What is the best treatment approach for severe insomnia?

Treatment of Severe Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for severe chronic insomnia, with pharmacotherapy reserved only after CBT-I has been attempted or when CBT-I is unavailable. 1, 2

First-Line Treatment: CBT-I

The American Academy of Sleep Medicine and American College of Physicians provide a strong recommendation that CBT-I be the initial treatment for all patients with chronic insomnia, including severe cases. 1, 2 This recommendation is based on:

• Sustained efficacy up to 2 years, unlike medications which show degradation of benefit after discontinuation 1, 2
• No risk of tolerance, dependence, or adverse medication effects 1
• Effectiveness across all age groups, including older adults and chronic hypnotic users 1

Core Components of CBT-I

CBT-I is a multicomponent treatment that must include the following elements 3, 1:

• Sleep restriction therapy: Limit time in bed to match actual sleep time (minimum 5 hours), creating mild sleep deprivation that strengthens homeostatic sleep drive. Adjust weekly by 15-20 minutes based on sleep efficiency (>85% = increase time; <80% = decrease time) 3, 1

• Stimulus control therapy: Go to bed only when sleepy, maintain regular schedule, use bed only for sleep, leave bed if unable to sleep within 20 minutes, avoid clock-watching 3, 1

• Cognitive therapy: Target maladaptive beliefs such as "I can't sleep without medication" or "My life will be ruined if I can't sleep" using structured psychoeducation and behavioral experiments 3, 1

• Relaxation training: Progressive muscle relaxation to lower somatic and cognitive arousal 3

Sleep hygiene education alone is insufficient for severe chronic insomnia and should not be used as monotherapy. 3, 2 While it is a component of CBT-I, multiple studies show it lacks efficacy as a standalone treatment. 3

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. 1, 2

First-Line Medications (when pharmacotherapy is indicated)

The American Academy of Sleep Medicine recommends 1:

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs) as first-line pharmacologic options 1
• Ramelteon (melatonin receptor agonist) for sleep onset difficulties, FDA-approved for insomnia characterized by difficulty with sleep onset 4
• Suvorexant (orexin antagonist) for insomnia with difficulties in sleep onset and/or sleep maintenance 5

Medication Selection Strategy

For patients with sleep onset insomnia: Use shorter-acting agents like ramelteon or zaleplon 1, 4

For patients with sleep maintenance insomnia (wake after sleep onset): Consider longer half-life BzRAs or low-dose doxepin 3, 1

For patients with residual sedation: Switch to shorter-acting agents 3

Special Population Considerations

Older adults (≥65 years): 3, 1

• CBT-I remains first-line and is highly effective with sustained benefits up to 2 years 3
• If medications needed, use lower doses (e.g., zolpidem 5 mg instead of 10 mg) 1
• Avoid flurazepam due to extended half-life 3

Patients with comorbid depression/anxiety: 1

• CBT-I remains first-line treatment 1
• If medications needed, consider sedating antidepressants 1

Treatment Algorithm for Severe Insomnia

1. Initiate CBT-I (4-8 sessions over 6 weeks) with all core components 1, 2
2. Monitor treatment response using sleep efficiency (total sleep time/time in bed × 100%) 3
3. If CBT-I fails or is unavailable, add pharmacotherapy through shared decision-making 1, 2
4. Select medication based on primary sleep complaint (onset vs. maintenance), age, and comorbidities 1
5. Prescribe hypnotics for short periods only, with frequency and duration customized to circumstances 6

Common Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment – this violates guideline recommendations and deprives patients of more effective, durable therapy 1, 2
• Do not rely on sleep hygiene education alone – it lacks efficacy as a single intervention for severe insomnia 3, 2
• Do not use benzodiazepines not specifically approved for insomnia (e.g., lorazepam, clonazepam) as routine first-line agents 3
• Do not expect immediate results with CBT-I – counsel patients that improvements are gradual but sustained 2
• Avoid routine use of over-the-counter antihistamines – they should be discouraged 6
• Never recommend alcohol as a sleep aid – it has potential for abuse 6

Delivery Methods for CBT-I

In-person, therapist-led programs are most beneficial, but digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable. 2 The evidence for Internet-based or group delivery compared to face-to-face treatment remains insufficient for definitive recommendations. 3