What are the guidelines for treating insomnia?

Guidelines for Treating Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for all adults 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: CBT-I

• CBT-I is the standard of care for chronic insomnia, with moderate-quality evidence showing clinically meaningful improvements in sleep parameters, including reduced sleep onset latency, decreased wake time after sleep onset, improved sleep efficiency, and enhanced sleep quality 2, 4
• CBT-I provides sustained benefits without the risk of tolerance or adverse effects associated with pharmacologic approaches, making it particularly valuable for long-term management 4, 5
• CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users 1, 2

Key Components of Effective CBT-I

• Stimulus control therapy (Standard): Designed to extinguish negative associations between the bed and wakefulness by instructing patients to go to bed only when sleepy, maintain regular schedules, avoid naps, use bed only for sleep, and leave bed if unable to fall asleep within 20 minutes 1
• Sleep restriction therapy (Guideline): Limits time in bed to match actual sleep time based on sleep logs, with the goal of achieving >85% sleep efficiency 1
• Cognitive therapy (Standard): Addresses maladaptive thoughts and unrealistic expectations about sleep such as "I can't sleep without medication" or "My life will be ruined if I can't sleep" 1
• Relaxation training (Standard): Techniques like progressive muscle relaxation to reduce somatic and cognitive arousal that interfere with sleep 1

Second-Line Treatment: Pharmacological Options

When CBT-I is ineffective, unavailable, or as a temporary adjunct to CBT-I, pharmacological options may be considered:

• Short/intermediate-acting benzodiazepine receptor agonists (BzRAs) such as zaleplon, zolpidem, eszopiclone, triazolam, and temazepam are effective for sleep onset and/or maintenance difficulties 1, 3
• Zolpidem is FDA-approved for short-term treatment of insomnia characterized by difficulties with sleep initiation 6
• Eszopiclone is FDA-approved for both sleep onset and maintenance insomnia 7
• Ramelteon, a melatonin receptor agonist, is specifically indicated for sleep onset difficulties and may be appropriate for patients who prefer not to use DEA-scheduled drugs or have a history of substance use disorders 1, 8

Medication Selection Algorithm

1. Match medication to specific symptom pattern:

   • For sleep onset insomnia: Consider zaleplon, zolpidem, ramelteon (all have short half-lives) 1, 6, 8
   • For sleep maintenance insomnia: Consider eszopiclone or temazepam (longer half-lives) 1, 7

2. If initial agent is ineffective, try a different agent within the same class, considering the patient's previous response and preferences 1

Important Considerations and Pitfalls

• Sleep hygiene education alone is insufficient for treating chronic insomnia and should be used in combination with other therapies 1, 3, 9
• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies whenever possible 1, 3
• Regular clinical reassessment should occur every few weeks until the insomnia appears stable or resolved, then every 6 months, as relapse rates for insomnia are high 1, 2
• Sleep diary data should be collected before and during treatment to monitor progress 1
• When a single treatment is ineffective, consider other behavioral therapies, pharmacological therapies, combined therapies, or reevaluation for occult comorbid disorders 1, 3
• Polysomnography is not indicated in routine evaluation of chronic insomnia but is warranted when there is suspicion of sleep apnea, movement disorders, treatment failure, or violent/injurious behavior during sleep 1

Recent Evidence on CBT-I Components

A 2024 systematic review and meta-analysis identified the most critical components of CBT-I as:

• Cognitive restructuring
• Third-wave components (mindfulness, acceptance)
• Sleep restriction
• Stimulus control
• In-person delivery format

This combination was associated with a number needed to treat of 3.0, suggesting high efficacy 10

Special Populations

• For older adults, use extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects 3
• For patients with comorbid mental disorders and insomnia, CBT-I shows significant benefits for both insomnia symptoms and mental health outcomes, particularly in depression, PTSD, and alcohol dependency 5