Insomnia Treatment
Primary Recommendation
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all adults with chronic insomnia before considering any medication. 1, 2, 3
Treatment Algorithm
Step 1: First-Line Treatment - CBT-I
CBT-I is superior to all pharmacological options with sustained benefits lasting up to 2 years and no risk of tolerance, dependence, or adverse effects. 1, 3
Core Components of Effective CBT-I (all must be included):
Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 3
Stimulus control therapy: Breaks the association between bed/bedroom and wakefulness through specific behavioral instructions 1, 3
Cognitive restructuring: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 3
Sleep hygiene education: Addresses environmental factors (avoiding excessive caffeine, evening alcohol, late exercise, optimizing sleep environment), though insufficient as monotherapy 1, 2
Delivery Options:
CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness 2, 3
Important caveat: Brief behavioral therapy (2-4 sessions emphasizing behavioral components) may be appropriate when resources are limited 2
Step 2: Pharmacotherapy (Only if CBT-I Insufficient or Unavailable)
Medications should only supplement, not replace, CBT-I and must be used short-term with the lowest effective dose. 1, 2
For Sleep Onset Insomnia:
First-line options:
- Ramelteon 8 mg (melatonin receptor agonist, reduced abuse potential) 2, 4
- Zaleplon 10 mg 2
- Zolpidem 10 mg (5 mg in elderly) 2, 5
- Triazolam 0.25 mg (associated with rebound anxiety, not truly first-line) 2
For Sleep Maintenance Insomnia:
First-line options:
Second-line option:
- Low-dose doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes) 2, 3
- Suvorexant (orexin receptor antagonist) 2
Critical Safety Warnings
Medications to AVOID:
Over-the-counter antihistamines (diphenhydramine): Lack efficacy data and cause daytime sedation and delirium, especially in older patients 1, 2, 3
Herbal supplements (valerian) and melatonin: Insufficient evidence of efficacy for chronic insomnia 2, 3
Antipsychotics: Should never be used as first-line treatment due to problematic metabolic side effects 1, 2
Trazodone: Not recommended for sleep onset or maintenance insomnia 2
Long-acting benzodiazepines: Increased risks without clear benefit 2
Medication Risks (Particularly in Elderly):
All benzodiazepine receptor agonists carry significant risks including:
- Falls and fractures 1, 2
- Cognitive impairment and associations with dementia 2
- Complex sleep behaviors (sleep-driving, sleep-walking) 2, 5
- Dependence and withdrawal reactions 1, 2
- Next-day driving impairment 2
The American Geriatrics Society recommends maximum zolpidem dose of 5 mg in elderly due to increased sensitivity and fall risk. 2
Common Pitfalls to Avoid
Never use medications as first-line treatment without attempting CBT-I 1, 2, 3
Never continue pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 1, 2
Never use sleep hygiene education alone as primary treatment—it is insufficient as monotherapy 1, 2, 6
Never combine multiple sedative medications—this significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures 2
Never fail to assess for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment 2
Special Population Considerations
Elderly Patients:
- Require lower medication doses (zolpidem 5 mg maximum) 2
- Higher risk of falls, cognitive impairment, and complex sleep behaviors 2
- More likely to report sleep maintenance problems 2
Patients with Comorbid Psychiatric/Medical Conditions:
- CBT-I remains first-line treatment and is highly effective for comorbid insomnia 7, 8
- Sedating antidepressants (amitriptyline, mirtazapine) may be considered when comorbid depression/anxiety is present 2, 3
- CBT-I shows medium to large effect sizes for sleep parameters and small to medium positive effects on comorbid symptoms (larger effects on psychiatric than medical conditions) 7
Patients with Substance Abuse History:
Pregnant Women:
- CBT-I remains first-line treatment with favorable benefit-to-risk ratio without medication exposure 3
Monitoring and Follow-Up
- Regular follow-up is necessary until insomnia stabilizes, then every 6 months 3
- Monitor for treatment response, side effects, and need for medication adjustments 2, 3
- Taper medications when conditions allow to prevent discontinuation symptoms 3
- Educate patients about treatment goals, safety concerns, and potential side effects 3