What are the recommended medications and treatments for insomnia?

Recommended Medications and Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for all adults with chronic insomnia, with pharmacological therapy reserved as second-line treatment only when CBT-I alone is unsuccessful. 1, 2

First-Line Treatment: CBT-I

• CBT-I has demonstrated superior long-term efficacy compared to pharmacological options and carries minimal risk of adverse effects 1
• Key components of CBT-I include:
  • Stimulus control (using bed only for sleep and sex) 1, 3
  • Sleep restriction therapy 1
  • Cognitive therapy to restructure maladaptive thoughts about sleep 1
  • Sleep hygiene education 1, 3
  • Relaxation techniques to reduce psychophysiological arousal 1
• Collection of sleep diary data before and during treatment is recommended to monitor progress 1
• CBT-I should be implemented for at least 4-8 weeks to evaluate effectiveness 1

Second-Line Treatment: Pharmacological Options

When CBT-I is insufficient after an adequate trial, consider the following medications:

FDA-Approved Medications for Insomnia:

• Non-benzodiazepine receptor agonists (Z-drugs):
  • Zolpidem - indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation 4
  • Eszopiclone - effective for sleep onset and maintenance issues 1, 2
  • Zaleplon - shorter half-life, better for sleep onset issues 1
• Orexin receptor antagonists:
  • Suvorexant - effective for improving treatment response and sleep outcomes 2
• Melatonin receptor agonists:
  • Ramelteon - specifically indicated for insomnia characterized by difficulty with sleep onset 5
  • Lower abuse potential, making it suitable for patients with substance use history 2, 3
• Sedating antidepressants:
  • Low-dose doxepin (3-6 mg) - particularly effective for sleep maintenance insomnia 1, 2
  • Trazodone and mirtazapine - may be considered, with mirtazapine beneficial for patients with comorbid depression 1

Medication Selection Considerations

• Choose medications based on:
  • Symptom pattern (sleep onset vs. maintenance issues) 1
  • Patient's age and comorbidities 1
  • Previous treatment response 1
  • Risk of abuse/dependence 1, 3
• Important cautions:
  • Use medications at the lowest effective dose for the shortest period possible (4-5 weeks) 1, 2
  • Benzodiazepines should be avoided in patients with substance use history due to high abuse potential 1, 3
  • Potential adverse effects of sedative-hypnotics include:
    • Residual sedation and daytime impairment 1, 2
    • Memory and performance impairment 1
    • Falls and injuries 1, 2
    • Behavioral abnormalities including "sleep driving" 1, 2
  • Antihistamine sleep aids and herbal substances such as valerian are not recommended due to lack of efficacy and safety data 1, 6

Treatment Algorithm

1. Start with CBT-I as first-line treatment 1, 2, 3

   • Implement all components (stimulus control, sleep restriction, cognitive therapy, sleep hygiene, relaxation)
   • Continue for at least 4-8 weeks

2. If CBT-I is insufficient after adequate trial, add pharmacological therapy 1, 2

   • For sleep onset insomnia: Consider ramelteon, zaleplon, or zolpidem 1, 5, 4
   • For sleep maintenance insomnia: Consider low-dose doxepin or eszopiclone 1, 2
   • For patients with substance use history: Consider ramelteon or low-dose doxepin 3

3. When using medications 1, 2

   • Start with the lowest effective dose
   • Limit duration to 4-5 weeks when possible
   • Continue incorporating behavioral techniques
   • Monitor regularly for treatment response, adverse effects, and potential misuse

Common Pitfalls to Avoid

• Relying solely on medications without implementing CBT-I 1, 7
• Using medications for longer than recommended (>4-5 weeks) 1, 2
• Prescribing benzodiazepines for patients with substance use history 1, 3
• Using antipsychotics as first-line treatment for insomnia due to metabolic side effects 2
• Overlooking the potential for long-term adverse effects with hypnotic drugs, including possible associations with dementia, injury, and fractures 2, 6