What is the recommended treatment approach for insomnia?

Treatment Approach for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for all adults with chronic insomnia and should be initiated before any pharmacological intervention. 1, 2, 3

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Initial Treatment: CBT-I as Primary Intervention

CBT-I demonstrates superior long-term efficacy compared to medications and should be the starting point for all patients with chronic insomnia. 1, 2, 3

Core Components of Effective CBT-I:

• Sleep restriction therapy limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 2, 3
• Stimulus control therapy breaks 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 2, 3
• Cognitive restructuring addresses maladaptive thoughts and beliefs about sleep that perpetuate insomnia through psychoeducation, Socratic questioning, and behavioral experiments 3
• Sleep hygiene education should be included but is insufficient as a standalone treatment 2

Treatment Structure:

• CBT-I is typically delivered over 4-8 sessions with a trained specialist, using sleep diary data throughout to monitor progress 3
• Benefits are sustained for up to 2 years without risk of tolerance or adverse effects 2
• Brief behavioral therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions 1, 3

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Pharmacological Treatment: 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. 2

First-Line Pharmacological Options (When Medication is Necessary):

For sleep onset insomnia:

• Zaleplon 10 mg 4
• Ramelteon 8 mg 4
• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Triazolam 0.25 mg (though associated with rebound anxiety) 4

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 4
• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Temazepam 15 mg 4
• Low-dose doxepin 3-6 mg 4
• Suvorexant (orexin receptor antagonist) 4

Critical Prescribing Principles:

• Use the lowest effective dose for the shortest period possible 1
• Short-term use only (typically less than 4 weeks for acute insomnia) 1, 5
• Zolpidem has demonstrated efficacy for up to 35 days in controlled trials but is indicated for short-term treatment 5
• Always supplement pharmacotherapy with behavioral and cognitive therapies 4
• Regular monitoring is essential, especially during the initial treatment period 4

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Medications to Avoid

The following agents are NOT recommended due to lack of efficacy data, safety concerns, or problematic side effects:

• Over-the-counter antihistamines (e.g., diphenhydramine) cause daytime sedation and delirium, especially in older patients and those with advanced illness 1, 2, 4
• Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects 1, 2
• Herbal supplements (e.g., valerian) and melatonin lack sufficient evidence of efficacy 4, 3
• Trazodone is not recommended for sleep onset or maintenance insomnia 4
• Long-acting benzodiazepines carry increased risks without clear benefit 1

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Treatment Algorithm

Step 1: Initiate CBT-I

• Begin with comprehensive CBT-I including sleep restriction, stimulus control, cognitive therapy, and sleep hygiene education 1, 2, 3
• Collect sleep diary data before and during treatment to monitor progress 3
• Continue for 4-8 sessions with regular follow-up 3

Step 2: If CBT-I is Insufficient or Not Feasible

• Consider short-term use of FDA-approved sleep medications 2
• Select agent based on symptom pattern (sleep onset vs. maintenance) 4
• Start with short/intermediate-acting benzodiazepine receptor agonists or ramelteon 4

Step 3: If First-Line Medications Fail

• Try alternative agents in the same class 4
• Consider sedating antidepressants (e.g., doxepin 3-6 mg) for patients with comorbid depression/anxiety 4

Step 4: Ongoing Management

• Periodic reassessment is mandatory for any patient on long-term pharmacotherapy 2, 4
• Taper medications when conditions allow to prevent discontinuation symptoms 4
• Continue behavioral interventions alongside any medication use 4

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Special Populations and Critical Pitfalls

Older Adults:

• Use extra caution with all sleep medications due to increased risk of falls, cognitive impairment, and adverse effects 2
• Reduce zolpidem dose to 5 mg in elderly patients 4, 5
• Benzodiazepines carry particularly high risks in this population 2

Contraindications for Sleep Restriction:

• High-risk occupations (e.g., commercial drivers, pilots) 3
• Predisposition to mania/hypomania 3
• Poorly controlled seizure disorders 3

Common Pitfalls to Avoid:

• Using medications as first-line treatment instead of CBT-I 2
• Continuing pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 2, 4
• Prescribing over-the-counter antihistamines or herbal supplements 2, 4
• Using antipsychotics for insomnia treatment 1, 2
• Failing to consider drug interactions, contraindications, and patient-specific factors when selecting medications 1, 4
• Using sedating agents without matching them to specific sleep complaints (onset vs. maintenance) 4