What are the best treatment options for a patient with insomnia?

Treatment of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for this patient, as it is the only intervention with a strong recommendation from major guidelines and provides sustained benefits lasting up to 2 years without the risks of pharmacotherapy. 1, 2

First-Line Treatment: CBT-I

The American Academy of Sleep Medicine designates CBT-I as the standard of care for chronic insomnia in adults, and the American College of Physicians provides a strong recommendation that all patients with chronic insomnia receive CBT-I as the initial treatment intervention. 1, 2

Why CBT-I is Superior

• CBT-I produces clinically meaningful improvements that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation 2
• It has minimal adverse effects compared to medications and no risk of tolerance or dependence 3, 2
• The treatment is effective across different age groups with durable long-term outcomes 3, 2

Core Components of CBT-I

The multicomponent intervention includes: 1

• Sleep restriction therapy: Limiting time in bed to increase sleep efficiency 1, 3
• Stimulus control therapy: Associating the bed with sleep rather than wakefulness 1, 3
• Cognitive therapy: Addressing negative thoughts and beliefs about sleep 1
• Relaxation strategies: May be included but not always necessary 1
• Sleep hygiene education: Should be included but is insufficient as a single intervention 1, 3

Practical Implementation

• In-person, therapist-led programs are most beneficial, typically requiring 4-8 sessions over 6 weeks 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 4

Second-Line Treatment: Pharmacotherapy

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making with the patient. 4, 2

First-Line Pharmacological Options

When medication is necessary, the American Academy of Sleep Medicine recommends: 4

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) - effective for both sleep onset and maintenance 4, 5
• Zaleplon 10 mg - specifically for sleep onset 4
• Ramelteon 8 mg - melatonin receptor agonist with minimal side effects 4
• Triazolam 0.25 mg - though associated with rebound anxiety and not considered first-line 4

For sleep maintenance insomnia:

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

Second-Line Pharmacological Options

• Doxepin 3-6 mg - specifically for sleep maintenance insomnia 4
• Suvorexant (orexin receptor antagonist) - for sleep maintenance 4
• Sedating antidepressants (e.g., amitriptyline, mirtazapine) - may be considered when comorbid depression/anxiety is present 4

Medications NOT Recommended

The following should be avoided: 4

• Over-the-counter antihistamines (e.g., diphenhydramine) - lack of efficacy data and safety concerns, especially daytime sedation and delirium risk 4
• Trazodone - not recommended by the American Academy of Sleep Medicine 4
• Tiagabine (anticonvulsant) - not recommended 4
• Herbal supplements (e.g., valerian) and melatonin - insufficient evidence of efficacy 4
• Barbiturates and chloral hydrate - older hypnotics with unfavorable risk profiles 4

Pharmacotherapy Principles

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

Treatment Algorithm

1. Initiate CBT-I as first-line treatment for all patients with chronic insomnia 1, 2
2. If CBT-I is ineffective after adequate trial (typically 4-8 sessions over 6 weeks), consider pharmacotherapy through shared decision-making 4, 2
3. Select medication based on symptom pattern:
   • Sleep onset difficulty: zaleplon, ramelteon, zolpidem, or triazolam 4
   • Sleep maintenance: eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 4
4. If first-line medications fail, consider alternative benzodiazepine receptor agonists or sedating antidepressants if comorbid depression/anxiety exists 4

Common Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment - this violates guideline recommendations and deprives patients of more effective, durable therapy 4, 2
• Do not rely on sleep hygiene education alone - it lacks efficacy as a single intervention and may divert resources from more effective treatments 1
• Avoid using sedating agents without considering their specific effects on sleep onset versus maintenance 4
• Do not fail to consider drug interactions and contraindications when prescribing pharmacotherapy 4
• Avoid continuing pharmacotherapy long-term without periodic reassessment 4
• Do not use over-the-counter sleep aids or herbal supplements with limited efficacy data 4
• Counsel patients that CBT-I improvements are gradual but sustained - do not expect immediate results 2