What are the recommended treatments for chronic insomnia?

Treatment for Chronic Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as 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
• The American Academy of Sleep Medicine, American College of Physicians, and VA/DoD all recommend CBT-I as the initial treatment for chronic insomnia 2
• CBT-I provides clinically meaningful improvements in sleep parameters without the risks of tolerance or adverse effects associated with medications 3

Core Components of Effective CBT-I:

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, enhancing sleep drive and consolidating sleep 2
• Stimulus control: Designed to extinguish the association between bed/bedroom and wakefulness 2
• Cognitive restructuring: Targets maladaptive thoughts and beliefs about sleep that perpetuate insomnia 2
• Sleep hygiene education: Important as part of comprehensive treatment, though not effective alone 1

Implementation of CBT-I:

• Typically delivered over 4-8 sessions with a trained CBT-I specialist 2
• Sleep diary data should be collected before and during treatment to monitor progress 2
• Brief Therapies for Insomnia (BTIs) are abbreviated versions that may be appropriate when resources are limited 2

Second-Line Treatment: Pharmacological Options

Medications should only be considered when:

• Patients are unable to participate in CBT-I
• Patients still have symptoms despite participation in CBT-I
• As a temporary adjunct to CBT-I 1

FDA-Approved Medication Options:

• For sleep onset insomnia:

  • Benzodiazepine receptor agonists (BzRAs) such as zolpidem, eszopiclone, and zaleplon 1, 4, 5
  • Ramelteon (melatonin receptor agonist) 1, 6

• For sleep maintenance insomnia:

  • Low-dose doxepin 1
  • Eszopiclone 5

Important Medication Considerations:

• Short-term use is preferred due to concerns about tolerance, dependence, and adverse effects 1
• Benzodiazepines and non-benzodiazepine hypnotics carry risks of falls, cognitive impairment, and next-day psychomotor impairment 1, 5, 4
• Older adults require extra caution with medications due to increased risk of adverse effects 1

Sleep Hygiene Practices

• While not adequate alone for treating chronic insomnia, sleep hygiene should be included as part of comprehensive treatment 1
• Key practices include:
  • Avoiding frequent daytime napping
  • Avoiding spending too much time in bed
  • Avoiding late evening exercise, caffeine, evening alcohol, and smoking
  • Creating a comfortable sleep environment 1

Treatment Algorithm

1. Start with CBT-I as primary intervention 1, 2

   • Implement all core components (sleep restriction, stimulus control, cognitive restructuring, sleep hygiene)
   • Monitor progress with sleep diaries
   • Continue for 4-8 sessions

2. If CBT-I is ineffective or not feasible:

   • Consider short-term use of FDA-approved sleep medications 1
   • Select medication based on insomnia type (onset vs. maintenance)
   • Start with lowest effective dose, especially in older adults
   • Monitor for adverse effects and efficacy

3. Regular follow-up:

   • Assess treatment response
   • Address emerging issues
   • Consider medication discontinuation when appropriate 1

Special Considerations

• Older adults: Use extra caution with medications; prefer CBT-I 1
• Patients with comorbid conditions: Optimize treatment of underlying conditions that may contribute to insomnia 7
• Sleep-disordered breathing: Screen for and address sleep apnea before treating insomnia 7

Common Pitfalls to Avoid

• Using medications as first-line treatment instead of CBT-I 1, 2
• Relying on sleep hygiene education alone 1, 8
• Long-term use of hypnotic medications without reassessment 1
• Failing to screen for other sleep disorders that may require specific treatment 7