Insomnia Treatment
Primary Recommendation
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all patients with chronic insomnia, regardless of age or comorbidities, before considering any pharmacological intervention. 1, 2, 3
Treatment Algorithm
Step 1: First-Line Treatment - CBT-I
CBT-I is the gold standard initial therapy due to superior long-term efficacy with sustained benefits up to 2 years and no risk of tolerance, dependence, or adverse effects inherent to medications. 1, 3, 4
Essential components that must be included: 1, 3
- Sleep restriction therapy: Limit time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 3
- Stimulus control therapy: Break the association between bed/bedroom and wakefulness through specific behavioral instructions 1, 3
- Cognitive restructuring: Target maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 3
- Sleep hygiene education: Address environmental and behavioral factors (avoiding frequent daytime napping, excessive time in bed, late evening exercise, caffeine, evening alcohol, smoking) 1
Treatment delivery considerations: 5
- Face-to-face sessions of at least 4 sessions are more effective than self-help interventions or fewer sessions 5
- Brief behavioral therapy (2-4 sessions emphasizing behavioral components) may be appropriate when resources are limited 2
- Results are robust across patient populations: those with or without comorbid disease, younger or older patients, and those using or not using sleep medication 5
Evidence of effectiveness: 4, 6
- Sleep onset latency improves by 19 minutes 4
- Wake after sleep onset improves by 26 minutes 4
- Sleep efficiency improves by 9.91% 4
- 36% of patients achieve remission from insomnia with CBT-I versus 16.9% with control conditions 6
Step 2: Pharmacotherapy (Only When CBT-I Fails or Is Unavailable)
Medications should only be considered when: 1, 2
- Patients are unable to participate in CBT-I
- Symptoms persist despite adequate CBT-I trial
- As a temporary adjunct to CBT-I during initial treatment phase
Prescribing principles: 2
- Use the lowest effective dose for the shortest period possible (typically less than 4 weeks for acute insomnia) 2
- Short-term use is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use 1
- Supplement hypnotic treatment with behavioral and cognitive therapies when possible 2
- Regular monitoring is essential, especially during initial treatment period 2
Medication Selection by Sleep Pattern
For Sleep Onset Difficulty:
First-line options: 2
- Zolpidem 10 mg (5 mg in elderly): Effective for both sleep onset and maintenance 2, 7
- Zaleplon 10 mg: Specifically for sleep onset 2
- Ramelteon 8 mg: Melatonin receptor agonist for sleep onset 2, 8
- Triazolam 0.25 mg: For sleep onset, though associated with rebound anxiety and not considered first-line 2
For Sleep Maintenance Difficulty:
First-line options: 2
- Eszopiclone 2-3 mg: For both sleep onset and maintenance 2
- Zolpidem 10 mg (5 mg in elderly): For both sleep onset and maintenance 2, 7
- Temazepam 15 mg: For both sleep onset and maintenance 2
Second-line option: 2
- Low-dose doxepin 3-6 mg: Specifically for sleep maintenance 2, 3
- Suvorexant (orexin receptor antagonist): For sleep maintenance 2
For Comorbid Depression/Anxiety:
Consider sedating antidepressants such as amitriptyline or mirtazapine when comorbid depression/anxiety is present. 2, 3
Medications to AVOID
Never use as first-line or routine treatment: 1, 2, 3
- Over-the-counter antihistamines (e.g., diphenhydramine): Lack efficacy data and carry safety concerns including daytime sedation and delirium, especially in older patients 1, 2, 3
- Herbal supplements (e.g., valerian): Insufficient evidence of efficacy 2
- Melatonin: Insufficient evidence for chronic insomnia treatment 3
- Trazodone: Not recommended for sleep onset or maintenance insomnia 2
- Antipsychotics: Should not be used as first-line treatment due to problematic metabolic side effects 1, 2
- Barbiturates and chloral hydrate: Older hypnotics not recommended 2
- Long-acting benzodiazepines: Carry increased risks without clear benefit 2
- Tiagabine (anticonvulsant): Not recommended 2
Special Population Considerations
Older Adults (≥65 years):
- Extra caution with all medications due to increased risk of falls, cognitive impairment, and adverse effects 1
- Lower doses required: Zolpidem 5 mg (not 10 mg), ramelteon 4-8 mg 2, 7
- CBT-I remains first-line with same core components and effectiveness 3
Pregnant Women:
- CBT-I is the first-line treatment with favorable benefit-to-risk ratio without medication exposure 3
Critical Pitfalls to Avoid
Common errors that compromise treatment outcomes: 1, 2
- Using benzodiazepines as first-line treatment instead of CBT-I 2
- Continuing pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 1, 2
- Failing to implement CBT-I techniques alongside medication when pharmacotherapy is used 2
- Using sedating agents without considering their specific effects on sleep onset versus maintenance 2
- Ignoring drug interactions and contraindications 2
- Prescribing over-the-counter sleep aids or herbal supplements with limited efficacy data 2
- Using sleep hygiene education alone as monotherapy for severe chronic insomnia (insufficient but should be included as part of comprehensive approach) 1, 3
Follow-Up and Monitoring
Regular follow-up is essential: 2, 3
- Monitor treatment response, effectiveness, and side effects during initial treatment period 2
- Assess need for medication adjustments 3
- Continue regular follow-up until insomnia stabilizes, then every 6 months 3
- Taper medication when conditions allow to prevent discontinuation symptoms 3
- Educate patients about treatment goals, safety concerns, and potential side effects 3