What is the recommended treatment algorithm for patients with insomnia?

Insomnia Treatment Algorithm

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all adults with chronic insomnia before considering any pharmacological intervention. 1, 2, 3

Step 1: First-Line Treatment - CBT-I

CBT-I is the gold standard initial approach due to superior long-term efficacy, sustained benefits up to 2 years, and minimal adverse effects compared to medications. 1, 2

Core Components of CBT-I:

• Sleep restriction therapy: Limit time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive 2
• Stimulus control: Go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 15-20 minutes 2
• Cognitive therapy: Address dysfunctional beliefs about sleep through psychoeducation, Socratic questioning, and behavioral experiments 2
• Sleep hygiene education: Avoid excessive caffeine, evening alcohol, late exercise, and optimize sleep environment (though insufficient as monotherapy) 4

Treatment Structure:

• Standard format: 4-8 sessions with trained CBT-I specialist 2
• Brief Behavioral Therapy (BBT): Abbreviated 2-4 session version when resources limited, emphasizing behavioral components 3
• Delivery options: Individual therapy, group sessions, telephone-based, web-based modules, or self-help books—all showing effectiveness 3

Important Caveats:

• Sleep restriction contraindications: High-risk occupations, predisposition to mania/hypomania, poorly controlled seizure disorders 2
• Set realistic expectations: Improvements are gradual (not immediate like medications), but benefits are durable beyond treatment end 4
• Initial side effects: Mild sleepiness and fatigue typically resolve quickly 4

Step 2: When to Add Pharmacotherapy

Medications should only be considered when: 1

• CBT-I is unavailable or patient unable to participate
• Symptoms persist despite adequate CBT-I trial
• As temporary adjunct to CBT-I (never as replacement)

First-Line Medication Options:

For Sleep Onset Insomnia:

• Zaleplon 10 mg 3
• Ramelteon 8 mg (melatonin receptor agonist, safer profile) 3, 5
• Zolpidem 10 mg (5 mg in elderly) 3, 6
• Triazolam 0.25 mg (not first-line due to rebound anxiety risk) 3

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg 3
• Zolpidem 10 mg (5 mg in elderly) 3
• Temazepam 15 mg 3
• Low-dose doxepin 3-6 mg (strong evidence for wake after sleep onset) 3
• Suvorexant (orexin receptor antagonist) 3

Critical Medication Principles:

• Use lowest effective dose for shortest duration (typically <4 weeks for acute insomnia) 3
• Always supplement with behavioral interventions—never use medications alone 3
• Short-term use only due to tolerance, dependence, and adverse effect risks 1
• Regular monitoring required, especially during initial treatment period 3

Step 3: Second-Line Options

If first-line medications fail or are contraindicated: 3

• Consider alternative BzRAs in same class
• Sedating antidepressants (e.g., mirtazapine, amitriptyline) for comorbid depression/anxiety 3
• Lorazepam may be considered when first-line failed, comorbid anxiety present, or longer duration needed for sleep maintenance 3

What NOT to Use:

Strongly avoid these agents: 1, 3

• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and delirium especially in elderly 1, 3
• Herbal supplements (valerian) and melatonin: Insufficient evidence of efficacy 3
• Trazodone: Not recommended by AASM 3
• Tiagabine: Not recommended 3
• Antipsychotics: Never first-line due to problematic metabolic side effects 1
• Barbiturates and chloral hydrate: Outdated, not recommended 3
• Sleep hygiene alone: Insufficient as single-component therapy 4

Special Population Considerations:

Elderly Patients (≥65 years):

• Lower medication doses required: Zolpidem 5 mg maximum 3
• Higher risk: Falls, cognitive impairment, complex sleep behaviors, fractures 3
• Avoid benzodiazepines when possible due to fall risk and cognitive decline 3

Patients with Comorbidities:

• Seizure disorder or bipolar disorder: Caution with sleep restriction due to sleep deprivation effects 4
• Substance abuse history: Avoid benzodiazepines, consider ramelteon or suvorexant 3
• Depression/anxiety: Consider sedating antidepressants as first-line pharmacotherapy 3

Common Pitfalls to Avoid:

• Starting with medications instead of CBT-I—this violates evidence-based guidelines 1, 2
• Using sleep hygiene education alone—insufficient efficacy as monotherapy 4
• Continuing pharmacotherapy long-term without reassessment—increases dependence and adverse effect risks 3
• Combining multiple sedative medications—significantly increases risks of complex sleep behaviors, cognitive impairment, and falls 3
• Failing to implement CBT-I alongside medications—medications should supplement, not replace behavioral interventions 3
• Prescribing long-acting benzodiazepines—increased risks without clear benefit 3
• Not considering drug interactions and contraindications before prescribing 3

Monitoring and Follow-Up:

• Collect sleep diary data before and during treatment to monitor progress 2
• Regular follow-up until insomnia stabilizes, then every 6 months 2
• Assess for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment 4, 3
• Taper medications when conditions allow to prevent discontinuation symptoms 3