Treatment of 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: CBT-I
- CBT-I is recommended as the initial treatment for all adults with chronic insomnia by the American Academy of Sleep Medicine and American College of Physicians 3
- CBT-I has demonstrated clinically significant improvements in sleep parameters with effects sustained for up to 2 years 2
- CBT-I is effective for both primary insomnia and insomnia comorbid with medical or psychiatric conditions 4
Key Components of CBT-I:
- Sleep restriction therapy - limiting time in bed to match actual sleep time 3
- Stimulus control - using the bed only for sleep and sex, leaving if unable to fall asleep 3
- Cognitive restructuring - addressing dysfunctional beliefs about sleep 3
- Sleep hygiene education - as part of a comprehensive approach, not as standalone therapy 3
- Relaxation techniques - may include progressive muscle relaxation 3
CBT-I Delivery Methods:
- In-person individual treatment with a trained provider is the most widely evaluated delivery method 3
- Group therapy, internet-based programs, and self-help books are alternative delivery options 2
- Internet-based CBT-I has shown clinically significant improvements 3
Single-Component Behavioral Interventions
The American Academy of Sleep Medicine gives conditional recommendations for the following single-component therapies when full CBT-I is not available 3:
Sleep hygiene alone is not recommended as a single-component therapy for chronic insomnia 3, 1
Second-Line Treatment: Pharmacological Options
- Medications should only be considered when patients are unable to participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I 1
FDA-Approved Medications:
For sleep onset insomnia:
For sleep maintenance insomnia:
Important Considerations for Pharmacotherapy:
- Short-term use is preferred due to concerns about tolerance, dependence, and adverse effects 1
- In older adults, start at the lowest available dose due to increased risk of adverse effects 7
- Benzodiazepines and non-benzodiazepine hypnotics carry risks of falls, cognitive impairment, and next-day residual effects, particularly in older adults 7, 5
Special Considerations for Older Adults
- CBT-I remains the first-line treatment for older adults with chronic insomnia 7
- Older adults typically report more difficulty maintaining sleep rather than initiating sleep 3
- Pharmacological interventions carry higher risks in older adults, including falls, fractures, and cognitive impairment 7
- If medications are necessary, short-intermediate acting non-benzodiazepine receptor agonists or ramelteon are preferred 7
Common Pitfalls to Avoid
- Relying solely on sleep hygiene without other behavioral interventions 7
- Using medications as first-line treatment instead of CBT-I 1
- Continuing ineffective treatments without reassessment 7
- Failing to address underlying medical or psychiatric conditions contributing to insomnia 7
- Using over-the-counter antihistamines or herbal supplements without sufficient evidence 7
Treatment Algorithm
- Begin with CBT-I as the primary intervention 1, 2
- If CBT-I is not available or feasible, use single-component behavioral interventions 3
- If behavioral interventions are ineffective or not feasible, consider short-term use of FDA-approved sleep medications with careful monitoring 1
- Regular follow-up is essential to monitor treatment response and address any emerging issues 2