From the Guidelines
All adult patients with chronic insomnia disorder should receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment. This recommendation is based on a strong recommendation and moderate-quality evidence from the American College of Physicians 1. The treatment of insomnia begins with a thorough clinical evaluation of sleep patterns, including difficulty falling asleep, staying asleep, or waking too early, persisting for at least three nights per week for three months.
Key Components of CBT-I
- Maintaining consistent sleep schedules
- Avoiding caffeine and electronics before bed
- Creating a comfortable sleep environment
- Sleep hygiene practices
For patients who are unable to derive benefit from CBT-I alone, pharmacological therapy may be considered. The American Academy of Sleep Medicine clinical practice guideline recommends that medications for chronic insomnia disorder should be considered mainly in patients who are unable to access or participate in CBT-I, or who have not responded to CBT-I 1.
Medication Management
- Over-the-counter options like melatonin (0.5-5mg taken 30-60 minutes before bedtime)
- Prescription medications such as zolpidem (5-10mg), eszopiclone (1-3mg), or trazodone (25-100mg) at bedtime
- Limit medications to 2-4 weeks to prevent dependence
- For chronic insomnia, doxepin (3-6mg) or ramelteon (8mg) may be safer for longer use
Underlying conditions like depression, anxiety, sleep apnea, or restless leg syndrome should be addressed, as they often contribute to sleep difficulties. Regular reassessment is essential to monitor effectiveness and adjust treatment as needed. The selection of a particular drug should rest on the evidence summarized, as well as additional patient-level factors, such as the optimal pharmacokinetic profile, assessments of benefits versus harms, and past treatment history 1.
From the FDA Drug Label
Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated.
The diagnosis of insomnia should involve a careful evaluation of the patient to rule out underlying physical and/or psychiatric disorders.
- Key considerations for treatment include:
- Initiating symptomatic treatment of insomnia only after a careful evaluation of the patient
- Monitoring for worsening of insomnia or the emergence of new thinking or behavior abnormalities
- Evaluating for comorbid diagnoses if insomnia does not remit after 7 to 10 days of treatment Zolpidem tartrate can be used for the short-term treatment of insomnia characterized by difficulties with sleep initiation 2.
From the Research
Diagnosis of Insomnia
- The diagnostic procedure for insomnia should include a clinical interview consisting of a sleep history, the use of sleep questionnaires and sleep diaries, questions about somatic and mental health, a physical examination, and additional measures if indicated 3.
- Polysomnography can be used to evaluate other sleep disorders if suspected, in treatment-resistant insomnia, for professional at-risk populations, and when substantial sleep state misperception is suspected 3.
Treatment of Insomnia
- Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia in adults of any age 3, 4.
- CBT-I is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep and is delivered over the course of six to eight sessions 5.
- The primary goal of CBT-I is to address the perpetuating factors that contribute to the development of chronic insomnia 5.
- CBT-I has been shown to be effective in reducing insomnia severity and improving mental health in patients with comorbid mental disorders, such as depression, PTSD, and alcohol dependency 6.
- Pharmacological interventions, such as benzodiazepines and non-benzodiazepine receptor agonists, can be offered if CBT-I is not sufficiently effective or not available, but their use should be limited due to potential side effects 3, 7.
- Other treatments, such as light therapy, exercise, and complementary and alternative therapies, may be considered, but their effectiveness is not well established 3, 7.
Considerations for Special Populations
- In older adults, cognitive behavioral therapy should always be the first-line treatment for insomnia, and pharmacologic options should be used with caution due to potential side effects 7.
- In patients with mental disorders and comorbid insomnia, CBT-I should be considered as a first-line treatment due to its effectiveness and lack of side effects 6.