What are the treatment options for insomnia?

Treatment Options for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as the first-line treatment for all adults with chronic insomnia due to its superior long-term efficacy and minimal risk of adverse effects. 1, 2, 3

First-Line Treatment: Psychological and Behavioral Therapies

• CBT-I is the most effective initial treatment approach for chronic insomnia, with benefits lasting up to 2 years 3
• CBT-I includes multiple components that should be implemented together:
  • Sleep restriction therapy (limiting time in bed to match actual sleep duration) 1, 3
  • Stimulus control therapy (associating bed only with sleep) 1, 3
  • Cognitive therapy (addressing maladaptive thoughts about sleep) 3
  • Sleep hygiene education (as part of comprehensive treatment, not alone) 1, 2
• Multicomponent behavioral therapy without cognitive therapy is also effective for chronic insomnia 1
• Other effective behavioral interventions include relaxation training and biofeedback therapy 1, 4
• Sleep diary data should be collected before and during treatment to monitor progress 1

Second-Line Treatment: Pharmacological Options

When CBT-I is unsuccessful or unavailable, pharmacological options should be considered in the following sequence:

First-Line Medications

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon 1, 2
  • Zolpidem (10mg, 5mg in elderly) for sleep onset and maintenance insomnia 2, 5
  • Eszopiclone (2-3mg) for sleep onset and maintenance insomnia 2
  • Zaleplon (10mg) for sleep onset insomnia 2
  • Temazepam (15mg) for sleep onset and maintenance insomnia 2
  • Ramelteon (8mg) for sleep onset insomnia 2, 6

Second-Line Medications

• Alternative BzRAs or ramelteon if initial agent unsuccessful 1, 2
• Sedating antidepressants when comorbid depression/anxiety exists:
  • Doxepin (3-6mg) for sleep maintenance insomnia 2
  • Amitriptyline, mirtazapine may be considered 2
• Suvorexant (orexin receptor antagonist) for sleep maintenance insomnia 2

Not Recommended

• Over-the-counter antihistamines (e.g., diphenhydramine) due to lack of efficacy data and safety concerns 2
• Herbal supplements (e.g., valerian) and melatonin due to insufficient evidence 2
• Trazodone is not recommended for sleep onset or maintenance insomnia 2
• Tiagabine (anticonvulsant) is not recommended 2

Treatment Algorithm

1. Initial Assessment:

   • Evaluate for comorbid conditions that may cause or worsen insomnia 1
   • Collect sleep diary data to assess sleep patterns 1

2. First-Line Treatment:

   • Implement CBT-I with all components (stimulus control, sleep restriction, cognitive therapy) 1, 3
   • Continue for 4-8 sessions with regular monitoring 3

3. If CBT-I is unsuccessful after adequate trial:

   • Select pharmacotherapy based on:
     • Symptom pattern (sleep onset vs. maintenance difficulties) 1, 2
     • Patient factors (age, comorbidities) 1
     • Previous treatment responses 1
     • Potential side effects and drug interactions 1

4. Pharmacotherapy Selection:

   • For sleep onset difficulty: zaleplon, ramelteon, zolpidem 2, 5
   • For sleep maintenance: eszopiclone, zolpidem, temazepam, doxepin 2, 5

5. Follow-up and Monitoring:

   • Clinical reassessment should occur every few weeks until insomnia stabilizes 1
   • Long-term follow-up every 6 months due to high relapse rate 1

Important Clinical Considerations

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies 1, 2
• Zolpidem has been shown to decrease sleep latency for up to 35 days in controlled clinical studies 5
• Pharmacological treatments have potential adverse effects including residual sedation, memory impairment, falls, and drug interactions 5, 2
• Older adults are more likely to report problems with sleep maintenance than sleep onset 1
• Regular follow-up is essential to assess effectiveness and side effects 1

Common Pitfalls to Avoid

• Using sleep hygiene education alone is insufficient for treating chronic insomnia 1, 2
• Starting with medications before trying CBT-I 1, 2
• Continuing pharmacotherapy long-term without periodic reassessment 1, 2
• Failing to consider drug interactions and contraindications 2
• Using over-the-counter sleep aids with limited efficacy data 2
• Neglecting to address underlying medical or psychiatric conditions 1