What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as the first-line treatment for chronic insomnia due to its superior long-term efficacy, sustained benefits, and lack of adverse effects compared to pharmacological options. 1, 2

First-Line Treatment: CBT-I

• CBT-I is the treatment of choice for chronic insomnia with the strongest evidence base and is the only approach to receive a Strong recommendation from the American Academy of Sleep Medicine 1
• CBT-I is a multicomponent intervention that typically includes:
  • Sleep restriction therapy (limiting time in bed to consolidate sleep)
  • Stimulus control (associating bed with sleep)
  • Cognitive therapy (addressing maladaptive thoughts about sleep)
  • Sleep hygiene education (as part of the comprehensive approach) 1, 2
• CBT-I provides gradual but durable improvements in insomnia symptoms that persist beyond the end of treatment 1, 2
• CBT-I can be delivered through various modalities:
  • In-person individual treatment (most widely evaluated)
  • Group treatment
  • Internet-based programs 1

Second-Line Treatments

• Brief Behavioral Treatments for Insomnia (BTIs) received a Conditional recommendation and can be considered when CBT-I is not available or appropriate 1
• Single-component behavioral therapies with Conditional recommendations include:
  • Sleep restriction therapy
  • Stimulus control
  • Relaxation therapy 1

Pharmacological Options (Third-Line)

• Pharmacotherapy should only be considered after CBT-I has been unsuccessful 2, 3
• FDA-approved medications for insomnia include:
  • Zolpidem (indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation) 4
  • Eszopiclone (indicated for treatment of insomnia, decreases sleep latency and improves sleep maintenance) 5
• Important limitations of pharmacological treatments:
  • Limited evidence for long-term efficacy 1, 4
  • Potential adverse effects including cognitive impairment, falls, and fractures 2
  • Risk of tolerance and dependence with benzodiazepines 1, 6

Ineffective or Not Recommended Approaches

• Sleep hygiene alone (without other components) is not recommended as a single-component therapy for chronic insomnia 1
  • The American Academy of Sleep Medicine found minimal benefits of sleep hygiene alone compared to control conditions 1
  • Using sleep hygiene as a standalone treatment may divert resources from more effective interventions 1, 7
• Melatonin is not recommended for chronic insomnia due to insufficient evidence 2

Implementation Considerations

• Patients should be informed that psychological and behavioral therapies typically produce gradual improvements rather than immediate results 1
• Initial undesirable effects of CBT-I (e.g., sleepiness and fatigue) are typically mild and resolve quickly for most patients 1
• Sleep diary data should be collected before and during treatment to monitor progress 2
• Challenges to CBT-I implementation include:
  • Limited availability of trained providers
  • Higher out-of-pocket costs compared to medications
  • Perceived stigma of mental health treatment 1

Special Populations

• CBT-I is effective for older adults and should be considered first-line treatment in this population 1, 2
• For patients with comorbid medical or psychiatric conditions, clinicians should consider how treatment-induced sleep deprivation might affect these conditions 1

By following this evidence-based approach prioritizing non-pharmacological interventions first, clinicians can effectively manage insomnia while minimizing risks associated with medication use.