How to manage severe insomnia?

From the Guidelines

To manage severe insomnia, Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered the first-line treatment, as it has been shown to improve global outcomes, reduce sleep onset latency, and improve sleep quality, as evidenced by moderate-quality evidence from the American College of Physicians guideline 1.

Key Components of CBT-I

• Cognitive therapy to address sleep-related beliefs and attitudes
• Behavioral interventions, such as sleep restriction and stimulus control, to establish a consistent sleep schedule and improve sleep environment
• Education on sleep hygiene, including relaxation techniques and sleep habits

Medication Options

If CBT-I is unsuccessful, short-term use of prescription sleep aids may be considered, including:

• Benzodiazepines like temazepam (15-30mg) or non-benzodiazepines like zolpidem (5-10mg)
• Melatonin receptor agonists like ramelteon (8mg)
• Low-dose doxepin (3-6mg), trazodone (25-100mg), or mirtazapine (7.5-15mg)

Important Considerations

• Medications should be taken 30 minutes before bedtime and used for the shortest duration possible, typically 2-4 weeks, to avoid dependence
• Underlying conditions like sleep apnea, restless legs syndrome, depression, or anxiety should be addressed, as they can contribute to insomnia
• If insomnia persists despite these interventions, consult a sleep specialist for comprehensive evaluation and personalized treatment, as recommended by the American College of Physicians guideline 1

From the FDA Drug Label

Zolpidem tartrate is used in adults for the short-term treatment of a sleep problem called insomnia (trouble falling asleep). Eszopiclone tablets are used in adults for the treatment of a sleep problem called insomnia. Symptoms of insomnia include: trouble falling asleep, waking up often during the night

To manage severe insomnia, consider the following:

• Medications: Zolpidem tartrate and eszopiclone are two options, but they should be used for short-term treatment only.
• Dosage and administration: Take the medication exactly as prescribed, and only when you are able to get a full night's sleep.
• Precautions: Do not take these medications with alcohol or other medicines that can make you sleepy, and be aware of the potential for serious side effects, such as sleepwalking or memory loss.
• Monitoring: Call your healthcare provider if your insomnia worsens or is not better within 7 to 10 days, as this may indicate an underlying condition that needs to be addressed 2, 3, 3.

From the Research

Managing Severe Insomnia

To manage severe insomnia, several approaches can be considered, including nonpharmacologic and pharmacologic treatments.

• Nonpharmacologic treatments, such as cognitive-behavioral therapy (CBT), have been shown to be effective in treating insomnia, with benefits including few or no adverse effects and no risk of abuse or dependence 4, 5, 6.
• Cognitive-behavioral therapies target behavioral, cognitive, and conditioning factors underlying insomnia, thereby restoring normal sleep-wake functioning 4.
• CBT can be used singly or in combination with medication, and the addition of medication to CBT may produce added benefits during acute therapy, but long-term outcome may be optimized when medication is discontinued during maintenance CBT 7.
• Other nonpharmacologic therapies, such as relaxation strategies, stimulus control therapy, bedtime restriction therapy, and bright light therapy, may also be effective in treating insomnia 8, 6.
• Pharmacologic treatments, including benzodiazepines and nonbenzodiazepine benzodiazepine receptor agonists, may be effective in the short term, but may have adverse effects and risks of dependence 5, 8.
• New types of medications, such as selective melatonin receptor agonists, are being developed and may provide alternative treatment options for insomnia 8.

Treatment Options

Treatment options for severe insomnia may include:

• Cognitive-behavioral therapy (CBT) alone or in combination with medication 4, 5, 7.
• Relaxation strategies, such as progressive muscle relaxation or mindfulness meditation 4, 6.
• Stimulus control therapy, which involves associating the bed with sleep and removing distractions 6.
• Bedtime restriction therapy, which involves restricting time in bed to improve sleep efficiency 6.
• Bright light therapy, which involves exposure to bright light to regulate the body's circadian rhythms 6.
• Pharmacologic treatments, such as benzodiazepines or nonbenzodiazepine benzodiazepine receptor agonists, under the guidance of a healthcare professional 5, 8.