From the Guidelines
Chronic insomnia can be effectively treated through a combination of behavioral changes and, when necessary, medication, with Cognitive Behavioral Therapy for Insomnia (CBT-I) being the first-line treatment, as recommended by the American Academy of Sleep Medicine in 2021 1.
Treatment Options
The treatment of chronic insomnia involves a multifaceted approach that includes:
- Establishing good sleep hygiene: maintaining a consistent sleep schedule, creating a relaxing bedtime routine, keeping the bedroom dark and cool, avoiding screens before bed, and limiting caffeine and alcohol.
- Cognitive Behavioral Therapy for Insomnia (CBT-I): considered the first-line treatment, teaching patients to recognize and change beliefs that affect their ability to sleep, with a strong recommendation based on moderate-quality evidence 1.
- Medication options: short-term use of sleep aids may include over-the-counter options like melatonin (0.5-5mg taken 1-2 hours before bedtime) or prescription medications such as zolpidem (Ambien, 5-10mg), eszopiclone (Lunesta, 1-3mg), or trazodone (50-100mg), with a weak recommendation based on low-quality evidence 1.
Key Considerations
- Underlying conditions like sleep apnea, restless leg syndrome, anxiety, or depression should be addressed, as they often contribute to insomnia.
- Regular exercise (but not within 3 hours of bedtime), stress management techniques like meditation, and limiting daytime napping can also significantly improve sleep quality.
- Insomnia often stems from disrupted sleep-wake cycles or heightened arousal at bedtime, so these approaches work by either resetting the body's natural rhythms or reducing the mental and physical activation that prevents sleep.
Delivery Methods
- CBT-I can be delivered through various methods, including individual or group therapy, telephone- or Web-based modules, or self-help books, with in-person one-on-one delivery being the most widely evaluated and considered the best available treatment 1.
- Other delivery methods, such as internet-based CBT-I, may also be effective and can be considered based on patient preferences and availability 1.
From the FDA Drug Label
Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo. Ramelteon reduced sleep latency at each time point when compared to placebo. Zolpidem 10 mg was superior to placebo on a subjective measure of sleep latency for all 4 weeks, and on subjective measures of total sleep time, number of awakenings, and sleep quality for the first treatment week. The treatment options for chronic insomnia include:
- Ramelteon (PO): reduces sleep latency
- Zolpidem (PO): improves sleep latency, sleep efficiency, and sleep quality 2, 3 Key points:
- Ramelteon and zolpidem have been shown to be effective in reducing sleep latency and improving sleep quality in patients with chronic insomnia.
- The efficacy of these medications has been demonstrated in clinical trials, including studies with polysomnographic measures and subjective measures of sleep latency and quality.
From the Research
Treatment Options for Chronic Insomnia
The following treatment options are available for chronic insomnia:
- Cognitive behavioral therapy for insomnia (CBT-I) is a recommended treatment for chronic insomnia, as it has been shown to be effective in improving sleep quality and reducing symptoms of insomnia 4, 5, 6, 7
- Stimulus control therapy, relaxation training, and cognitive behavior therapy are individually effective therapies in the treatment of chronic insomnia 4
- Sleep restriction therapy, multicomponent therapy (without cognitive therapy), biofeedback, and paradoxical intention are also individually effective therapies in the treatment of chronic insomnia 4
- Non-pharmacological treatments, such as cognitive/behavioral methods and relaxation strategies, are effective in treating insomnia and have the added benefits of few or no adverse effects and no risk of abuse or dependence 6
- Group CBT-I has been shown to be effective in a primary care setting, with significant improvements in sleep quality, sleep medication use, and mood ratings 7
Pharmacological Treatments
- Pharmacological recommendations for the treatment of insomnia disorder include positive GABAergic modulators, dual orexin receptor antagonists, and melatonin receptor agonists 8
- However, discontinuation of hypnotic benzodiazepines and Z-drugs should be gradual, with dose reductions of 10-25% each week, and may be facilitated by multi-component CBT-I or other therapies 8
Special Considerations
- Psychological and behavioral interventions are effective in the treatment of insomnia in older adults and in the treatment of insomnia among chronic hypnotic users 4
- CBT-I has been shown to be effective in reducing sleep medication use and improving sleep quality in patients with medical comorbidity 7