What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for all adults with chronic insomnia and should be initiated before any pharmacological intervention. 1, 2, 3

First-Line Treatment: CBT-I

CBT-I demonstrates superior long-term efficacy compared to medications and carries minimal risk of adverse effects, with sustained benefits lasting up to 2 years. 2, 3

Core Components of Effective CBT-I

• Sleep restriction therapy - limiting time in bed to consolidate sleep and increase sleep drive 1, 3
• Stimulus control therapy - re-establishing the bed as a cue for sleep rather than wakefulness by minimizing time spent awake in bed 1, 3
• Cognitive restructuring - addressing maladaptive beliefs and distorted thoughts about sleep that perpetuate insomnia 1, 3
• Sleep hygiene education - establishing regular sleep-wake schedules and optimizing the sleep environment, though this alone is insufficient as monotherapy 1, 2
• Relaxation techniques - reducing psychophysiological arousal and anxiety about sleep 1, 3

CBT-I Delivery Considerations

• In-person individual treatment by a trained CBT-I provider is the most widely evaluated and generally considered the best delivery method 1
• Alternative delivery modalities include group treatment and internet-based programs when access to trained providers is limited 1
• Treatment should continue for at least 4-8 weeks to adequately evaluate effectiveness 3

Critical Pitfall to Avoid

Sleep hygiene education as a single-component therapy is minimally effective and should never be used alone for chronic insomnia. 1 When used as a control in studies, it consistently underperforms compared to active treatments, and the vast majority of well-informed patients would not benefit from it as monotherapy 1

Second-Line Treatment: Pharmacological Options

Medications should only be considered when patients cannot participate in CBT-I, still have symptoms despite adequate CBT-I trial, or as a temporary adjunct to CBT-I. 2

FDA-Approved First-Line Medications

Short/intermediate-acting benzodiazepine receptor agonists (BzRAs) at the lowest effective dose for the shortest period possible (4-5 weeks maximum): 3, 4

• Eszopiclone 2-3 mg - for both sleep onset and maintenance insomnia 4
• Zolpidem 10 mg (5 mg in elderly) - for both sleep onset and maintenance insomnia 4, 5
• Zaleplon 10 mg - specifically for sleep onset insomnia 4
• Temazepam 15 mg - for both sleep onset and maintenance insomnia 4
• Ramelteon 8 mg - melatonin receptor agonist specifically for sleep onset insomnia with minimal abuse potential 4, 6

Alternative FDA-Approved Options

• Low-dose doxepin 3-6 mg - particularly effective for sleep maintenance insomnia 3, 4
• Suvorexant - orexin receptor antagonist for sleep maintenance insomnia 4

Medication Selection Algorithm

For sleep onset difficulty: Consider zaleplon, ramelteon, zolpidem, or triazolam based on patient age, comorbidities, and abuse risk 4

For sleep maintenance difficulty: Consider eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 4

For patients with comorbid depression/anxiety: Consider sedating antidepressants such as mirtazapine or low-dose doxepin 3, 4

Critical Safety Warnings

Potential adverse effects of BzRAs include: 1, 3

• Residual sedation and daytime impairment
• Memory and performance impairment
• Falls and injuries, particularly in older adults
• Behavioral abnormalities including "sleep driving"
• Risk of dependence and withdrawal

Benzodiazepines should be avoided in patients with substance use history due to high abuse potential. 3

Medications NOT Recommended

The following agents should NOT be used for insomnia treatment: 2, 4

• Over-the-counter antihistamines (e.g., diphenhydramine) - lack of efficacy data and safety concerns, especially daytime sedation and delirium in older patients 2, 4
• Herbal supplements (e.g., valerian) and melatonin - insufficient evidence of efficacy 1, 4
• Antipsychotics - should not be used as first-line treatment due to problematic metabolic side effects 2
• Trazodone - not recommended for sleep onset or maintenance insomnia 4
• Long-acting benzodiazepines - increased risks without clear benefit 4

Treatment Algorithm

Step 1: Initiate CBT-I as primary intervention, implementing all core components for 4-8 weeks 3

Step 2: If CBT-I is insufficient after adequate trial, consider short-term pharmacological options (4-5 weeks maximum) based on symptom pattern 3, 4

Step 3: When using medications, start with lowest effective dose and continue incorporating behavioral techniques 3

Step 4: Monitor regularly for treatment response, adverse effects, and potential misuse 3

Step 5: Taper medications when conditions allow to prevent discontinuation symptoms 4

Special Considerations for Older Adults

Use extra caution with all medications in older adults 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 in elderly) 4, 5

Critical Pitfalls to Avoid

• Never use pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 2, 4
• Never prescribe medications without first attempting or offering CBT-I 2, 3
• Never use sedating agents without considering their specific effects on sleep onset versus maintenance 4
• Never continue medications beyond 4-5 weeks without reassessing the need and effectiveness 3, 4