What are the treatment options for insomnia?

Treatment Options for Insomnia

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is the initial treatment for all adults with chronic insomnia and should be implemented before considering any pharmacological intervention. 1, 2, 3

This recommendation is based on consistent evidence from multiple major guidelines (American Academy of Sleep Medicine, American College of Physicians, VA/DoD) showing that CBT-I provides sustained benefits for up to 2 years without the risks of tolerance, dependence, or adverse effects inherent to medications. 2, 3

Core Components of Effective CBT-I

CBT-I must include the following critical elements to be effective: 2, 3

• 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, 3
• Stimulus control therapy: Breaks the association between bed/bedroom and wakefulness through specific behavioral instructions (e.g., go to bed only when sleepy, get out of bed if unable to sleep within 15-20 minutes, use bed only for sleep and sex) 1, 2, 3
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments 2, 3
• Sleep hygiene education: Addresses environmental and behavioral factors, though this component alone is insufficient as monotherapy 1, 2, 4

Efficacy Across Populations

CBT-I is effective for: 1, 3

• Adults of all ages, including older adults
• Chronic hypnotic users attempting to discontinue medications
• Patients with comorbid medical conditions (including congestive heart failure) 5
• Patients with comorbid psychiatric conditions 1, 3

Second-Line Treatment: Pharmacological Options

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, ineffective, or the patient cannot participate. 2, 3

Medication Selection Algorithm

When pharmacotherapy is necessary, follow this sequence: 1, 2, 3

First pharmacological choice:

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs): zolpidem, eszopiclone, zaleplon 1, 3, 6
• Ramelteon (melatonin receptor agonist): particularly for sleep onset difficulties 1, 3, 7
• Low-dose doxepin: specifically effective for sleep maintenance insomnia 2

Second pharmacological choice (if initial agent unsuccessful):

• Alternate short-intermediate acting BzRA or ramelteon 1

Third pharmacological choice:

• Sedating antidepressants: trazodone, amitriptyline, doxepin, mirtazapine—especially when treating comorbid depression/anxiety 1, 3

Fourth pharmacological choice:

• Combined BzRA or ramelteon with sedating antidepressant 1

Fifth pharmacological choice:

• Other sedating agents: anti-epilepsy medications (gabapentin, tiagabine) or atypical antipsychotics (quetiapine, olanzapine) 1

Medications to AVOID

• Melatonin: Insufficient evidence for chronic insomnia treatment 2
• Antihistamines (over-the-counter sleep aids): Lack demonstrated efficacy and have safety concerns, particularly in older adults 2

Special Dosing Considerations

Older adults: 3

• Use lower doses of BzRAs (e.g., zolpidem 5 mg instead of 10 mg)
• CBT-I remains preferred due to fall risk and cognitive impairment with sedatives

Patients with congestive heart failure: 5

• Avoid benzodiazepines and non-benzodiazepine hypnotics when possible due to respiratory depression risk
• Consider ramelteon or low-dose doxepin if pharmacotherapy necessary
• Screen for sleep-disordered breathing, as CPAP may be indicated

Treatment Duration and Monitoring

• Short-term pharmacotherapy: Zolpidem is FDA-approved for short-term treatment, with efficacy demonstrated for up to 35 days 6
• Ramelteon: Clinical trials support use up to 6 months 7
• Follow-up schedule: Reassess every few weeks to monthly until insomnia stabilizes, then every 6 months due to high relapse rates 1, 2
• Sleep diary: Collect data before, during, and after treatment to monitor outcomes 1

Common Pitfalls to Avoid

• Using sleep hygiene education alone: This is insufficient as monotherapy for chronic insomnia 1, 2, 4
• Starting with medications: This bypasses the most effective long-term treatment (CBT-I) and exposes patients to unnecessary risks 1, 2
• Failing to combine short-term hypnotics with behavioral therapy: When pharmacotherapy is used, it should be supplemented with CBT-I when possible 1
• Using sedatives in CHF patients without considering respiratory effects: This can worsen outcomes 5
• Inadequate follow-up: Insomnia has high relapse rates requiring regular monitoring 1, 2

Special Population: Pregnant Women

For pregnant women, CBT-I remains the first-line treatment with the same core components, as it has a favorable benefit-to-risk ratio without medication exposure. 2