What are the recommended treatments for insomnia?

Treatment of 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 demonstrated to be highly effective in treating insomnia across all age groups with sustained benefits for up to 2 years 1
• The American Academy of Sleep Medicine, American College of Physicians, and other major medical organizations uniformly support CBT-I as first-line treatment for chronic insomnia 3, 2
• CBT-I produces clinically significant improvements in sleep quality, sleep latency, wake after sleep onset, remission rates, and responder rates 3, 4

Key Components of Effective CBT-I

• Sleep restriction therapy: Limits time in bed to match actual sleep duration to enhance sleep drive and consolidate 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: Provides guidelines for creating optimal sleep conditions 1, 2

Delivery Methods for CBT-I

• Standard CBT-I is typically delivered over 4-8 sessions with a trained specialist 2
• Multiple delivery modalities have shown efficacy, including:
  • In-person individual sessions 3
  • Group therapy 3
  • Internet-based CBT-I 3
  • Brief Therapies for Insomnia (BTIs) - abbreviated versions emphasizing behavioral components 2

Pharmacological Options (Second-Line Only)

• Medications should only be considered when patients are unable to participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I 1, 5

FDA-Approved Medications

• Benzodiazepine receptor agonists (BzRAs) such as zolpidem may be considered for sleep onset and maintenance insomnia 1, 6
• Ramelteon is indicated specifically for sleep onset insomnia and has shown efficacy in reducing latency to persistent sleep 7
• Low-dose doxepin may be considered for sleep maintenance insomnia 1, 5

Important Considerations with Medications

• 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 dependence, particularly in older adults 1, 6
• Ramelteon has a more favorable safety profile with no evidence of abuse potential even at doses 20 times the recommended therapeutic dose 7

Treatment Algorithm

1. Begin with CBT-I as primary intervention 1, 2
2. If CBT-I is ineffective or not feasible:
   • Consider short-term use of FDA-approved sleep medications with careful monitoring 1
   • For patients with sleep onset insomnia, ramelteon may be appropriate 7
   • For patients with sleep maintenance insomnia, low-dose doxepin may be considered 1
3. For patients with substance use history, use extreme caution with medication choices:
   • Avoid benzodiazepines 5
   • Consider ramelteon due to its lack of abuse potential 5, 7

Common Pitfalls and Caveats

• 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
• For older adults, use extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects 1, 6
• Sleep restriction may be contraindicated in certain populations, such as those working in high-risk occupations or those predisposed to mania/hypomania or poorly controlled seizure disorders 2
• Regular follow-up is essential to monitor treatment response and address any emerging issues 1, 5