What are the recommended treatments for insomnia?

Insomnia Treatment Recommendations

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all adults with chronic insomnia, with pharmacological therapy reserved only when CBT-I alone is unsuccessful. 1

First-Line Treatment: CBT-I

CBT-I demonstrates superior long-term efficacy compared to pharmacological options and carries minimal risk of adverse effects. 1 This recommendation is endorsed by both the American Academy of Sleep Medicine and the American College of Physicians as the standard of care for chronic insomnia. 2

Core Components of Effective CBT-I

The following behavioral interventions should be included in initial treatment approaches:

• Stimulus control therapy: Extinguishes the association between bed/bedroom and wakefulness by instructing patients to go to bed only when sleepy and use the bed only for sleep and sex. 3

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and improves sleep efficiency. 3 This component may be contraindicated in patients with high-risk occupations, mania/hypomania predisposition, or poorly controlled seizure disorders. 3

• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments. 3

• Relaxation training: Reduces psychophysiological arousal associated with insomnia. 2

Treatment Structure and Monitoring

• CBT-I is typically delivered over 4-8 sessions with a trained specialist. 3

• Sleep diary data should be collected before and during treatment to monitor progress and guide adjustments. 2, 3

• Clinical reassessment should occur every few weeks until insomnia stabilizes, then every 6 months due to high relapse rates. 2

• CBT-I provides sustained benefits lasting up to 2 years without risk of tolerance or adverse effects. 4

Important Caveat About Sleep Hygiene

Sleep hygiene education alone is insufficient for treating chronic insomnia and should only be used in combination with other therapies. 2, 5 While all patients should adhere to good sleep hygiene principles, there is insufficient evidence that it is effective as a standalone intervention. 2

Second-Line Treatment: Pharmacological Options

Pharmacotherapy should only be considered after CBT-I has been unsuccessful following an adequate trial of 4-8 weeks. 1, 3

FDA-Approved Medications

When pharmacotherapy is necessary, the following options are available:

Benzodiazepine Receptor Agonists (BzRAs):

• Short/intermediate-acting BzRAs should be used at the lowest effective dose for the shortest period possible (4-5 weeks). 1
• Zolpidem is indicated for short-term treatment of insomnia characterized by sleep onset difficulties, with efficacy demonstrated for up to 35 days. 6
• Eszopiclone is indicated for both sleep onset and maintenance, with clinical trials supporting efficacy up to 6 months. 7
• Other options include zaleplon and temazepam, each with different half-lives suited to specific sleep complaints. 1

Low-Dose Doxepin (3-6 mg):

• Particularly effective for sleep maintenance insomnia with less cardiovascular risk than benzodiazepines. 1, 4

Ramelteon (Melatonin Receptor Agonist):

• May be considered for sleep onset difficulties with minimal respiratory depression. 4

Medication Selection Algorithm

Choose pharmacological agents based on:

1. Symptom pattern (sleep onset vs. maintenance difficulties) 2
2. Patient age and comorbidities (especially cardiac or respiratory conditions) 1, 4
3. Previous treatment responses 2
4. Risk of abuse/dependence (avoid benzodiazepines in patients with substance use history) 1
5. Potential drug interactions with concurrent medications 2
6. Cost and patient preference 2

Critical Safety Warnings

Potential adverse effects of BzRAs include:

• Residual sedation and daytime impairment 1
• Memory and performance impairment, including anterograde amnesia (particularly at doses >10 mg) 6
• Falls and injuries, especially in elderly patients 1
• Behavioral abnormalities including "sleep driving" 1
• Respiratory depression in patients with cardiac or pulmonary conditions 4

Medications to avoid:

• Antihistamine sleep aids and herbal substances such as valerian are not recommended due to lack of efficacy and safety data. 1
• Benzodiazepines should be avoided in patients with substance use history due to high abuse potential. 1

Treatment Algorithm for Clinical Practice

Step 1: Initial Assessment and CBT-I Implementation

• Collect baseline sleep diary data 2, 3
• Implement all core CBT-I components (stimulus control, sleep restriction, cognitive therapy, relaxation) 2, 3
• Continue for at least 4-8 weeks to evaluate effectiveness 1, 3
• Monitor with sleep diaries and reassess every few weeks 2

Step 2: If CBT-I Insufficient After Adequate Trial

• Consider adding pharmacological options based on symptom pattern and patient characteristics 1
• Start with lowest effective dose 1
• Limit duration to 4-5 weeks when possible 1
• Continue incorporating behavioral techniques alongside medication 2
• Monitor regularly for treatment response, adverse effects, and potential misuse 1

Step 3: If Initial Treatment Combination Ineffective

• Consider alternative psychological/behavioral therapies 2
• Reevaluate for occult comorbid disorders (psychiatric, medical, or other sleep disorders) 2
• Consider combination CBT-I therapies or different pharmacological agents 2

Special Populations

Older Adults:

• CBT-I is effective for adults of all ages, including older adults. 2
• Older adults are more likely to report sleep maintenance problems than sleep onset difficulties. 2
• Increased caution with pharmacotherapy due to higher risk of falls, cognitive impairment, and drug interactions. 1

Patients with Comorbid Conditions:

• Psychological and behavioral interventions are effective for both primary and comorbid (secondary) insomnia. 2
• For patients with congestive heart failure, optimize cardiac management first, as improved cardiac function may alleviate sleep disturbances. 4
• Screen for sleep-disordered breathing in cardiac patients, as CPAP may be beneficial if obstructive sleep apnea is present. 4