What is the recommended treatment plan for insomnia?

Treatment Plan for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all adults with chronic insomnia, before considering any pharmacological intervention. 1, 2

First-Line Treatment: CBT-I

CBT-I is designated as the standard of care by the American Academy of Sleep Medicine and receives a strong recommendation from the American College of Physicians as the initial treatment intervention for chronic insomnia. 3, 1, 2

Why CBT-I First?

• CBT-I produces clinically meaningful improvements in sleep parameters that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation 1, 2, 4
• CBT-I provides sustained benefits without the risk of tolerance or adverse effects associated with medications 1, 4
• CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users 3

Core Components of CBT-I

The treatment typically requires 4-8 sessions over 6 weeks and must include these critical behavioral components: 1, 2

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 1

  • Initial restriction of time in bed to average sleep duration from sleep diary
  • Gradually adjust based on sleep efficiency thresholds (typically >85% to increase, <80% to decrease)
  • Contraindicated in patients working high-risk occupations, those predisposed to mania/hypomania, or those with poorly controlled seizure disorders 1

• Stimulus control therapy: Extinguishes the association between bed/bedroom and wakefulness 1

  • Go to bed only when sleepy
  • Use bed only for sleep and sex
  • Leave bedroom if unable to fall asleep within 15-20 minutes
  • Maintain consistent wake time regardless of sleep duration

• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments 1

• Sleep hygiene education: Must be combined with other therapies, as it is insufficient as a standalone intervention 3, 1, 5

Delivery Methods

• In-person, therapist-led programs are most beneficial 2
• Digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable 2
• Brief Behavioral Therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions 6

Monitoring During CBT-I

• Collect sleep diary data before and during treatment to monitor progress and guide adjustments 3, 1
• Clinical reassessment should occur every few weeks until insomnia stabilizes or resolves, then every 6 months due to high relapse rates 3

Pharmacological Treatment (Second-Line)

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 6, 2

When to Consider Pharmacotherapy

• After unsuccessful CBT-I trial 3, 6
• When CBT-I is not available or accessible 2
• For acute insomnia with clear stressor (typically <4 weeks duration) 6

First-Line Pharmacological Options

The American Academy of Sleep Medicine recommends short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon as first-line medications: 6

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) 6, 7
• Zaleplon 10 mg 6
• Ramelteon 8 mg 6
• Triazolam 0.25 mg (not first-line due to rebound anxiety risk) 6

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 6, 8
• Zolpidem 10 mg (5 mg in elderly) 6, 7
• Temazepam 15 mg 6

Second-Line Pharmacological Options

• Doxepin 3-6 mg for sleep maintenance insomnia 6
• Suvorexant (orexin receptor antagonist) for sleep maintenance insomnia 6
• Sedating antidepressants (e.g., amitriptyline, mirtazapine) for patients with comorbid depression/anxiety 6

Agents NOT Recommended

• Trazodone: Not recommended by the American Academy of Sleep Medicine 6
• Over-the-counter antihistamines (e.g., diphenhydramine): Lack efficacy data and have safety concerns including daytime sedation and delirium, especially in older adults 6
• Melatonin: Insufficient evidence for chronic insomnia 1, 6
• Herbal supplements (e.g., valerian): Insufficient evidence 6
• Barbiturates and chloral hydrate: Not recommended 6
• Tiagabine: Not recommended 6
• Antipsychotics: Should not be used as first-line due to problematic metabolic side effects 6

Pharmacotherapy Principles

• Use the lowest effective dose for the shortest period possible (typically less than 4 weeks for acute insomnia) 6
• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible 3, 6
• Taper medication when conditions allow to prevent discontinuation symptoms 6
• Monitor patients regularly during initial treatment to assess effectiveness and side effects 6

Selection Algorithm for Medications

1. Assess symptom pattern: Sleep onset difficulty versus sleep maintenance difficulty 6
2. Consider patient factors: Age, comorbid conditions, contraindications, concurrent medications, past treatment responses, cost, and patient preference 3, 6
3. Medication trial sequence: If first-line BzRA unsuccessful, try alternative BzRA, then consider ramelteon or sedating antidepressants if comorbid depression/anxiety present 6

Treatment Goals and Outcomes

Primary treatment goals regardless of therapy type: 3

• Improve sleep quality and quantity
• Improve insomnia-related daytime impairments

Specific outcome indicators to monitor: 3

• Wake time after sleep onset (WASO)
• Sleep onset latency (SOL)
• Number of awakenings
• Total sleep time or sleep efficiency
• Sleep-related psychological distress

When Initial Treatment Fails

If a single treatment or combination of treatments has been ineffective, consider: 3

• Other behavioral therapies or combination CBT-I therapies
• Alternative pharmacological therapies
• Combined behavioral and pharmacological treatments
• Reevaluation for occult comorbid disorders (psychiatric, medical, or other sleep disorders)

Common Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment without attempting CBT-I, as this violates guideline recommendations and deprives patients of more effective, durable therapy 1, 2
• Do not rely on sleep hygiene education alone, as it lacks efficacy as a single intervention 3, 1, 5
• Do not use long-acting benzodiazepines (e.g., lorazepam) as first-line treatment due to increased risks without clear benefit 6
• Do not continue pharmacotherapy long-term without periodic reassessment 6
• Do not fail to consider drug interactions and contraindications when prescribing medications 3, 6
• Do not expect immediate results from CBT-I; counsel patients that improvements are gradual but sustained 2

Special Populations

• Older adults: CBT-I is effective and preferred; if medications needed, use lower doses (e.g., zolpidem 5 mg instead of 10 mg) 3, 6
• Patients with comorbid depression/anxiety: CBT-I remains first-line; if medications needed, consider sedating antidepressants 3, 6
• Patients with medical comorbidities: CBT-I is effective for insomnia with medical comorbidities 3

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