What treatment options are available for insomnia?

Treatment for 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, 3

First-Line Treatment: CBT-I

• The American College of Physicians provides a strong recommendation that all patients with chronic insomnia receive CBT-I as the initial treatment intervention, based on moderate-quality evidence showing superior long-term efficacy compared to medications. 1, 3

• CBT-I produces clinically meaningful improvements that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation. 3

• The treatment is noninvasive and likely to have fewer harms than pharmacologic therapy, which can be associated with serious adverse events including cognitive impairment, falls, and fractures. 1, 4

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 improves sleep efficiency. 4

• Stimulus control therapy extinguishes the association between bed/bedroom and wakefulness through specific instructions: go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes. 4

• Cognitive therapy targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments. 4

• Sleep hygiene education should be included but is insufficient as a standalone intervention. 1, 5

Treatment Structure

• CBT-I is typically delivered over 4-8 sessions with a trained specialist, using sleep diary data throughout treatment to monitor progress. 4, 6

• In-person, therapist-led programs are most beneficial, though digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable. 3

• Brief Behavioral Therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions. 2

Pharmacological Treatment (Second-Line)

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 1, 3

First-Line Pharmacological Options

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

For Sleep Onset Insomnia:

• Ramelteon 8 mg is suggested as first-line, particularly for patients where benzodiazepine receptor agonists are contraindicated. 2, 7
• Zaleplon 10 mg is an alternative option. 2
• Zolpidem 10 mg (5 mg in elderly) can be used for both sleep onset and maintenance. 2, 8
• Triazolam 0.25 mg is suggested but has been associated with rebound anxiety and is not considered first-line. 2

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg is suggested for both sleep onset and maintenance. 2
• Temazepam 15 mg is recommended for both sleep onset and maintenance. 2
• Zolpidem 10 mg (5 mg in elderly) is effective for maintenance as well as onset. 2, 8

Second-Line Pharmacological Options

• Doxepin 3-6 mg is suggested specifically for sleep maintenance insomnia. 2
• Suvorexant (orexin receptor antagonist) is recommended for sleep maintenance insomnia. 2
• Sedating antidepressants may be considered when comorbid depression/anxiety is present. 2

Important Pharmacotherapy Principles

• Use the lowest effective dose for the shortest period possible (typically less than 4 weeks for acute insomnia). 2
• FDA labeling indicates pharmacologic treatments for insomnia are intended for short-term use, and patients should be discouraged from using these drugs for extended periods. 1
• Long-term adverse effects are unknown because few studies evaluated medications for more than 4 weeks. 1
• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible. 2

Agents NOT Recommended

• Over-the-counter antihistamines (e.g., diphenhydramine) are not recommended due to lack of efficacy data and safety concerns, particularly daytime sedation and delirium risk in older patients. 2
• Trazodone is not recommended for sleep onset or maintenance insomnia. 2
• Herbal supplements (e.g., valerian) and melatonin are not recommended due to insufficient evidence of efficacy. 2, 4
• Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects. 2
• Long-acting benzodiazepines carry increased risks without clear benefit. 2
• Older hypnotics including barbiturates and chloral hydrate are not recommended. 2

Treatment Algorithm

1. Initiate CBT-I as first-line treatment for all patients with chronic insomnia. 1, 3

2. If CBT-I is insufficient or unavailable, consider short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon based on symptom pattern:

   • For sleep onset difficulty: zaleplon, ramelteon, zolpidem, or triazolam. 2
   • For sleep maintenance: eszopiclone, zolpidem, temazepam, doxepin, or suvorexant. 2

3. If first-line medications fail, try alternative BzRAs or sedating antidepressants if comorbid depression/anxiety is present. 2

4. Monitor patients regularly, especially during initial treatment period, to assess effectiveness and side effects. 2

5. Taper medication when conditions allow to prevent discontinuation symptoms, and continue CBT-I techniques alongside medication. 2

Common Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment, as this violates guideline recommendations and deprives patients of more effective, durable therapy. 3
• Do not rely on sleep hygiene education alone, as it lacks efficacy as a single intervention. 3, 5
• Do not continue pharmacotherapy long-term without periodic reassessment and attempts to implement CBT-I. 2
• Do not use sedating agents without considering their specific effects on sleep onset versus maintenance. 2
• Do not fail to consider drug interactions and contraindications, particularly in elderly patients and those with comorbid conditions. 2

Special Considerations

• CBT-I is effective for older adults and patients with comorbid psychiatric or medical conditions, with a small to medium positive effect on comorbid outcomes. 4, 9
• Sleep restriction may be contraindicated in patients working in high-risk occupations or those predisposed to mania/hypomania or poorly controlled seizure disorders. 4
• Polysomnography is not indicated as initial management for uncomplicated chronic insomnia and should be reserved for cases where other sleep disorders are suspected. 4