What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

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

First-Line Treatment: CBT-I

CBT-I is superior to medications for long-term outcomes, with sustained benefits lasting up to 2 years and minimal risk of adverse effects. 1, 2 The American Academy of Sleep Medicine and American College of Physicians both recommend CBT-I as the initial treatment due to its favorable benefit-to-risk ratio compared to all pharmacological options. 1

Core Components of Effective CBT-I

• Sleep restriction therapy limits time in bed to increase sleep efficiency and consolidate sleep. 1
• Stimulus control therapy associates the bed exclusively with sleep rather than wakefulness. 1, 2
• Cognitive restructuring addresses maladaptive thoughts and beliefs about sleep. 1
• Sleep hygiene education includes avoiding excessive caffeine, evening alcohol, late exercise, frequent daytime napping, and optimizing the sleep environment—though this alone is insufficient as monotherapy. 1, 3

Delivery Methods for CBT-I

CBT-I can be effectively delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books. 3 Brief behavioral therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions. 3

Second-Line Treatment: Pharmacotherapy

Medications should only be considered when patients cannot participate in CBT-I, still have symptoms despite adequate CBT-I, or as a temporary adjunct to CBT-I—never as a replacement. 1, 3

First-Line Medication Options

When pharmacotherapy is necessary, the following FDA-approved medications are recommended:

For Sleep Onset Insomnia:

• Ramelteon 8 mg (melatonin receptor agonist) is effective for sleep onset difficulties with minimal respiratory depression and reduced abuse potential. 3, 4
• Zaleplon 10 mg (short-acting BzRA) specifically targets sleep onset. 3
• Zolpidem 10 mg (5 mg in elderly) is effective for both sleep onset and maintenance. 3, 5
• Triazolam 0.25 mg may be used for sleep onset but is not considered first-line due to rebound anxiety. 3

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg is effective for both sleep onset and maintenance. 3
• Temazepam 15 mg addresses both sleep onset and maintenance issues. 3
• Low-dose doxepin 3-6 mg is specifically recommended for sleep maintenance with less cardiovascular risk than benzodiazepines. 3, 6
• Suvorexant (orexin receptor antagonist) reduces wake after sleep onset by 16-28 minutes. 3

Medication Selection Algorithm

1. Assess the primary sleep complaint: Determine whether the patient has difficulty with sleep onset, sleep maintenance, or both. 3
2. Consider patient-specific factors: Age, comorbidities (especially cardiac or respiratory conditions), history of substance abuse, and concurrent medications. 3, 6
3. For patients with substance abuse history: Avoid benzodiazepines; consider ramelteon or suvorexant instead. 3
4. For elderly patients: Use lower doses (e.g., zolpidem 5 mg maximum) due to increased sensitivity and fall risk. 3
5. For patients with comorbid depression/anxiety: Consider sedating antidepressants after first-line options fail. 3

Duration and Monitoring

• Use the lowest effective dose for the shortest period possible—typically less than 4 weeks for acute insomnia. 3
• Short-term use is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use. 1
• Regular follow-up is essential to monitor treatment response, assess for side effects, and periodically reassess the need for continued medication. 1, 3
• Always supplement pharmacotherapy with behavioral interventions—medications should never be used without concurrent CBT-I techniques. 3

Medications NOT Recommended

The following agents should be avoided due to lack of efficacy data, safety concerns, or problematic side effects:

• Over-the-counter antihistamines (e.g., diphenhydramine) carry risks of daytime sedation and delirium, especially in older patients. 1, 3
• Herbal supplements (e.g., valerian) and melatonin have insufficient evidence of efficacy. 3
• Trazodone is not recommended for sleep onset or maintenance insomnia. 3
• Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects. 1, 3
• Long-acting benzodiazepines carry increased risks without clear benefit. 3
• Older hypnotics including barbiturates and chloral hydrate are not recommended. 3

Critical Pitfalls to Avoid

• Never use sedative medications as first-line treatment before attempting CBT-I. 1, 6
• Do not continue pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions. 1, 3
• Avoid combining multiple sedative medications, which significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures. 3
• Do not use sleep hygiene education alone as it is insufficient for treating chronic insomnia. 1, 7
• Screen for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment. 3

Special Population Considerations

Elderly Patients

• Require lower medication doses due to increased sensitivity. 3
• Are at higher risk for falls, cognitive impairment, and complex sleep behaviors with hypnotics. 3
• Benzodiazepines should be avoided due to increased risk of falls and decreased cognitive performance. 3

Patients with Congestive Heart Failure

• CBT-I remains first-line treatment. 6
• Screen for obstructive sleep apnea, which increases mortality risk 2.7-fold in CHF patients. 6
• Consider CPAP therapy if sleep apnea is diagnosed, as it improves left ventricular ejection fraction and functional status. 6
• Avoid benzodiazepines and non-benzodiazepine hypnotics when possible due to respiratory depression risks. 6
• If medication is necessary, ramelteon or low-dose doxepin have lower cardiovascular risk profiles. 6