What are the recommended treatments for insomnia?

Treatment of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for all adults with chronic insomnia and should be initiated before any pharmacological intervention. 1, 2

First-Line Treatment: CBT-I

CBT-I is recommended as the standard of care due to its superior long-term efficacy, sustained benefits up to 2 years, and minimal risk of adverse effects compared to medications. 1, 2 This recommendation comes from the American Academy of Sleep Medicine and American College of Physicians and represents the strongest evidence-based approach. 1

Core Components of Effective CBT-I

CBT-I must include these specific therapeutic elements to be effective:

• Stimulus control therapy: Go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes, maintain consistent wake time. 3, 2

• Sleep restriction therapy: Limit time in bed to match actual sleep duration (creating mild sleep deprivation), then gradually adjust based on sleep efficiency thresholds of 80-85%. 3, 2 Caution: Contraindicated in patients with seizure disorders, bipolar disorder, or high-risk occupations due to daytime sleepiness risks. 2, 4

• Cognitive restructuring: Address dysfunctional beliefs about sleep through psychoeducation, Socratic questioning, and behavioral experiments. 2

• Sleep hygiene education: Avoid excessive caffeine, evening alcohol, late exercise; optimize sleep environment. This is insufficient as monotherapy but essential as part of comprehensive treatment. 1, 4

Treatment Delivery

• Standard format: 4-8 sessions with trained CBT-I specialist 2
• Alternative formats when resources limited: Brief Behavioral Therapy (2-4 sessions), group therapy, telephone-based, web-based modules, or self-help books—all showing effectiveness 2, 4
• Sleep diary monitoring throughout treatment is essential 2

Second-Line Treatment: Pharmacotherapy

Medications should only be considered when CBT-I is unavailable, insufficient after adequate trial, or as temporary adjunct—never as monotherapy or first-line treatment. 1, 4

FDA-Approved First-Line Medications

When pharmacotherapy is necessary, the American Academy of Sleep Medicine recommends short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon: 3, 4

For sleep onset insomnia:

• Zaleplon 10 mg (very short half-life, no residual sedation) 3, 4
• Ramelteon 8 mg (melatonin receptor agonist, no dependence risk) 3, 4
• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Triazolam 0.25 mg (associated with rebound anxiety, not first-line) 4

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 4
• Zolpidem 10 mg (5 mg in elderly) 4, 5
• Temazepam 15 mg 4
• Low-dose doxepin 3-6 mg (sedating antidepressant) 4
• Suvorexant (orexin receptor antagonist) 4

Critical Medication Safety Considerations

All BzRAs carry significant risks that must be discussed with patients: 4, 5

• Complex sleep behaviors: Sleep-driving, sleep-walking, sleep-eating that have caused serious injury and death. Patients must be able to stay in bed 7-8 hours after dosing. 5
• Cognitive impairment and falls: Particularly dangerous in elderly patients (use maximum zolpidem 5 mg in this population) 4
• Dependence and tolerance: Short-term use only (typically <4 weeks), with periodic reassessment mandatory 4
• Next-day impairment: Residual sedation affecting driving and performance 5
• Anterograde amnesia: Memory impairment for events occurring after medication administration 5

Medications NOT Recommended

The American Academy of Sleep Medicine explicitly recommends against: 1, 4

• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and delirium especially in elderly 1, 4
• Melatonin supplements: Insufficient evidence for chronic insomnia 2, 4
• Herbal supplements (valerian): Lack efficacy data 4
• Antipsychotics: Problematic metabolic side effects, not first-line 1
• Trazodone: Not recommended by American Academy of Sleep Medicine 4
• Long-acting benzodiazepines (lorazepam): Increased risks without clear benefit, only second/third-line 4

Treatment Algorithm

Step 1: Initiate CBT-I for all patients with chronic insomnia 1, 2

Step 2: If CBT-I insufficient after adequate trial (4-8 weeks), add short-term pharmacotherapy as supplement, not replacement 4

Step 3: Select medication based on symptom pattern:

• Sleep onset difficulty → zaleplon, ramelteon, or zolpidem 4
• Sleep maintenance → eszopiclone, temazepam, doxepin, or suvorexant 4

Step 4: Use lowest effective dose for shortest duration, with mandatory periodic reassessment 4

Step 5: If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) 4, 5

Special Population Considerations

Elderly patients require extra caution: 4

• Higher risk of falls, cognitive impairment, complex sleep behaviors
• Require lower medication doses (zolpidem maximum 5 mg)
• More likely to have sleep maintenance problems
• American Geriatrics Society recommends avoiding benzodiazepines entirely

Patients with comorbid conditions: 2

• CBT-I remains effective for insomnia comorbid with psychiatric disorders and medical conditions 2
• Consider sedating antidepressants (doxepin, mirtazapine) when depression/anxiety present 4
• Avoid benzodiazepines in those with substance abuse history; consider ramelteon or suvorexant instead 4

Common Pitfalls to Avoid

• Using medications as first-line treatment undermines long-term outcomes and creates dependency risk 2
• Prescribing sleep hygiene education alone as treatment—it is insufficient as monotherapy 1, 2
• Combining multiple sedative medications significantly increases risks of complex sleep behaviors, falls, and cognitive impairment 4
• Continuing pharmacotherapy long-term without reassessment and without concurrent behavioral interventions 1, 4
• Failing to screen for underlying sleep disorders when insomnia persists despite treatment 4, 5
• Using medications without patient education about complex sleep behavior risks and the requirement to stay in bed 7-8 hours 5