What is the recommended algorithm for managing insomnia?

Insomnia Management Algorithm

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for all adults with chronic insomnia disorder, and pharmacotherapy should only be considered after CBT-I has been attempted or as a short-term adjunct during CBT-I implementation. 1, 2

Step 1: Initial Treatment - CBT-I (First-Line for All Patients)

All patients with chronic insomnia must begin with CBT-I, which demonstrates superior long-term efficacy compared to medications and sustained benefits up to 2 years without risk of tolerance, dependence, or adverse effects. 1, 2, 3

Core CBT-I Components (Implement All):

• Sleep Restriction Therapy: Limit time in bed to match actual sleep duration from sleep diary (minimum 5 hours), then adjust weekly based on sleep efficiency (SE%). If SE >85-90%, increase time in bed by 15-20 minutes; if SE <80%, decrease by 15-20 minutes. 1, 4

• Stimulus Control: Go to bed only when sleepy; use bed only for sleep and sex; leave bed after 20 minutes of perceived wakefulness (no clock-watching); maintain consistent wake time daily; eliminate daytime naps. 1

• Cognitive Therapy: Address dysfunctional beliefs such as "I can't sleep without medication," "My life will be ruined if I can't sleep," using Socratic questioning and behavioral experiments. 1, 4

• Relaxation Training: Progressive muscle relaxation involving systematic tensing and relaxing of muscle groups. 1

CBT-I Delivery Options:

• Standard format: 4-8 sessions with trained specialist 4
• Brief Behavioral Therapy: 2-4 sessions emphasizing behavioral components when resources limited 5
• Alternative delivery: Individual, group, telephone, web-based modules, or self-help books 1

Important Contraindications for Sleep Restriction:

• High-risk occupations requiring alertness 4
• Predisposition to mania/hypomania 4
• Poorly controlled seizure disorders 4

Step 2: Pharmacotherapy (Only After CBT-I Unsuccessful or as Short-Term Adjunct)

Medications should only be added when patients cannot participate in CBT-I, still have symptoms despite CBT-I, or as temporary adjunct to CBT-I. 2 Use shared decision-making discussing benefits, harms, and costs. 1

First-Line Pharmacotherapy Selection Algorithm:

For Sleep Onset Insomnia:

• Zaleplon 10 mg (5 mg elderly) 5
• Zolpidem 10 mg (5 mg elderly) 5, 6
• Ramelteon 8 mg 5
• Triazolam 0.25 mg (associated with rebound anxiety, not preferred) 5

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg 5
• Zolpidem 10 mg (5 mg elderly) 5, 6
• Temazepam 15 mg (7.5 mg elderly or debilitated) 5, 7
• Suvorexant (orexin antagonist) 1, 5

For Both Sleep Onset and Maintenance:

• Eszopiclone 2-3 mg 5
• Zolpidem 10 mg (5 mg elderly) 5, 6
• Temazepam 15 mg 5, 7

Second-Line Pharmacotherapy:

If first-line BzRAs unsuccessful or contraindicated:

• Low-dose doxepin 3-6 mg for sleep maintenance 1, 5
• Sedating antidepressants (trazodone, mirtazapine, amitriptyline) when comorbid depression/anxiety present 1, 5

Alternative BzRAs within same class if initial agent unsuccessful, considering patient's response pattern (e.g., switch to longer half-life if wake after sleep onset persists, shorter-acting if residual sedation occurs). 1

Critical Medication Principles:

• Use lowest effective dose for shortest duration possible (typically <4 weeks for acute insomnia) 5
• Short-term use only due to risks of tolerance, dependence, cognitive impairment, falls, and fractures, especially in older adults 1, 2
• Always supplement with behavioral/cognitive therapies when using medications 5
• Taper gradually when discontinuing to prevent withdrawal reactions 7
• Regular monitoring required during initial treatment and periodic reassessment for long-term use 2, 5

Step 3: Agents NOT Recommended

Avoid these medications due to lack of efficacy data or safety concerns:

• Over-the-counter antihistamines (diphenhydramine): Risk of daytime sedation and delirium, especially in older adults 2, 5
• Herbal supplements (valerian) and melatonin: Insufficient evidence of efficacy 1, 5
• Trazodone: Not recommended by American Academy of Sleep Medicine 5
• Antipsychotics: Not first-line due to problematic metabolic side effects 2
• Long-acting benzodiazepines (flurazepam): Increased risks without clear benefit 1, 5
• Barbiturates and chloral hydrate: Not recommended 5

Common Pitfalls to Avoid

• Starting with medication instead of CBT-I: This violates guideline recommendations and misses the only treatment with durable long-term effects. 1, 2
• Using benzodiazepines not approved for insomnia (lorazepam, clonazepam) as first-line: These are second or third-line options only. 1, 5
• Continuing pharmacotherapy long-term without reassessment: Increases risks of dependence, cognitive impairment, and falls without proven long-term efficacy. 2, 5
• Prescribing sleep hygiene education alone: Insufficient as monotherapy for chronic insomnia, though should be included in comprehensive approach. 1, 2
• Failing to implement CBT-I alongside medication: Medications alone lack durability after discontinuation. 8
• Clock-watching during stimulus control: Patients should use perceived time (approximately 20 minutes), not actual clock-watching. 1

Special Populations

Older Adults:

• Extra caution with all medications due to increased risk of falls, cognitive impairment, and adverse effects 2
• Start with lower doses: zolpidem 5 mg, temazepam 7.5 mg 5, 6, 7
• CBT-I remains highly effective and preferred 1, 9

Comorbid Depression/Anxiety:

• Consider sedating antidepressants (mirtazapine, doxepin, amitriptyline) 1, 5
• CBT-I still effective for secondary insomnia 9