Insomnia Management
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all adults with chronic insomnia, with pharmacological therapy reserved only as second-line treatment when CBT-I alone is unsuccessful. 1, 2, 3
First-Line Treatment: CBT-I
CBT-I is the gold standard initial treatment based on the American College of Physicians' strong recommendation with moderate-quality evidence, demonstrating superior long-term efficacy compared to medications with minimal adverse effects. 1, 2, 3
Core Components of Effective CBT-I
The most efficacious CBT-I programs include these critical components:
Cognitive restructuring to challenge maladaptive beliefs about sleep (e.g., "I can't sleep without medication," "My life will be ruined if I can't sleep") is the most powerful component with an incremental odds ratio of 1.68 for remission. 1, 4
Sleep restriction therapy limits time in bed to match actual sleep duration (minimum 5 hours), creating mild sleep deprivation that strengthens homeostatic sleep drive and improves sleep efficiency. 1, 2, 5, 4
Stimulus control breaks the association between bed and wakefulness by instructing patients to: go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes, and maintain consistent wake times. 1, 5, 4
Third-wave components (mindfulness-based approaches) enhance treatment efficacy with an incremental odds ratio of 1.49. 4
What NOT to Include
Relaxation procedures alone may be counterproductive (incremental odds ratio 0.81) and should not be the primary intervention. 4
Sleep hygiene education alone is insufficient as monotherapy (incremental odds ratio 1.01) but can be included as an adjunct. 1, 4
Delivery Format
In-person, therapist-led delivery is most beneficial (incremental odds ratio 1.83), though telephone, web-based, and self-help formats are acceptable alternatives when resources are limited. 1, 5, 4
Treatment duration should be 4-8 sessions delivered weekly or biweekly, with sleep diary monitoring throughout. 2, 5, 6
Expected Outcomes
CBT-I produces a 54% reduction in wake after sleep onset, normalizes sleep to >6 hours total sleep time, and achieves 85% sleep efficiency. 7
Benefits are sustained for at least 6 months to 2 years after treatment completion. 3, 7
The number needed to treat is 3.0 compared to psychoeducation alone. 4
Second-Line Treatment: Pharmacotherapy
Medications should only be considered when CBT-I is unavailable, unsuccessful after adequate trial (4-8 weeks), or as a temporary adjunct during CBT-I. 1, 2, 3
FDA-Approved First-Choice Medications
For sleep onset insomnia:
Zolpidem 5-10 mg (5 mg for elderly) decreases sleep latency for up to 35 days in controlled trials. 8
Zaleplon (shortest half-life) for patients needing middle-of-night dosing or concerned about morning sedation. 1, 2
Ramelteon (melatonin receptor agonist) has minimal abuse potential but weaker efficacy data. 1
For sleep maintenance insomnia:
Low-dose doxepin 3-6 mg is particularly effective for middle and terminal insomnia. 2, 3
Eszopiclone is FDA-approved for up to 6 months of use, the longest duration studied. 9
Temazepam (intermediate-acting benzodiazepine) for patients with both onset and maintenance issues. 1, 2
Critical Prescribing Parameters
Duration: Limit to 4-5 weeks when possible, as FDA approval is for short-term use only. 2, 8
Dosing: Start with the lowest effective dose; elderly patients require 50% dose reduction (e.g., zolpidem 5 mg vs 10 mg). 1, 8
Monitoring: Assess for residual daytime sedation, memory impairment, falls (especially in elderly), and behavioral abnormalities including sleep-driving. 2, 8
Second-Tier Pharmacological Options
When first-line medications fail or comorbid depression exists:
Trazodone 25-100 mg has minimal anticholinergic effects but lacks robust efficacy data. 1
Mirtazapine 7.5-15 mg is beneficial for comorbid depression and insomnia but causes weight gain. 1, 2
Avoid: Longer-acting benzodiazepines like flurazepam due to extended half-life and accumulation risk. 1
Medications to Avoid
Over-the-counter antihistamines lack efficacy and safety data, cause daytime sedation and delirium in elderly patients. 3
Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects. 3
Herbal supplements (valerian, etc.) are not recommended due to lack of efficacy and safety data. 2
Benzodiazepines should be avoided in patients with substance use history due to high abuse potential. 2
Treatment Algorithm
Step 1: Initiate CBT-I with all four critical components (cognitive restructuring, sleep restriction, stimulus control, third-wave approaches) delivered in-person when possible. 1, 2, 3, 4
Step 2: Continue CBT-I for minimum 4-8 weeks with weekly sleep diary monitoring to assess response. 2, 5
Step 3: If CBT-I is insufficient after adequate trial, add short-term pharmacotherapy using shared decision-making:
- For sleep onset: zolpidem, zaleplon, or ramelteon 2, 8
- For sleep maintenance: low-dose doxepin or eszopiclone 2, 9
- Limit duration to 4-5 weeks 2, 8
Step 4: When combining medication with CBT-I, extend CBT-I throughout drug tapering to prevent relapse. 6
Step 5: If first medication fails, switch based on symptom pattern: longer half-life for persistent wake after sleep onset, shorter half-life for residual morning sedation. 1
Critical Pitfalls to Avoid
Do not use sleep hygiene education or relaxation therapy alone as primary treatment—these are insufficient for chronic insomnia. 1, 6, 4
Do not prescribe medications long-term without periodic reassessment and concurrent behavioral interventions. 3
Do not use sleep restriction in patients with seizure disorders, mania/hypomania risk, or high-risk occupations (e.g., commercial drivers). 5
Do not assume melatonin is effective—it is not recommended for chronic insomnia treatment. 3, 5
Do not order polysomnography for uncomplicated chronic insomnia—reserve for suspected comorbid sleep disorders. 5