What are the recommended treatments 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 medication. 1, 2, 3, 4

First-Line Treatment: CBT-I

CBT-I demonstrates superior long-term efficacy compared to pharmacotherapy with minimal adverse effects and sustained benefits lasting up to 2 years. 1, 3

Core Components of CBT-I

• Sleep restriction therapy limits time in bed to consolidate sleep and increase homeostatic sleep drive 1, 3, 4
• Stimulus control therapy re-associates the bed with sleep by limiting non-sleep activities in bed 1, 3, 4
• Cognitive restructuring addresses dysfunctional beliefs and anxiety about sleep 1, 3
• Relaxation techniques reduce physiological and cognitive arousal 1, 4
• Sleep hygiene education should be combined with other therapies, as it is insufficient alone 3, 4

Delivery Methods

CBT-I can be effectively delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 2

Second-Line Treatment: Pharmacotherapy

Medications should only be considered when CBT-I is unavailable, ineffective after adequate trial, or as a temporary adjunct—never as monotherapy or replacement for behavioral interventions. 2, 3, 4

First-Line Medications (When Pharmacotherapy is Necessary)

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) for both sleep onset and maintenance 2, 4, 5
• Zaleplon 10 mg specifically for sleep onset 2, 4
• Ramelteon 8 mg for sleep onset with favorable safety profile 2, 4
• Eszopiclone 2-3 mg for both onset and maintenance, with efficacy demonstrated up to 6 months 2, 6

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 2, 4
• Temazepam 15 mg (7.5 mg in elderly/debilitated) 2, 4
• Low-dose doxepin 3-6 mg specifically for maintenance 2, 4
• Suvorexant (orexin receptor antagonist) for maintenance 2

Medication Selection Algorithm

1. Identify primary sleep complaint: onset difficulty versus maintenance difficulty versus both 2, 4
2. Consider patient-specific factors: age, comorbidities (especially depression/anxiety), substance abuse history, fall risk 2, 4
3. For substance abuse history: avoid benzodiazepines; consider ramelteon or suvorexant 2
4. For comorbid depression/anxiety: consider sedating antidepressants as alternative 2
5. Use lowest effective dose for shortest duration possible 2

Medications NOT Recommended

The following should be avoided due to lack of efficacy data, safety concerns, or superior alternatives:

• Over-the-counter antihistamines (diphenhydramine) cause daytime sedation, delirium risk in elderly, and lack efficacy data 2, 3, 4
• Trazodone is not recommended despite common clinical use 2, 4
• Melatonin, valerian, L-tryptophan have insufficient evidence 2, 4
• Barbiturates and chloral hydrate are obsolete with unacceptable risk profiles 2, 4
• Antipsychotics should not be first-line due to problematic metabolic side effects 2, 3
• Long-acting benzodiazepines carry increased risks without clear benefit 2

Critical Safety Considerations

All hypnotics carry significant risks that must be weighed carefully:

• Complex sleep behaviors including sleep-driving, sleep-walking 2
• Falls and fractures, particularly in elderly patients 2
• Cognitive impairment and daytime sedation 2, 5
• Dependence and withdrawal reactions with prolonged use 2
• Anterograde amnesia, especially at higher doses 5
• Driving impairment the morning after use 2

Special Considerations for Elderly Patients

• Use lower doses: zolpidem 5 mg maximum, temazepam 7.5 mg 2, 4
• Higher risk of falls, cognitive impairment, and complex sleep behaviors 2
• Avoid benzodiazepines when possible due to increased sensitivity 2

Monitoring and Follow-Up

• Follow patients every few weeks initially to assess effectiveness and side effects 4
• Reassess need for ongoing medication regularly—do not continue long-term without periodic evaluation 2, 3, 4
• Always supplement pharmacotherapy with behavioral interventions 2, 4
• If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders like sleep apnea 2

Common Pitfalls to Avoid

• Using medications as first-line treatment instead of CBT-I 2, 3
• Prescribing without concurrent behavioral therapy 2, 4
• Continuing medications indefinitely without reassessment 2, 3
• Using over-the-counter sleep aids with limited evidence 2, 3
• Failing to consider drug interactions and contraindications 2
• Not adjusting doses appropriately for elderly patients 2
• Combining multiple sedative medications, which significantly increases risks 2