What are the treatment options for insomnia (insomnia tx)?

Treatment of 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 the gold standard treatment for chronic insomnia, producing 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 This multimodal intervention combines several evidence-based components delivered over 4-10 weekly or biweekly sessions. 3

Core Components of 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

• Stimulus control therapy re-establishes the bed and bedroom as cues for sleep rather than wakefulness, breaking the conditioned association between the sleep environment and arousal. 1, 2

• Cognitive therapy targets maladaptive thoughts and beliefs about sleep (e.g., catastrophic thinking about consequences of poor sleep) using structured psychoeducation, Socratic questioning, and behavioral experiments. 2

• Relaxation techniques reduce physiological and mental hyperarousal that perpetuates insomnia. 1

Important caveat: Sleep hygiene education alone is insufficient as a single-component therapy and should only be used in combination with other interventions. 1 While sleep hygiene may be necessary, it is not a sufficient condition for treating chronic insomnia. 3

Effectiveness Across Populations

CBT-I is effective for adults of all ages, including older adults and chronic hypnotic users. 1, 2 It works equally well for primary insomnia and insomnia with medical or psychiatric comorbidities. 1

Delivery Modalities

When access to in-person CBT-I is limited, alternative delivery methods are effective, including group therapy, internet-based programs, telephone-based modules, and self-help books. 1 Clinicians should discuss these options with patients based on availability, affordability, and patient preference. 1

Pharmacological Treatment

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, and should always be supplemented with behavioral and cognitive therapies when possible. 1, 4

First-Line Medications

When pharmacotherapy is necessary, the recommended sequence begins with short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon. 1, 4

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) is effective for both sleep onset and maintenance. 4, 5
• Zaleplon 10 mg specifically targets sleep onset difficulty. 4
• Ramelteon 8 mg (melatonin receptor agonist) for sleep onset without respiratory depression risk. 4
• Triazolam 0.25 mg for sleep onset, though not considered first-line due to rebound anxiety risk. 4, 6

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg for both sleep onset and maintenance. 4
• Temazepam 15 mg for both sleep onset and maintenance. 4
• Zolpidem 10 mg (5 mg in elderly) also effective for maintenance. 4

Second-Line Medications

If first-line BzRAs or ramelteon are unsuccessful, consider alternative agents in the same class first, then move to second-line options. 1, 4

• Doxepin 3-6 mg specifically for sleep maintenance insomnia, with less cardiovascular risk than benzodiazepines. 4, 7
• Suvorexant (orexin receptor antagonist) for sleep maintenance. 4
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine) when comorbid depression/anxiety is present. 1, 4

Critical warning: Trazodone is NOT recommended for sleep onset or maintenance insomnia despite widespread off-label use. 4

Medications NOT Recommended

• Over-the-counter antihistamines (diphenhydramine) lack efficacy data and carry safety concerns including daytime sedation and delirium, especially in older adults. 4
• Herbal supplements (valerian) and melatonin have insufficient evidence of efficacy. 4
• Tiagabine (anticonvulsant) is not recommended. 4
• Older hypnotics including barbiturates and chloral hydrate. 4

Medication Selection Algorithm

When choosing a specific agent, prioritize based on: 1

1. Symptom pattern (sleep onset vs. maintenance)
2. Treatment goals and duration needed
3. Past treatment responses
4. Comorbid conditions (cardiac disease, respiratory disorders, depression/anxiety)
5. Contraindications and drug interactions
6. Side effect profile
7. Patient age (lower doses in elderly)

Duration and Monitoring

• Use the lowest effective dose for the shortest period possible, typically less than 4 weeks for acute insomnia. 4
• Clinical reassessment should occur every few weeks to monthly until insomnia appears stable or resolved, then every 6 months due to high relapse rates. 1
• Taper medications when conditions allow to prevent discontinuation symptoms. 4
• Collect sleep diary data before, during, and after treatment to guide therapy adjustments. 1

Combined Treatment Approach

When pharmacotherapy is utilized, it should be supplemented with behavioral and cognitive therapies. 1, 4 CBT-I should be extended throughout drug tapering to prevent relapse upon medication discontinuation. 3

If a single treatment or combination has been ineffective, consider other behavioral therapies, alternative pharmacological agents, combined therapies, or reevaluation for occult comorbid disorders (sleep apnea, restless legs syndrome, psychiatric conditions). 1

Common Pitfalls to Avoid

• Starting with medications instead of CBT-I bypasses the most effective long-term treatment. 1
• Using sleep hygiene education alone is insufficient for chronic insomnia. 1
• Prescribing trazodone despite lack of evidence for efficacy. 4
• Continuing pharmacotherapy long-term without periodic reassessment increases risk of dependence and adverse effects. 4
• Failing to screen for sleep-disordered breathing (sleep apnea) which requires specific treatment approaches. 7
• Using long-acting benzodiazepines which carry increased risks without clear benefit. 4
• Ignoring drug interactions and contraindications, particularly in patients with cardiac or respiratory conditions. 1, 4

Special Populations

Older adults: CBT-I remains first-line and is highly effective. 1, 2 If medications are needed, use lower doses (zolpidem 5 mg instead of 10 mg) due to increased sensitivity and fall risk. 4, 2

Patients with congestive heart failure: Optimize cardiac management first, as improved cardiac function may alleviate sleep disturbances. 7 Screen for sleep apnea, which increases mortality risk 2.7-fold in CHF patients. 7 Avoid benzodiazepines due to respiratory depression risk; consider ramelteon or low-dose doxepin if CBT-I is insufficient. 7

Chronic hypnotic users: CBT-I is effective for this population and should be implemented during medication tapering. 1, 2