From the Guidelines
For insomnia without using controlled prescription medications, I strongly recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the first line of treatment, as it has the most evidence available in the literature and is the only approach to receive a Strong recommendation. According to the American Academy of Sleep Medicine clinical practice guideline 1, CBT-I is a multicomponent intervention that includes sleep restriction therapy, stimulus control, and some form of cognitive therapy, and it is generally regarded as the treatment of choice for chronic insomnia disorder.
Some key considerations for CBT-I include:
- It is typically provided by mental health professionals, and in-person one-on-one delivery by a trained CBT-I provider is the most widely evaluated delivery method
- Clinicians should discuss different CBT-I delivery modalities with their patients, including in-person individual treatment, group treatment, and internet-based programs, and align the delivery modality based on availability, affordability, treatment format, duration, and the patient’s preferences and values
- CBT-I treatment typically ranges from 4–8 visits, and patients may face barriers to treatment completion, such as the ability to attend sessions and adhere to treatment recommendations
In addition to CBT-I, other potentially useful interventions with minimal undesirable effects include:
- Behavioral therapy for insomnia (BTIs)
- Sleep restriction therapy
- Stimulus control
- Relaxation therapy These interventions may be considered as viable treatment alternatives when CBT-I is not available or not desired by, or appropriate for, the patient.
It is also important for clinicians to consider comorbid medical and psychiatric conditions that may change the balance of benefits vs harms when selecting appropriate treatments for chronic insomnia disorder. By prioritizing CBT-I and other non-pharmacological interventions, clinicians can help patients achieve durable improvements in insomnia symptoms while minimizing the risks associated with controlled prescription medications.
From the Research
Non-Prescription Treatments for Insomnia
- Cognitive Behavioral Therapy for Insomnia (CBT-i) is a highly effective treatment for chronic insomnia, with clinically meaningful effect sizes 2, 3, 4, 5.
- CBT-i incorporates several key components, including sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques 3, 5.
- This non-pharmacological approach produces results equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment 3.
Comparison with Prescription Medications
- Prescription sleep medications, such as benzodiazepines and nonbenzodiazepine receptor agonists, have significant adverse effects, including dementia, serious injury, and fractures, which should limit their use 6.
- Ramelteon has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time, making it a valuable first-line option 6.
- Sedating low-dose antidepressants should only be used for insomnia when the patient has comorbid depression 6.