What is the first-line treatment for insomnia?

From the Guidelines

Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment for adults with chronic insomnia disorder. This approach includes a combination of treatments such as cognitive therapy around sleep, behavioral interventions (like sleep restriction and stimulus control), and education (such as sleep hygiene) 1. CBT-I can be delivered in various formats, including individual or group therapy, telephone- or Web-based modules, or self-help books, and has been shown to be effective in improving global outcomes, including increased remission and treatment response, and reduced insomnia severity index (ISI) and Pittsburgh Sleep Quality Index (PSQI) scores compared to controls 1.

Key components of CBT-I include:

• Maintaining a consistent sleep schedule
• Creating a comfortable sleep environment
• Avoiding caffeine and alcohol before bedtime
• Limiting screen time before bed
• Establishing a relaxing bedtime routine
• Regular exercise during the day, but not close to bedtime

The benefits of starting with CBT-I over pharmacological treatment include its ability to address the underlying causes of insomnia, lack of physical side effects, and provision of long-lasting benefits without the risk of dependence associated with sleep medications 1. If CBT-I alone is unsuccessful, a shared decision-making approach can be used to consider adding pharmacological therapy, discussing the benefits, harms, and costs of short-term medication use 1.

From the FDA Drug Label

Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation.

First-line treatment options for insomnia include:

• Ramelteon (PO) 2
• Zolpidem (PO) 3 These medications have been shown to decrease sleep latency in controlled clinical studies. However, it is essential to note that the choice of first-line treatment should be individualized based on patient-specific factors, such as medical history, concomitant medications, and potential side effects. Ramelteon and zolpidem are both viable options, but the decision should be made on a case-by-case basis.

From the Research

First-Line Treatment for Insomnia

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is considered the first-line treatment for insomnia, as stated in studies 4, 5, 6.
• CBT-I has been shown to be effective in reducing insomnia severity and improving mental health in patients with comorbid mental disorders, such as depression, post-traumatic stress disorder (PTSD), and alcohol dependency 4.
• Telephone-guided Sleep Restriction Therapy (SRT), a core component of CBT-I, has also been found to be an effective treatment for insomnia, with large between-group effects on insomnia severity and medium-to-large effects on secondary outcomes 7.
• The key components of CBT-I include sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques 6.
• Cognitive behavioral therapy should always be considered as the first-line treatment for insomnia, with pharmacologic options used only when necessary and with caution, especially in older adults 8.

Benefits of CBT-I

• CBT-I produces results equivalent to sleep medication, with no side effects and fewer episodes of relapse 6.
• CBT-I has been shown to improve sleep latency and sleep duration, with limited awakenings and no significant adverse effects such as daytime somnolence or decreased alertness 8.
• CBT-I can also improve mental health in patients with comorbid mental disorders, making it a viable approach to treating patients with co-morbid insomnia and psychiatric disorders 4, 5.

Limitations and Future Directions

• Despite its effectiveness, CBT-I is often underutilized due to a shortage of trained practitioners and lack of patient awareness 6.
• Future directions for insomnia treatment should emphasize nonpharmacologic interventions, treating comorbid conditions, and using benzodiazepines and non-BzRAs as last resorts 8.