What is the best approach to manage chronic insomnia?

Management of Chronic Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adults with chronic insomnia due to its superior long-term efficacy and safety profile compared to pharmacological options. 1, 2

First-Line Treatment: CBT-I

• CBT-I is recommended as the initial treatment for chronic insomnia by the American College of Physicians, American Academy of Sleep Medicine, and VA/DoD with moderate-quality evidence supporting its effectiveness 1, 2
• CBT-I produces reliable and durable improvements in sleep parameters that are sustained for at least 6 months after treatment completion 3, 4
• 70-80% of patients treated with nonpharmacological interventions benefit from treatment 4

Key Components of CBT-I

• Stimulus control therapy (Standard): Designed to extinguish negative associations between bed and wakefulness 1

  • Go to bed only when sleepy
  • Maintain a regular schedule
  • Use the bed only for sleep and sex
  • Leave the bed if unable to fall asleep within 20 minutes
  • Return to bed only when sleepy again 1

• Relaxation training (Standard): Reduces somatic and cognitive arousal that interferes with sleep 1

  • Progressive muscle relaxation involves methodically tensing and relaxing different muscle groups 1

• Sleep restriction (Guideline): Limits time in bed to match actual sleep time 1

  • Maintain sleep logs to determine mean total sleep time
  • Set bedtime and wake time to achieve >85% sleep efficiency
  • Make weekly adjustments based on sleep efficiency 1

• Cognitive therapy: Addresses dysfunctional beliefs and attitudes about sleep 1

  • Identifies common cognitive distortions like "I can't sleep without medication" or "My life will be ruined if I can't sleep" 1, 5

Second-Line Treatment: Pharmacotherapy

• If CBT-I alone is unsuccessful, clinicians should use a shared decision-making approach to discuss adding pharmacological therapy 1, 6
• Short to intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon are recommended as first pharmacological options 1, 7

Medication Selection Considerations

• For sleep onset difficulties: Consider zaleplon or ramelteon due to their short half-lives 1
• For sleep maintenance problems: Consider eszopiclone or temazepam with relatively longer half-lives 1
• For patients with substance use history: Ramelteon may be appropriate as it is not a DEA-scheduled drug 1

Important Medication Considerations

• Start at the lowest available dose, especially in older adults 6
• Zolpidem 10mg has shown efficacy for chronic insomnia in controlled studies, improving sleep latency and efficiency 7
• Be aware of potential adverse effects including residual sedation, memory impairment, falls (especially in older adults), and anterograde amnesia 6, 7

Special Considerations for Older Adults

• CBT-I remains highly effective in older adults and should still be first-line treatment 2, 6
• Pharmacological treatments carry increased risks in older adults due to pharmacokinetic changes 6
• Medication-related risks include falls, fractures, cognitive impairment, and potential for dependence 6

Implementation and Monitoring

• Collect sleep diary data before and during treatment 2, 6
• Follow up regularly until insomnia stabilizes, then every 6 months 2, 6
• Evaluate for improvement in sleep parameters (sleep onset latency <30 minutes, wake after sleep onset <30 minutes, sleep efficiency >80-85%) 1

Common Pitfalls to Avoid

• Relying solely on sleep hygiene without other behavioral interventions 6
• Using over-the-counter antihistamines or herbal supplements without sufficient evidence 6
• Prescribing benzodiazepines as first-line agents, especially in older adults 6
• Continuing ineffective treatments without reassessment 6
• Failing to address underlying medical or psychiatric conditions contributing to insomnia 6