What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is 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 has been shown to be highly effective across all age groups with sustained benefits for up to 2 years 1
• Key components of effective CBT-I include:
  • Sleep restriction therapy
  • Stimulus control
  • Sleep hygiene education
  • Cognitive restructuring to address maladaptive thoughts about sleep 1, 2
• CBT-I provides sustained benefits without the risk of tolerance or adverse effects, making it particularly suitable for older adults 2
• Regular monitoring with sleep diaries before and during treatment is essential to track progress 2

Pharmacological Options (Second-Line Only)

Medications should only be considered when:

• Patients are unable to participate in CBT-I
• Symptoms persist despite participation in CBT-I
• As a temporary adjunct to CBT-I 1, 3

First-Line Pharmacotherapy Options:

• For sleep onset insomnia:

  • Zaleplon (10 mg) 3
  • Ramelteon (8 mg) - FDA approved for sleep onset insomnia 3, 4
  • Zolpidem (10 mg, 5 mg in elderly) 3, 5
  • Triazolam (0.25 mg) - note: associated with rebound anxiety 3

• For sleep maintenance insomnia:

  • Eszopiclone (2-3 mg) 3
  • Zolpidem (10 mg, 5 mg in elderly) 3, 5
  • Temazepam (15 mg) 3
  • Doxepin (3-6 mg) 1, 3
  • Suvorexant (orexin receptor antagonist) 3

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 1
• Important sleep hygiene practices include:
  • Avoiding frequent daytime napping
  • Avoiding spending too much time in bed
  • Avoiding late evening exercise
  • Avoiding caffeine, evening alcohol consumption, and smoking
  • Creating a comfortable sleep environment 1

Treatment Algorithm

1. Start with CBT-I as the primary intervention for all patients with chronic insomnia 1, 3, 2
2. If CBT-I is ineffective or not feasible:
   • Consider short-term use of FDA-approved sleep medications with careful monitoring 1
   • Select medication based on insomnia pattern:
     • Sleep onset difficulty: zaleplon, ramelteon, zolpidem, or triazolam 3
     • Sleep maintenance: eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 3
3. For older adults: Use extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects 1, 3

Important Considerations and Pitfalls

• Short-term use of medications is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use 1, 3
• Benzodiazepines and non-benzodiazepine hypnotics carry risks of falls, cognitive impairment, and dependence, particularly in older adults 1, 3
• Over-the-counter antihistamines (e.g., diphenhydramine) are not recommended due to lack of efficacy data and safety concerns 3
• Herbal supplements (e.g., valerian) and nutritional substances (e.g., melatonin) are not recommended due to insufficient evidence of efficacy 3
• Avoid using sedating agents without considering their specific effects on sleep onset versus maintenance 3
• Regular follow-up is essential to monitor treatment response and address any emerging issues 1, 2
• Newer-generation nonbenzodiazepines (zolpidem, zaleplon, eszopiclone, and ramelteon) have better safety profiles than traditional benzodiazepines for long-term treatment 6