What are the treatment options for insomnia?

Treatment Options for 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, 3

First-Line Treatment: Psychological and Behavioral Therapies

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is a multimodal therapy that combines cognitive therapy, behavioral interventions, and educational components 1
• CBT-I has demonstrated sustained benefits for up to 2 years after treatment completion 2, 3
• CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users 1, 2
• Key components include:
  • Sleep restriction therapy
  • Stimulus control
  • Sleep hygiene education
  • Cognitive restructuring to address maladaptive thoughts about sleep 2, 3

Other Effective Behavioral Treatments

• Stimulus control therapy (Standard recommendation) 1, 4
• Relaxation training (Standard recommendation) 1, 4
• Sleep restriction therapy (Guideline recommendation) 1, 4
• Multicomponent therapy without cognitive components (Guideline recommendation) 1, 4
• Biofeedback therapy (Guideline recommendation) 1
• Paradoxical intention (Guideline recommendation) 1

Important Considerations for Behavioral Treatments

• Sleep hygiene alone is insufficient for treating chronic insomnia and should be used in combination with other therapies 1, 3, 5
• Behavioral treatments typically produce gradual improvements that are durable beyond the end of treatment 1
• Initial side effects (sleepiness, fatigue) are typically mild and resolve quickly for most patients 1

Second-Line Treatment: Pharmacological Options

Medications should only be considered when:

• Patients are unable to participate in CBT-I 3
• Patients still have symptoms despite participation in CBT-I 3
• As a temporary adjunct to CBT-I 3

FDA-Approved Medications

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs):
  • Zolpidem (indicated for difficulties with sleep initiation, shown to decrease sleep latency for up to 35 days) 6
  • Eszopiclone, zaleplon, triazolam, temazepam (for sleep onset and maintenance insomnia) 1, 3
• Orexin receptor antagonists (for sleep onset and maintenance insomnia) 3
• Ramelteon (specifically for sleep onset insomnia) 7
• Low-dose doxepin (for sleep maintenance insomnia) 3

Recommended Sequence for Pharmacologic Treatment

1. Short-intermediate acting benzodiazepine receptor agonists or ramelteon 1
2. Alternative short-intermediate acting BzRAs or ramelteon if initial agent unsuccessful 1
3. Sedating antidepressants (especially when comorbid depression/anxiety exists) 1
4. Combined BzRA or ramelteon and sedating antidepressant 1
5. Other sedating agents (anti-epilepsy medications, atypical antipsychotics) 1

Treatment Monitoring and Follow-up

• Sleep diary data should be collected before and during treatment 1, 2
• Clinical reassessment should occur every few weeks until insomnia appears stable or resolved, then every 6 months 1
• When initial treatment is ineffective, consider:
  • Other behavioral therapies
  • Pharmacological therapies
  • Combined therapies
  • Reevaluation for occult comorbid disorders 1, 3

Important Cautions and Pitfalls

• Short-term use of medications is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use 3
• Benzodiazepines and non-benzodiazepine hypnotics carry risks of:
  • Falls and fractures (especially in older adults)
  • Cognitive impairment
  • Anterograde amnesia (particularly at doses above 10 mg for zolpidem) 6
  • Dependence 3
• Patients may get discouraged if immediate results are not observed with CBT-I, as improvements typically develop gradually compared to pharmacological interventions 1
• Comorbid medical and psychiatric conditions may change the balance of benefits vs. harms of certain treatments 1