What is the recommended algorithm for managing insomnia?

Algorithm for Managing Insomnia

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

Step 1: Initial Treatment - CBT-I as First-Line

All patients with chronic insomnia should receive CBT-I as standard first-line therapy. 1, 2 This recommendation is based on moderate-quality evidence showing superior long-term efficacy compared to medications, with sustained benefits up to 2 years and minimal risk of adverse effects. 2, 3

Core Components of CBT-I

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

• Sleep Restriction Therapy: Limit time in bed to match actual total sleep time from baseline sleep logs (minimum 5 hours), then adjust weekly based on sleep efficiency (>85-90% efficiency = increase by 15-20 minutes; <80% efficiency = decrease by 15-20 minutes). 1, 4

• Stimulus Control: Go to bed only when sleepy, use bed only for sleep and sex, leave bed after approximately 20 minutes if unable to sleep (avoid clock-watching), maintain regular wake time, avoid naps. 1

• Cognitive Therapy: Address maladaptive beliefs such as "I can't sleep without medication," "My life will be ruined if I can't sleep," and "If I can't sleep I should stay in bed and rest." 1, 4

• Relaxation Training: Progressive muscle relaxation involving systematic tensing and relaxing of muscle groups. 1

Delivery Methods

CBT-I can be delivered through multiple effective formats: 1, 2

• Individual or group therapy sessions
• Telephone-based programs
• Web-based digital modules (dCBT)
• Self-help books

Brief Behavioral Therapy (BBT) may be used when resources are limited, emphasizing behavioral components over 2-4 sessions. 1

Important Cautions with CBT-I

• Sleep restriction may be contraindicated in patients with seizure disorders, bipolar disorder, or those working in high-risk occupations requiring alertness. 2, 4
• Initial mild sleepiness and fatigue typically resolve quickly as treatment progresses. 5

Step 2: Pharmacological Treatment (Only if CBT-I Insufficient)

Medications should only be considered when patients cannot participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I. 2 Use shared decision-making discussing benefits, harms, and costs of short-term medication use. 1

First-Line Pharmacological Options

For Sleep Onset Insomnia: 5

• Zaleplon 10 mg
• Ramelteon 8 mg
• Zolpidem 10 mg (5 mg in elderly)
• Triazolam 0.25 mg (not preferred due to rebound anxiety)

For Sleep Maintenance Insomnia: 5

• Eszopiclone 2-3 mg
• Zolpidem 10 mg (5 mg in elderly)
• Temazepam 15 mg
• Low-dose doxepin 3-6 mg
• Suvorexant

Medication Selection Algorithm

1. Identify primary complaint: Sleep onset difficulty versus sleep maintenance problems. 5
2. Consider patient factors: Age (lower doses for elderly), comorbid conditions, substance abuse history. 1, 5
3. Match medication to symptom pattern: Shorter-acting agents for sleep onset; longer-acting for wake after sleep onset. 1
4. Adjust based on response: If residual sedation occurs, switch to shorter-acting drug; if wake after sleep onset persists, consider longer half-life agent. 1

Second-Line Pharmacological Options

Sedating antidepressants should be considered when: 1

• Comorbid depression or anxiety is present
• First-line medications have failed
• Examples include trazodone, mirtazapine, doxepin, amitriptyline (note: evidence for efficacy is relatively weak)

Critical Medication Safety Warnings

Avoid the following: 2, 5

• Over-the-counter antihistamines (diphenhydramine) - lack efficacy data and cause daytime sedation, delirium in elderly
• Herbal supplements (valerian) and melatonin - insufficient evidence
• Antipsychotics as first-line - problematic metabolic side effects
• Long-acting benzodiazepines (flurazepam) - extended half-life increases risks
• Trazodone for insomnia (not recommended by guidelines)

FDA warnings for all hypnotics: 1, 5

• Risk of driving impairment and motor vehicle accidents
• Complex sleep behaviors (sleep-driving, sleep-walking)
• Cognitive and behavioral changes
• Associations with dementia and fractures from observational studies
• Recommend lower doses in women and elderly (e.g., zolpidem 5 mg maximum in elderly)

Use shortest duration possible (typically less than 4 weeks for acute insomnia), with periodic reassessment if continued beyond short-term use. 1, 5

Step 3: Combination Therapy

Short-term hypnotic treatment should always be supplemented with behavioral and cognitive therapies. 5 CBT-I should be extended throughout any drug tapering period to prevent relapse. 6

Step 4: Treatment-Resistant Cases

If insomnia persists beyond 7-10 days of treatment, evaluate for: 5

• Underlying sleep disorders (sleep apnea, restless legs syndrome)
• Circadian rhythm disorders
• Inadequate implementation of CBT-I components

Consider alternative benzodiazepine receptor agonists or switching medication class based on patient response and side effect profile. 1

Common Pitfalls to Avoid

• Never use sleep hygiene education alone - it is insufficient as monotherapy and should only be an adjunct to other treatments. 1, 2, 6
• Never prescribe medications as first-line - this undermines long-term outcomes and creates dependency risk. 2, 4
• Never continue pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions. 2, 5
• Never combine multiple sedative medications - significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures, particularly in elderly. 5
• Never use benzodiazepines not approved for insomnia (lorazepam, clonazepam) as first-line options. 1, 5

Special Population Considerations

Elderly patients: 1, 5

• More likely to report sleep maintenance problems than sleep onset difficulty
• Require lower medication doses (zolpidem 5 mg maximum)
• Higher risk of falls, cognitive impairment, and complex sleep behaviors
• Avoid benzodiazepines due to increased fall risk and cognitive decline

Patients with comorbid conditions: 1, 4

• CBT-I remains effective for insomnia comorbid with psychiatric and medical conditions
• Low-dose sedating antidepressants may be appropriate when depression/anxiety coexists
• Note that low-dose sedating antidepressants do not constitute adequate treatment for major depression

Monitoring and Follow-Up

• Maintain sleep logs throughout treatment to track progress. 1, 5
• Regular follow-up during initial treatment period to assess effectiveness and side effects. 5
• Continue monitoring until insomnia stabilizes, then every 6 months. 4
• Reassess for medication discontinuation when conditions allow, using gradual taper. 5