What are the treatment options 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 medications. 1, 2

First-Line Treatment: CBT-I

CBT-I is the treatment of choice based on strong evidence showing superior long-term efficacy compared to pharmacological options, with sustained benefits up to 2 years and minimal risk of adverse effects. 1, 2 This recommendation comes from the American College of Physicians (2016) and American Academy of Sleep Medicine (2021), representing the most current high-quality guideline evidence. 1

Core Components of Effective CBT-I

CBT-I must include these critical behavioral elements: 1, 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 1, 3
• Stimulus control therapy: Breaks the association between bed/bedroom and wakefulness by instructing patients to go to bed only when sleepy, use bed only for sleep and sex, and leave bed if unable to sleep within 15-20 minutes 1, 3
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 1, 3
• Sleep hygiene education: Should be included but is insufficient as monotherapy 1

Treatment Delivery and Structure

CBT-I is typically delivered over 4-8 sessions with a trained specialist, though alternative delivery methods exist including group therapy, internet-based programs, and self-help formats. 1, 3 Brief Behavioral Therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions. 1, 3

Sleep diary data should be collected before and throughout treatment to monitor progress and guide adjustments. 1, 3

Second-Line Treatment: Pharmacotherapy

Medications should only be considered when CBT-I alone is unsuccessful, the patient cannot participate in CBT-I, or as a temporary adjunct to CBT-I. 1, 2 The American College of Physicians (2016) provides a weak recommendation for adding pharmacotherapy only after CBT-I failure, using shared decision-making. 1

First-Line Pharmacological Options

When medication is necessary, the recommended sequence is: 1, 4

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Zaleplon 10 mg 4
• Ramelteon 8 mg (melatonin receptor agonist) 4
• Triazolam 0.25 mg (associated with rebound anxiety, not first-line) 4

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 4, 6
• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Temazepam 15 mg 4
• Low-dose doxepin 3-6 mg 4
• Suvorexant (orexin receptor antagonist) 4

Medication Selection Algorithm

The choice of specific agent should be directed by: 1

1. Symptom pattern (sleep onset vs. maintenance)
2. Patient age and comorbidities
3. Past treatment responses
4. Contraindications and drug interactions
5. Side effect profile

Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon are recommended as first-line pharmacotherapy, followed by alternative agents in the same class if unsuccessful. 1, 4

Second-Line Pharmacological Options

If first-line medications fail: 1, 4

• Sedating antidepressants (trazodone, amitriptyline, mirtazapine) especially when comorbid depression/anxiety is present 1, 4
• Combined BzRA and sedating antidepressant 1
• Other sedating agents (gabapentin, tiagabine, quetiapine, olanzapine) for refractory cases 1

Agents NOT Recommended

The following should be avoided: 4, 2

• Over-the-counter antihistamines (e.g., diphenhydramine): lack efficacy data and cause daytime sedation, delirium risk in elderly 4, 2
• Trazodone: not recommended by American Academy of Sleep Medicine 4
• Tiagabine: not recommended 4
• Herbal supplements (valerian) and melatonin: insufficient evidence 4
• Barbiturates and chloral hydrate: not recommended 4
• Antipsychotics as first-line: problematic metabolic side effects 2

Critical Treatment Principles

Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies when possible. 1, 4 Medications are intended for short-term use (typically less than 4 weeks), and FDA labeling reflects this limitation. 1, 5

Use the lowest effective dose for the shortest period possible. 2 Long-term adverse effects of most sleep medications beyond 4 weeks are unknown. 1

Monitoring and Follow-Up

Clinical reassessment should occur every few weeks to monthly until insomnia stabilizes or resolves, then every 6 months, as relapse rates are high. 1, 2 Sleep diary data should be collected throughout treatment and during any relapse. 1

Common Pitfalls to Avoid

• Never use medications as first-line treatment without attempting CBT-I 1, 2
• Avoid long-acting benzodiazepines: increased risks without clear benefit, particularly falls and cognitive impairment in elderly 2
• Do not continue pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 4, 2
• Avoid using sleep hygiene education alone: insufficient as monotherapy but should be combined with other therapies 1
• Do not prescribe antipsychotics as first-line treatment: problematic metabolic side effects 2

Special Considerations

For older adults: Extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects. 2 Lower doses are required (e.g., zolpidem 5 mg instead of 10 mg). 4

Sleep restriction may be contraindicated in patients working high-risk occupations, those predisposed to mania/hypomania, or those with poorly controlled seizure disorders. 3