment of insomnia characterized by difficulties with sleep initiation 5
• Newer-generation nonbenzodiazepines have better safety profiles than traditional benzodiazepines for long-term treatment 7

Treatment Selection Factors

When selecting pharmacological treatment, consider: 1

• Symptom pattern (sleep onset vs. maintenance issues)
• Treatment goals
• Past treatment responses
• Patient preference
• Cost
• Availability of other treatments
• Comorbid conditions
• Contraindications
• Medication interactions
• Side effects

Monitoring and Follow-up

• Sleep diary data should be collected before and during treatment, and in case of relapse 1
• Clinical reassessment should occur every few weeks until insomnia stabilizes or resolves 1
• After stabilization, follow-up every 6 months is recommended as relapse rates for insomnia are high 1
• When a single treatment is ineffective, consider other behavioral therapies, pharmacological options, combined therapies, or reevaluation for comorbid disorders 1

Common Pitfalls to Avoid

• Relying solely on sleep hygiene education without additional interventions 1
• Using over-the-counter antihistamines or alcohol as sleep aids 1, 7
• Prescribing medications without addressing behavioral components 1
• Failing to reassess treatment effectiveness regularly 1
• Not considering potential for dependence with long-term benzodiazepine use 7
• Overlooking comorbid conditions that may be contributing to insomnia 1