Insomnia Treatment
Primary Recommendation
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all patients with chronic insomnia before considering any medication. 1, 2, 3
Treatment Algorithm
Step 1: First-Line Treatment - CBT-I
CBT-I is superior to all pharmacological options with sustained benefits lasting up to 2 years and no risk of tolerance, dependence, or adverse effects. 1, 3
Essential components that must be included:
- 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 1, 3
- Sleep hygiene education - Address environmental and behavioral factors, though this alone is insufficient as monotherapy 1, 3
Evidence strength: Meta-analyses demonstrate large effect sizes for CBT-I on insomnia severity (Hedges g = 0.98), sleep efficiency (g = 0.91), and sleep onset latency (g = 0.80), with 36% of patients achieving complete remission compared to 16.9% in control conditions. 4, 5, 6
Delivery format: Face-to-face treatment with at least 4 sessions is more effective than self-help interventions or fewer sessions. 4
Step 2: Pharmacotherapy (Only if CBT-I Fails, Is Unavailable, or Patient Cannot Participate)
Medications should only be used short-term (typically less than 4 weeks) and must be supplemented with behavioral interventions. 1, 2
For Sleep Onset Insomnia:
- Zolpidem 10 mg (5 mg in elderly) - FDA-approved for short-term treatment, decreases sleep latency for up to 35 days 2, 7
- Zaleplon 10 mg 2
- Ramelteon 8 mg - Melatonin receptor agonist option 2
- Triazolam 0.25 mg - Not first-line due to rebound anxiety risk 2
For Sleep Maintenance Insomnia:
- Eszopiclone 2-3 mg - FDA-approved with efficacy demonstrated up to 6 months 2, 8
- Zolpidem 10 mg (5 mg in elderly) 2, 7
- Temazepam 15 mg 2
- Low-dose doxepin 3-6 mg - Particularly effective for sleep maintenance 2, 3
- Suvorexant - Orexin receptor antagonist 2
Critical Medications to Avoid
Never use as first-line treatment:
- Over-the-counter antihistamines (diphenhydramine) - Lack efficacy data and cause daytime sedation and delirium, especially in older adults 1, 2, 3
- Herbal supplements (valerian) and melatonin - Insufficient evidence of efficacy for chronic insomnia 2, 3
- Antipsychotics - Problematic metabolic side effects without demonstrated benefit 1, 2
- Trazodone - Not recommended by guidelines despite common off-label use 2
- Long-acting benzodiazepines - Increased risks without clear benefit 2
Special Populations
Older Adults (≥65 years):
- Use extra caution with all medications due to increased risk of falls, cognitive impairment, and adverse effects 1
- Reduce zolpidem dose to 5 mg 2, 7
- Avoid long-acting benzodiazepines entirely 2
- CBT-I remains first-line with same efficacy as younger adults 1
Pregnant Women:
- CBT-I is the only recommended treatment due to favorable benefit-to-risk ratio without medication exposure 3
Patients with Comorbid Depression/Anxiety:
- Consider sedating antidepressants (amitriptyline, mirtazapine) after CBT-I trial 2
- CBT-I shows larger effect sizes on psychiatric comorbidities (Hedges g = 0.39) compared to medical conditions 5
Common Pitfalls to Avoid
- Starting with medication instead of CBT-I - This violates all major guideline recommendations and deprives patients of the most effective long-term treatment 1, 2, 3
- Continuing pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 1, 2
- Using medications without considering specific sleep pattern - Sleep onset versus maintenance problems require different agents 2
- Failing to taper medications when conditions allow - Prevents discontinuation symptoms 2
- Prescribing lorazepam or other non-specific benzodiazepines as first-line - These are second or third-line options only 2