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. 1, 2, 3

First-Line Treatment: CBT-I

• CBT-I is a multicomponent intervention that has the strongest evidence base and is the only approach to receive a Strong recommendation from the American Academy of Sleep Medicine 1
• CBT-I combines multiple behavioral treatments including sleep restriction therapy, stimulus control, and cognitive therapy to address maladaptive thoughts and behaviors perpetuating insomnia 2, 3
• CBT-I demonstrates clinically meaningful improvements in sleep parameters, including reduced sleep onset latency, decreased wake after sleep onset, improved sleep efficiency, and enhanced sleep quality 1, 4
• Effects of CBT-I are sustained for up to 2 years, making it superior to pharmacological options for long-term management 3, 4
• 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, 2

Other Effective Behavioral Interventions

• Brief Behavioral Therapy for Insomnia (BBT-I), sleep restriction therapy, stimulus control, and relaxation therapy all received Conditional recommendations from the American Academy of Sleep Medicine 1
• Stimulus control involves going to bed only when sleepy, using the bedroom only for sleep and sex, leaving the bedroom if unable to fall asleep, and maintaining consistent wake-up times 3
• Sleep restriction therapy limits time in bed to match actual sleep time and gradually increases time in bed as sleep efficiency improves 3
• Relaxation techniques help reduce physiological and cognitive arousal that interferes with sleep 1, 5

Important Caution About Sleep Hygiene

• Sleep hygiene alone is NOT recommended as a single-component therapy for chronic insomnia 1, 5
• When sleep hygiene was used as a control group in studies of other interventions, it was less beneficial than active treatments 1
• Sleep hygiene should be considered an adjunct to other empirically supported treatments rather than a standalone intervention 5

Pharmacological Options (Second-Line Treatment)

• Pharmacological therapy should be considered only when CBT-I has been unsuccessful or is unavailable 1, 3
• Short to intermediate-acting non-benzodiazepine receptor agonists (Z-drugs like zolpidem) or ramelteon are recommended as first pharmacological options 3, 6, 7
• Zolpidem has shown efficacy for both sleep onset and maintenance insomnia in clinical trials, but carries risks of next-day residual effects and potential for anterograde amnesia, particularly at doses above 10mg 6
• Ramelteon has demonstrated effectiveness in reducing sleep latency in both younger adults and older adults with chronic insomnia 7
• Sedating antidepressants may be considered, especially with comorbid depression/anxiety 3

Special Considerations for Older Adults

• CBT-I remains highly effective in older adults and should still be first-line treatment 3
• Older adults should start at the lowest available dose of any medication due to increased risk of adverse effects 3
• Pharmacokinetic changes in older adults increase the risk of adverse effects from sedative-hypnotics, including falls, fractures, and cognitive impairment 3

Implementation and Monitoring

• Sleep diary data should be collected before and during treatment to monitor progress 2, 3
• Follow-up should occur regularly until insomnia stabilizes or resolves, then every 6 months 2, 3
• For pharmacological treatment, start with the lowest effective dose and reassess regularly for continued need, efficacy, and adverse effects 3

Common Pitfalls to Avoid

• Relying solely on sleep hygiene without other behavioral interventions 1, 3, 5
• Using over-the-counter antihistamines or herbal supplements without sufficient evidence 3
• Prescribing benzodiazepines as first-line agents, especially for older adults 3
• Continuing ineffective treatments without reassessment 3
• Failing to address underlying medical or psychiatric conditions contributing to insomnia 3