Recommended Medications for Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for chronic insomnia, with pharmacological therapy reserved as second-line treatment only when CBT-I alone is unsuccessful. 1
First-Line Treatment: Non-Pharmacological
- CBT-I has demonstrated superior long-term efficacy compared to pharmacological options with minimal risk of adverse effects 1, 2
- CBT-I components include cognitive therapy, behavioral interventions (sleep restriction, stimulus control), and educational interventions (sleep hygiene) 1, 3
- CBT-I can be delivered through various methods including in-person individual or group therapy, telephone/web-based modules, and self-help books 4
Pharmacological Treatment Algorithm (When CBT-I is Unsuccessful)
First-Line Medications:
- Short to intermediate-acting benzodiazepine receptor agonists (BzRAs):
- Non-benzodiazepine "Z-drugs" (zolpidem, eszopiclone, zaleplon) at lowest effective dose for short-term use (4-5 weeks) 4, 1
- Eszopiclone has shown efficacy in decreasing sleep latency and improving sleep maintenance 5
- Zolpidem has demonstrated effectiveness for sleep latency and efficiency in both transient and chronic insomnia 6
- Orexin receptor antagonists (e.g., suvorexant) have shown moderate-quality evidence for improving sleep outcomes 1
- Melatonin receptor agonists (e.g., ramelteon) are indicated for insomnia characterized by difficulty with sleep onset 7
Second-Line Medications:
- Low-dose doxepin (3-6mg) is particularly appropriate for sleep maintenance insomnia in older adults with a favorable safety profile 8
- Other sedating antidepressants (trazodone, amitriptyline, mirtazapine) may be considered, especially when treating comorbid depression/anxiety 4
Third-Line Medications:
- Combined BzRA or ramelteon with a sedating antidepressant 4
- Other sedating agents such as anti-epilepsy medications (gabapentin, tiagabine) or atypical antipsychotics (quetiapine, olanzapine) - suitable only for patients with comorbid conditions who may benefit from the primary action of these drugs 4
Special Considerations for Elderly Patients
- Start with CBT-I as first-line treatment before considering medication 8
- If medication is necessary, low-dose doxepin (3-6mg) is the most appropriate choice for sleep maintenance insomnia 8
- Avoid benzodiazepines due to risks of dependency, falls, cognitive impairment, and respiratory depression 8
- Avoid antihistamines (including OTC sleep aids) due to anticholinergic effects 8
- Use the lowest available doses due to altered pharmacokinetics and increased sensitivity to side effects 8
Medications NOT Recommended
- Over-the-counter antihistamines or antihistamine/analgesic combinations ("sleep aids") due to lack of efficacy and safety data 4, 1
- Herbal and nutritional substances (e.g., valerian and melatonin) due to limited efficacy evidence 4
- Older drugs including barbiturates, barbiturate-type drugs, and chloral hydrate 4
- Antipsychotics as first-line treatment due to metabolic side effects 1
Important Prescribing Guidelines
- Pharmacological treatment should be accompanied by patient education regarding treatment goals, safety concerns, potential side effects, and drug interactions 4
- Regular follow-up is essential to assess effectiveness, monitor for side effects, and evaluate the need for ongoing medication 4, 1
- Use medications at the lowest effective dose for the shortest duration possible (ideally ≤4-5 weeks) 1
- Continue to incorporate behavioral techniques even when using medications 1
- Be aware of potential serious adverse effects including next-day impairment, "sleep driving," behavioral abnormalities, and worsening depression 1
Medication Selection Factors
The choice of a specific pharmacological agent should be directed by:
- Symptom pattern (difficulty falling asleep vs. staying asleep)
- Treatment goals
- Past treatment responses
- Patient preference
- Comorbid conditions
- Contraindications and drug interactions
- Side effect profile 4