What is the first-line management for insomnia?

First-Line Management for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for all patients with chronic insomnia and should be initiated before any pharmacological intervention. 1, 2

Why CBT-I is First-Line

The American Academy of Sleep Medicine, American College of Physicians, and VA/DoD all recommend CBT-I as the initial treatment due to its superior long-term efficacy compared to medications and favorable benefit-to-risk ratio. 1, 2 Unlike pharmacotherapy, CBT-I provides sustained benefits for up to 2 years without risk of tolerance, dependence, or adverse effects. 1, 2

CBT-I demonstrates moderate to large effect sizes across diverse populations, including patients with comorbid mental health conditions such as depression (effect size 0.5), PTSD (effect size 1.5), and alcohol dependency (effect size 1.4). 3

Essential Components of Effective CBT-I

The most efficacious CBT-I programs include these critical components:

• Cognitive restructuring - addresses maladaptive thoughts and beliefs about sleep (incremental odds ratio 1.68 for remission) 4
• Sleep restriction therapy - limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive (incremental odds ratio 1.49) 1, 4
• Stimulus control therapy - extinguishes the association between bed/bedroom and wakefulness by instructing patients to go to bed only when sleepy and use bed only for sleep and sex (incremental odds ratio 1.43) 2, 4
• Third-wave components such as mindfulness-based techniques (incremental odds ratio 1.49) 4

What NOT to Include

• Sleep hygiene education alone is insufficient for treating chronic insomnia, though it should be included as part of comprehensive treatment (incremental odds ratio 1.01, not statistically significant). 1, 4
• Relaxation procedures may be counterproductive and are not essential components (incremental odds ratio 0.81). 4

Delivery Format

In-person, therapist-led CBT-I is most beneficial (incremental odds ratio 1.83), though digital CBT-I (dCBT) represents a scalable alternative when in-person therapy is unavailable. 5, 4 Standard CBT-I is typically delivered over 4-8 sessions with a trained specialist, using sleep diary data throughout to monitor progress. 2

The most efficacious combination—cognitive restructuring, third-wave components, sleep restriction, and stimulus control delivered in-person—increases remission rates by 33% compared to psychoeducation alone, with a number needed to treat of 3.0. 4

When Pharmacotherapy May Be Considered (Second-Line Only)

Medications should only be considered when patients cannot participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I. 1

If pharmacotherapy becomes necessary:

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs) such as eszopiclone (2-3 mg), zolpidem (10 mg, 5 mg in elderly), zaleplon (10 mg), or temazepam (15 mg) are first-line medication options. 6
• Ramelteon (8 mg) for sleep onset insomnia. 6
• Low-dose doxepin (3-6 mg) for sleep maintenance insomnia. 6

Critical Pitfalls to Avoid

• Never use benzodiazepines or hypnotics as first-line treatment without attempting CBT-I, as they carry risks of falls, cognitive impairment, and dependence, particularly in older adults. 1, 6
• Do not prescribe over-the-counter antihistamines (e.g., diphenhydramine) or herbal supplements (e.g., valerian, melatonin) due to lack of efficacy data and safety concerns, especially daytime sedation and delirium in older patients. 7, 6
• Avoid long-term pharmacotherapy without periodic reassessment and concurrent behavioral interventions. 7, 6
• Do not use antipsychotics as first-line treatment due to problematic metabolic side effects. 7

Special Considerations

Sleep restriction may be contraindicated in patients working in high-risk occupations or those predisposed to mania/hypomania or poorly controlled seizure disorders. 2

For patients with comorbid depression or anxiety, sedating antidepressants may be considered after first-line options, but CBT-I remains the initial approach as it also improves mental health symptoms. 6, 3