What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all patients with chronic insomnia, as it demonstrates superior long-term efficacy compared to medications with sustained benefits up to 2 years and minimal risk of adverse effects. 1

First-Line Treatment: CBT-I

CBT-I is recommended by the American Academy of Sleep Medicine and American College of Physicians as the gold standard initial approach for chronic insomnia across all age groups. 1, 2 This recommendation is based on its favorable benefit-to-risk ratio and durability of effects that persist well beyond treatment completion. 1

Core Components of Effective CBT-I

• Sleep restriction therapy limits time in bed to increase sleep efficiency and consolidate sleep. 1, 3
• Stimulus control therapy retrains the brain to associate the bed with sleep rather than wakefulness. 1, 3
• Cognitive restructuring addresses maladaptive thoughts and anxiety about sleep. 1
• Relaxation techniques reduce physiological and cognitive arousal. 1, 4
• Sleep hygiene education should be included but is insufficient as monotherapy. 1, 2

Delivery Methods

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

Important Considerations

• Improvements from CBT-I are gradual, with initial mild sleepiness and fatigue that typically resolve quickly. 2
• Exercise caution with sleep restriction in patients with seizure disorder or bipolar disorder due to sleep deprivation effects. 2

Second-Line Treatment: Pharmacotherapy

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—never as monotherapy without concurrent behavioral interventions. 1

First-Line Medication Options

When pharmacotherapy is necessary, the following agents are recommended:

For Sleep Onset Insomnia:

• Zolpidem 10 mg (5 mg in elderly) is effective for both sleep onset and maintenance. 2, 5
• Zaleplon 10 mg specifically targets sleep onset difficulty. 2
• Ramelteon 8 mg (melatonin receptor agonist) has minimal respiratory depression risk and no abuse potential. 2, 6
• Triazolam 0.25 mg may be used but has been associated with rebound anxiety and is not considered first-line. 2

For Sleep Maintenance Insomnia:

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

Medication Selection Algorithm

1. Assess symptom pattern: Determine whether the primary complaint is sleep onset difficulty, sleep maintenance problems, or both. 2
2. Consider patient factors: Age, comorbidities (especially cardiac, respiratory, psychiatric), history of substance abuse, and fall risk. 2, 3
3. Start with lowest effective dose for shortest duration: Typically less than 4 weeks for acute insomnia. 2
4. Always combine with behavioral interventions: Short-term hypnotic treatment must be supplemented with CBT-I techniques. 2

Agents NOT Recommended

• Over-the-counter antihistamines (e.g., diphenhydramine) lack efficacy data and carry safety concerns including daytime sedation and delirium, especially in older patients. 1, 2
• Herbal supplements (e.g., valerian) and melatonin have insufficient evidence of efficacy. 2
• Trazodone is not recommended despite common off-label use. 2
• Antipsychotics should not be used as first-line treatment due to problematic metabolic side effects. 1, 2
• Tiagabine (anticonvulsant) is not recommended. 2
• Older hypnotics including barbiturates and chloral hydrate should be avoided. 2

Critical Safety Considerations and Common Pitfalls

Risks of Benzodiazepines and Non-Benzodiazepine Hypnotics

• Falls and fractures, particularly in older adults. 1, 2
• Cognitive impairment and daytime sedation. 1, 2
• Complex sleep behaviors including sleep-driving and sleep-walking. 2, 5
• Tolerance and dependence with long-term use. 1
• Anterograde amnesia, especially at doses above 10 mg of zolpidem. 5
• Associations with dementia in elderly patients with prolonged use. 2

Special Population Considerations

Elderly Patients:

• Require lower doses: zolpidem 5 mg maximum (not 10 mg). 2
• Higher risk of falls, cognitive impairment, and complex sleep behaviors. 2
• More likely to report sleep maintenance problems rather than onset difficulties. 2

Patients with Substance Abuse History:

• Avoid benzodiazepines entirely. 2
• Consider ramelteon or suvorexant as safer alternatives. 2

Patients with Congestive Heart Failure:

• Screen for sleep-disordered breathing, as CHF patients with sleep apnea have 2.7-fold greater mortality risk. 3
• Optimize CHF management first, as improved cardiac function may alleviate sleep disturbances. 3
• Consider CPAP therapy if obstructive sleep apnea is diagnosed. 3
• Avoid benzodiazepines due to respiratory depression risk. 3

Critical Pitfalls to Avoid

• Using medications as first-line treatment without attempting CBT-I. 1, 2
• Continuing pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions. 1, 2
• Combining multiple sedative medications, which significantly increases risks. 2
• Failing to screen for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment. 2
• Using sleep hygiene education alone as single-component therapy—it must be combined with other CBT-I components. 1, 2
• Prescribing long-acting benzodiazepines, which carry increased risks without clear benefit. 2

Treatment Algorithm Summary

1. Initiate CBT-I as primary intervention for all patients with chronic insomnia. 1, 2
2. If CBT-I is insufficient or unavailable after adequate trial, add short-term pharmacotherapy (not as replacement). 1, 2
3. Select medication based on symptom pattern: sleep onset vs. maintenance problems. 2
4. Use lowest effective dose for shortest duration with regular monitoring. 2
5. Reassess periodically for treatment response, adverse effects, and need for medication adjustments. 1, 2
6. Taper medications when conditions allow to prevent discontinuation symptoms. 2