What are the recommended medications and treatments for insomnia in adolescents?

Treatment of Insomnia in Adolescents

Behavioral and educational interventions should be the first-line treatment for insomnia in adolescents, with pharmacologic therapy considered only in specific situations when behavioral approaches are not feasible or when symptoms have reached a crisis point. 1

Assessment and Screening

• All adolescents with sleep difficulties should be screened for insomnia using targeted questions about sleep onset, sleep maintenance, sleep quality, and daytime functioning 1
• Evaluation should include assessment of potential medical contributors to insomnia, including gastrointestinal disorders, epilepsy, pain, nutritional issues, and other sleep disorders such as sleep-disordered breathing 1
• Psychiatric conditions such as anxiety, depression, and bipolar disorder should be considered as they may contribute to insomnia 1
• A careful review of current medications should be performed as many can contribute to insomnia 1

First-Line Treatment: Behavioral and Educational Interventions

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for adolescents with insomnia 1, 2
• CBT-I techniques for adolescents include:
  • Sleep restriction (bedtime shifts)
  • Stimulus control
  • Cognitive therapy (thought challenging)
  • Sleep hygiene education
  • Relaxation techniques 2, 3
• The integration of parents in the treatment process is highly recommended, especially for younger adolescents 2
• Educational approaches should include:
  • Promotion of good sleep habits
  • Assessment of habits that may interfere with sleep
  • Implementation of consistent bedtime routines
  • Visual supports and schedules when appropriate 1
• Internet-delivered CBT-I has shown promise for adolescents with insomnia comorbid to psychiatric conditions, with improvements in both sleep and psychiatric symptoms 4

Pharmacologic Treatment (Second-Line)

Pharmacologic therapy may be indicated in specific situations when:

• Behavioral approaches are not feasible
• The intensity of symptoms has reached a crisis point
• Behavioral interventions have been unsuccessful 1

When pharmacologic treatment is necessary:

• Melatonin may be considered for adolescents with insomnia, though evidence for its use as a primary treatment for insomnia is limited 5
• Short-intermediate acting benzodiazepine receptor agonists may be considered in specific cases, but should be used with caution in adolescents 1
• Any pharmacologic treatment should be supplemented with behavioral and cognitive therapies whenever possible 1

Treatment Monitoring and Follow-up

• Sleep diary data should be collected prior to and during the course of active treatment 1
• Clinical reassessment should occur every few weeks until the insomnia appears stable or resolved 1
• When a single treatment has been ineffective, other behavioral therapies, pharmacological therapies, combined therapies, or reevaluation for occult comorbid disorders should be considered 1

Important Considerations

• The efficacy of CBT-I has been demonstrated across various populations, including adolescents 6, 7
• Face-to-face treatments of at least four sessions appear to be more effective than self-help interventions or briefer interventions 6
• Sleep hygiene alone is insufficient for treating chronic insomnia and should be used in combination with other therapies 1
• The choice of specific pharmacological agent, when needed, should be directed by symptom pattern, treatment goals, past treatment responses, patient preference, comorbid conditions, and potential side effects 1