What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

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

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is recommended as the initial treatment for all patients with chronic insomnia by the American Academy of Sleep Medicine, American College of Physicians, and other major medical organizations 1, 2
• CBT-I has been shown to be highly effective in the treatment of insomnia across all age groups with sustained benefits for up to 2 years 2
• Key components of effective CBT-I include:
  • Sleep restriction therapy (limiting time in bed to consolidate actual sleep time) 2
  • Stimulus control (using bed only for sleep and sex) 1
  • Sleep hygiene education 2
  • Cognitive restructuring to address maladaptive thoughts about sleep 1
• CBT-I provides clinically meaningful improvements in sleep parameters, including reduced sleep onset latency, decreased wake time after sleep onset, and improved sleep efficiency 3, 4

Pharmacological Options (Second-Line Only)

The American Academy of Sleep Medicine suggests that medications should only be considered when:

• Patients are unable to participate in CBT-I
• Patients still have symptoms despite participation in CBT-I
• As a temporary adjunct to CBT-I 2

Recommended Pharmacological Options (Weak Evidence)

• Benzodiazepine receptor agonists (BzRAs):

  • Eszopiclone for sleep onset and maintenance insomnia 2
  • Zolpidem for sleep onset and maintenance insomnia 2, 5
  • Zaleplon for sleep onset insomnia 2
  • Triazolam for sleep onset insomnia 2
  • Temazepam for sleep onset and maintenance insomnia 2

• Other approved medications:

  • Ramelteon for sleep onset insomnia 2, 6
  • Low-dose doxepin for sleep maintenance insomnia 2

Medications NOT Recommended

• Trazodone is not recommended for sleep onset or maintenance insomnia 2
• Tiagabine is not recommended for sleep onset or maintenance insomnia 2
• Diphenhydramine is not recommended for sleep onset and maintenance insomnia 2
• Melatonin is not recommended for sleep onset or maintenance insomnia 2
• Tryptophan is not recommended for sleep onset or maintenance insomnia 2
• Valerian is not recommended for sleep onset or maintenance insomnia 2

Sleep Hygiene Practices

• Sleep hygiene education alone is usually not adequate for treating severe chronic insomnia but should be included as part of a comprehensive treatment approach 2
• Important sleep hygiene practices include:
  • Avoiding frequent daytime napping 2
  • Avoiding spending too much time in bed 2
  • Increasing daytime activities and bright light exposure 2
  • Avoiding late evening exercise 2
  • Limiting caffeine, evening alcohol consumption, and smoking 2
  • Avoiding heavy late dinners 2
  • Creating a comfortable sleep environment (proper temperature, noise level, and lighting) 2

Treatment Algorithm

1. Initial approach: Begin with CBT-I as the primary intervention 2, 1
2. If CBT-I is ineffective or not feasible: Consider short-term use of FDA-approved sleep medications with careful monitoring 2
   • For sleep onset problems: Consider zolpidem, zaleplon, ramelteon 2, 6
   • For sleep maintenance problems: Consider doxepin or eszopiclone 2
3. For older adults: Use extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects 2
4. Continue to incorporate behavioral techniques even when using medications 7

Important Considerations and Pitfalls

• Short-term use of medications is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use 2, 8
• Benzodiazepines and non-benzodiazepine hypnotics carry risks of falls, cognitive impairment, and dependence, particularly in older adults 1
• Over-the-counter sleep aids containing antihistamines should be discouraged due to limited efficacy and potential side effects 2, 8
• Alcohol should not be used as a sleep aid despite its sedative properties due to disruption of sleep architecture and potential for abuse 2, 8
• Regular follow-up is essential to monitor treatment response and address any emerging issues 1