What are the latest recommendations for managing insomnia?

Latest Recommendations for Insomnia Management

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

Initial Treatment Approach

CBT-I as Mandatory First-Line Therapy

• All adult patients with chronic insomnia should receive CBT-I as initial treatment based on strong recommendation with moderate-quality evidence showing sustained benefits without risk of tolerance or adverse effects. 1

• CBT-I consists of multiple components delivered over 4-8 sessions: sleep restriction therapy (limiting time in bed to actual sleep time, then gradually increasing), stimulus control (going to bed only when sleepy, using bed only for sleep/sex), cognitive therapy targeting maladaptive beliefs about sleep, and sleep hygiene education. 1, 3

• CBT-I produces clinically meaningful improvements: 19-minute reduction in sleep onset latency, 26-minute reduction in wake after sleep onset, 10% improvement in sleep efficiency, and these effects are maintained long-term. 4

• Alternative delivery methods are effective when in-person therapy is unavailable: individual or group therapy, telephone-based programs, web-based modules (showing 56.6% remission at 1-year follow-up), or self-help books. 1, 5

• Brief Behavioral Therapy for Insomnia (BBT-I) focusing on behavioral components only may be offered when resources are limited, though CBT-I has more robust evidence. 1, 2

Critical Implementation Points

• Sleep hygiene education alone is insufficient as monotherapy and must be combined with other CBT-I components. 1, 3

• Sleep restriction may be contraindicated in patients with seizure disorders, bipolar disorder, or those working in high-risk occupations due to sleep deprivation effects. 3

• CBT-I is effective even in patients with comorbid psychiatric disorders (depression, PTSD, alcohol dependency) and medical conditions, with effect sizes of 0.5-1.5 for insomnia severity reduction. 6

Pharmacological Treatment (Second-Line Only)

When to Consider Medications

Pharmacotherapy should only be added after CBT-I has been unsuccessful, using shared decision-making that includes discussion of benefits, harms, and costs, with emphasis on short-term use only. 1

First-Line Pharmacological Options (After CBT-I Failure)

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) for short-term treatment of sleep initiation difficulties. 2, 7
• Zaleplon 10 mg specifically for sleep onset problems. 2
• Ramelteon 8 mg (melatonin receptor agonist) for sleep onset, with evidence showing reduced latency to persistent sleep. 2, 8

For sleep maintenance insomnia:

• Suvorexant (orexin receptor antagonist) reduces wake after sleep onset by 16-28 minutes with moderate-quality evidence. 2, 9
• Low-dose doxepin 3-6 mg specifically for sleep maintenance, reducing wake after sleep onset by 22-23 minutes. 1, 2
• Eszopiclone 2-3 mg for both sleep onset and maintenance. 1, 2

For both sleep onset and maintenance:

• Temazepam 15 mg as a benzodiazepine option. 2

Medications NOT Recommended

• Over-the-counter antihistamines (diphenhydramine) are not recommended due to lack of efficacy data, safety concerns including daytime sedation and delirium risk, especially in older adults. 2, 3

• Trazodone is not recommended for sleep onset or maintenance insomnia despite widespread use. 2

• Melatonin and herbal supplements (valerian) are not recommended due to insufficient evidence of efficacy. 1, 2

• Benzodiazepines (except temazepam) are not first-line due to insufficient evidence in systematic reviews and associations with serious adverse effects. 1

• Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects. 2

Critical Safety Warnings

• All hypnotic drugs carry FDA warnings about daytime impairment, "sleep driving," complex sleep behaviors, behavioral abnormalities, and observational studies show associations with dementia, serious injury, fractures, and falls. 1, 2

• Lower doses are mandatory in women and elderly patients: zolpidem maximum 5 mg in elderly, with FDA recommendations for dose reductions due to increased sensitivity and fall risk. 1, 2

• Short-term use only (typically less than 4 weeks) is recommended, though many patients continue use for extended periods despite lack of long-term efficacy data. 1, 2

• Combining multiple sedative medications significantly increases risks of cognitive impairment, falls, fractures, and complex sleep behaviors. 2

Treatment Algorithm

1. Screen and diagnose: Assess for chronic insomnia (difficulty initiating/maintaining sleep ≥3 nights/week for ≥3 months with daytime impairment). 1

2. Rule out other sleep disorders: If insomnia persists beyond 7-10 days of treatment, evaluate for sleep apnea, restless legs syndrome, or circadian rhythm disorders. 2, 3

3. Initiate CBT-I: Deliver 4-8 sessions incorporating sleep restriction, stimulus control, cognitive therapy, and sleep hygiene education. 1, 3

4. Monitor with sleep diaries: Collect data before and during treatment to guide adjustments. 3

5. If CBT-I insufficient: Use shared decision-making to add short-term pharmacotherapy based on symptom pattern (onset vs. maintenance), patient factors (age, comorbidities, substance abuse history), and medication safety profile. 1, 2

6. For patients with substance abuse history: Avoid benzodiazepines; consider ramelteon or suvorexant. 2

7. Regular reassessment: Monitor effectiveness and adverse effects, with periodic attempts to discontinue medications. 2

Common Pitfalls to Avoid

• Starting with medications instead of CBT-I undermines long-term outcomes and creates dependency risk. 3

• Using sleep hygiene education as standalone treatment when it must be combined with other CBT-I components. 1

• Prescribing long-acting benzodiazepines which carry increased risks without clear benefit. 2

• Failing to reduce doses in elderly patients leading to increased fall and cognitive impairment risk. 1, 2

• Continuing pharmacotherapy long-term without reassessment despite recommendations for short-term use only. 1, 2

• Not addressing underlying comorbid conditions (depression, anxiety, pain) that perpetuate insomnia. 1, 6