What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia disorder and should be offered to all patients before considering pharmacological options. 1, 2

Primary Treatment Approach

CBT-I as First-Line Therapy

• CBT-I receives a Strong recommendation from the American Academy of Sleep Medicine as the initial treatment for all adults with chronic insomnia disorder. 1
• CBT-I produces clinically meaningful improvements in sleep parameters that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation. 3
• The treatment is effective across all age groups, including older adults and chronic hypnotic users, without risk of tolerance or adverse effects. 4, 3

Core Components of Effective CBT-I

CBT-I is a multicomponent intervention that typically includes: 1, 4

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 4, 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) 4, 3
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments 4, 3
• Sleep hygiene education: Included as part of comprehensive treatment but insufficient as a single-component therapy 1

Treatment Delivery and Structure

• Standard CBT-I is typically delivered over 4-8 sessions with a trained CBT-I provider, using sleep diary data throughout treatment to monitor progress. 4
• Multiple delivery modalities are available: in-person individual treatment, group treatment, or internet-based programs—discuss options based on availability, affordability, and patient preferences. 1
• Brief Behavioral Therapies for Insomnia (BTIs) are abbreviated versions emphasizing behavioral components and may be appropriate when resources are limited. 4

Alternative Behavioral Interventions (When CBT-I Unavailable)

If CBT-I is not accessible or feasible, the following single-component therapies receive Conditional recommendations: 1

• Sleep restriction therapy alone: Effective for improving sleep consolidation 1
• Stimulus control therapy alone: Effective for reducing sleep-onset latency 1
• Relaxation therapy: Includes progressive muscle relaxation and other relaxation techniques 1
• Multicomponent behavioral therapy (brief behavioral therapy without cognitive component): Combines several behavioral therapies 1

Pharmacological Treatment (Second-Line Only)

When to Consider Medications

Pharmacotherapy 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. 2, 3

FDA-Approved Medication Options

• Benzodiazepine receptor agonists (BzRAs): Eszopiclone, zolpidem, zaleplon, triazolam, and temazepam for sleep onset and maintenance insomnia 2, 3
  • Zolpidem is indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation, with efficacy demonstrated for up to 35 days 5
  • Eszopiclone is indicated for treatment of insomnia with studies up to 6 months in duration 6
• Ramelteon: For sleep onset insomnia 2, 3
• Low-dose doxepin: For sleep maintenance insomnia 2

Critical Medication Safety Considerations

• Use short-term only due to concerns about tolerance, dependence, and adverse effects with long-term use. 2
• For older adults: Use extra caution and lower doses (e.g., zolpidem 5 mg instead of 10 mg) due to increased risk of falls, cognitive impairment, and adverse effects. 2, 3
• Avoid long-term pharmacotherapy without periodic reassessment and concurrent behavioral interventions. 2
• Benzodiazepines and non-benzodiazepine hypnotics carry risks of falls, cognitive impairment, next-day residual effects, and anterograde amnesia. 2, 5

What NOT to Do

Ineffective or Not Recommended Treatments

• Sleep hygiene education alone: Not recommended as a single-component therapy due to lack of evidence for efficacy—the American Academy of Sleep Medicine determined that the vast majority of well-informed patients would not choose or benefit from it as monotherapy. 1
• Over-the-counter antihistamines or herbal supplements: Not recommended due to lack of efficacy data and safety concerns, especially daytime sedation and delirium in older patients. 2
• Antipsychotics as first-line treatment: Not recommended due to problematic metabolic side effects. 2
• Melatonin: Not recommended for treatment of chronic insomnia due to insufficient evidence. 4

Special Populations and Contraindications

Older Adults

• CBT-I remains first-line and is highly effective in this population. 4, 3
• If medications are needed, use lower doses and monitor closely for falls and cognitive impairment. 3

Patients with Comorbid Conditions

• CBT-I remains first-line for patients with comorbid depression or anxiety. 3
• Sleep restriction may be contraindicated in patients working in high-risk occupations, those predisposed to mania/hypomania, or those with poorly controlled seizure disorders. 4
• Consider potential adverse effects of treatment-induced sleep deprivation on seizure disorder or bipolar disorder when selecting treatments. 1

Treatment Algorithm

1. Start with CBT-I as the primary intervention for all patients with chronic insomnia disorder 2, 3
2. If CBT-I is ineffective or not feasible, consider single-component behavioral therapies (sleep restriction, stimulus control, relaxation therapy) 1
3. If behavioral interventions fail or are unavailable, consider short-term use of FDA-approved sleep medications with careful monitoring and shared decision-making 2, 3
4. Regular follow-up is essential to monitor treatment response, address emerging issues, and reassess need for continued pharmacotherapy 2

Important Clinical Pitfalls to Avoid

• Do not allocate clinical time to sleep hygiene education as monotherapy—this diverts resources away from more effective treatments. 1
• Do not expect immediate results with CBT-I—improvements are gradual but durable beyond the end of treatment, unlike medications. 1
• Set realistic expectations before starting treatment—patients may experience initial mild undesirable effects (sleepiness, fatigue) that typically resolve quickly. 1
• Do not prescribe long-term hypnotics without concurrent behavioral interventions and periodic reassessment. 2
• Do not use polysomnography for initial management of uncomplicated chronic insomnia—reserve it for cases where other sleep disorders are suspected. 4