What is the first-line treatment for primary insomnia?

First-Line Treatment for Primary Insomnia

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

Why CBT-I is First-Line

• The American Academy of Sleep Medicine, American College of Physicians, and Australian Sleep Association uniformly recommend CBT-I as the initial treatment for all adult patients with chronic insomnia disorder, based on strong evidence showing superior long-term efficacy compared to medications 1, 2
• CBT-I produces clinically meaningful improvements in sleep parameters that are sustained for up to 2 years, whereas pharmacotherapy shows degradation of benefit after discontinuation 3, 4
• CBT-I provides sustained benefits without risk of tolerance, dependence, cognitive impairment, falls, or other adverse effects associated with sleep medications 2, 3, 4
• Meta-analysis demonstrates significant improvements: sleep onset latency reduced by 19 minutes, wake after sleep onset reduced by 26 minutes, and sleep efficiency improved by 9.91% 4

Core Components of Effective CBT-I

CBT-I is a multimodal intervention typically delivered over 4-8 sessions that includes: 1, 5, 6

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 5, 3
• Stimulus control therapy: Extinguishes the association between bed/bedroom and wakefulness through specific instructions (go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes) 1, 5, 3
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments to address dysfunctional beliefs that perpetuate insomnia 5, 3, 7
• Sleep hygiene education: Included as an adjunct but insufficient as monotherapy 2, 7

Alternative Delivery Formats When Traditional CBT-I is Unavailable

• Digital CBT-I (dCBT) is a safe, effective, and scalable alternative that can be disseminated as readily as medication, with meta-analytic reviews showing clinically significant improvements 1, 8
• Brief Therapies for Insomnia (BTIs) are abbreviated versions emphasizing behavioral components that may be appropriate when resources are limited 5
• Group therapy, telephone delivery, and self-help formats are also effective alternatives to individual in-person sessions 1

When to Consider Pharmacotherapy (Second-Line Only)

Medications should only be considered when patients are unable to participate in CBT-I, still have symptoms despite participation in CBT-I, or as a temporary adjunct to CBT-I 1, 2

If pharmacotherapy becomes necessary after CBT-I failure or unavailability: 1, 3

• First-line medications: Short/intermediate-acting benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon, triazolam, temazepam) or ramelteon for sleep onset insomnia 1, 2, 3, 9
• Alternative medications: Low-dose doxepin for sleep maintenance insomnia 2
• Use shared decision-making when determining whether to add pharmacotherapy after CBT-I 1, 3

Critical Pitfalls to Avoid

• Do NOT use over-the-counter antihistamines or herbal supplements due to lack of efficacy data and safety concerns, especially daytime sedation and delirium in older patients 2
• Do NOT use sleep hygiene education alone as primary treatment for chronic insomnia—it is insufficient as monotherapy and should only be an adjunct to CBT-I 2, 7
• Do NOT use antipsychotics as first-line treatment due to problematic metabolic side effects 2
• Do NOT prescribe long-term pharmacotherapy without periodic reassessment and concurrent behavioral interventions 2
• Avoid benzodiazepines and hypnotics in older adults when possible due to increased risk of falls, cognitive impairment, and dependence 2, 3

Special Populations

• Older adults: CBT-I remains first-line and is highly effective; if medications are needed, use lower doses (e.g., zolpidem 5 mg instead of 10 mg) 3
• Patients with comorbid depression, PTSD, or anxiety: CBT-I remains first-line treatment with moderate to large effect sizes (0.5-1.5) for both insomnia and comorbid symptoms 3, 10
• Patients with comorbid alcohol dependency: CBT-I shows large effect sizes (1.4) for insomnia reduction 10

Contraindications to Sleep Restriction Component

Sleep restriction may be contraindicated in: 5

• Patients working in high-risk occupations requiring alertness
• Those predisposed to mania/hypomania
• Patients with poorly controlled seizure disorders