What are the treatment options for insomnia?

Treatment for Insomnia

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

All adults with chronic insomnia should receive CBT-I as the initial treatment before any pharmacological intervention. 1, 2

Core Components of CBT-I

CBT-I is a multimodal therapy that combines several evidence-based techniques 1:

• Stimulus control therapy: Use the bed only for sleep and sex; go to bed only when sleepy; leave the bedroom if unable to sleep within 15-20 minutes; maintain a consistent wake time 1, 2, 3

• Sleep restriction therapy: Limit time in bed to match actual sleep duration (based on sleep diary data), then gradually adjust based on sleep efficiency thresholds of 85-90% 2, 3

• Cognitive therapy: Address dysfunctional beliefs about sleep, catastrophic thinking about sleep loss, and maladaptive thoughts that perpetuate insomnia 2, 3

• Sleep hygiene education: Maintain regular sleep-wake schedule, avoid caffeine/alcohol/nicotine before bed, optimize sleep environment—though this alone is insufficient as monotherapy 1, 2, 3

• Relaxation techniques: Progressive muscle relaxation and other relaxation strategies 1, 4

CBT-I Delivery and Efficacy

CBT-I can be delivered through multiple formats including individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all showing effectiveness 1, 2. Treatment typically consists of 4-8 sessions with a trained specialist 2. When resources are limited, Brief Behavioral Therapy (BBT) emphasizing behavioral components over 2-4 sessions may be appropriate 1, 2.

CBT-I produces superior long-term outcomes compared to pharmacotherapy, with 70-80% of patients benefiting from treatment 4. Benefits include reduced sleep onset latency, decreased wake time after sleep onset, improved sleep efficiency, and enhanced sleep quality—with improvements sustained for at least 6 months after treatment completion 2, 4.

Important Caveats for CBT-I

Sleep restriction may be contraindicated in patients with seizure disorders, bipolar disorder, or those working in high-risk occupations due to sleep deprivation effects 2, 3. Initial side effects such as mild sleepiness and fatigue typically resolve quickly 2.

Pharmacological Treatment Algorithm

Pharmacotherapy should only be added when CBT-I alone is insufficient, and should always supplement—not replace—behavioral interventions. 1, 5, 3

First-Line Medications

When pharmacotherapy is necessary, the recommended sequence is 1, 5:

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly) 5, 6
• Zaleplon 10 mg 5
• Ramelteon 8 mg (melatonin receptor agonist) 1, 5
• Triazolam 0.25 mg (though associated with rebound anxiety, not truly first-line) 5

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 5, 7
• Zolpidem 10 mg (5 mg in elderly) 5, 6
• Temazepam 15 mg 5

Second-Line Medications

If first-line agents are unsuccessful 1, 5:

• Low-dose doxepin 3-6 mg for sleep maintenance insomnia 5, 3
• Suvorexant (orexin receptor antagonist) for sleep maintenance 5, 3
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine) especially when comorbid depression/anxiety is present 1, 3

Medications NOT Recommended

• Over-the-counter antihistamines (diphenhydramine): Lack efficacy data, cause daytime sedation and delirium risk especially in elderly 5, 2, 3
• Trazodone: Not recommended by American Academy of Sleep Medicine for sleep onset or maintenance insomnia 5
• Herbal supplements and melatonin: Insufficient evidence of efficacy 5, 2
• Barbiturates and chloral hydrate: Not recommended 5
• Tiagabine: Not recommended 5

Medication Selection Factors

Choice of specific agent should be directed by 1, 5:

1. Symptom pattern (onset vs. maintenance)
2. Treatment goals
3. Past treatment responses
4. Patient preference
5. Comorbid conditions (depression, anxiety, substance abuse history)
6. Contraindications and drug interactions
7. Side effects profile
8. Age (elderly require lower doses)

Critical Safety Considerations

All hypnotics carry significant risks including daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, cognitive impairment, and potential for dependence—particularly in elderly patients 1, 5, 3.

• Use the lowest effective dose for the shortest duration (typically less than 4 weeks for acute insomnia) 1, 3
• Elderly patients require lower doses: zolpidem 5 mg maximum 5, 3
• Avoid benzodiazepines in older adults, those with cognitive impairment, and patients with substance abuse history 5, 3
• Avoid combining multiple sedative medications due to increased risk of falls, cognitive impairment, and complex sleep behaviors 3
• Long-acting benzodiazepines carry increased risks without clear benefit 1

Special Populations

Insomnia with Comorbid Depression/Anxiety

For patients with comorbid depression or anxiety 1, 3:

1. Start CBT-I as foundation of treatment 3
2. Select antidepressant with sleep-promoting properties: Mirtazapine 15-30 mg or trazodone 150-300 mg at full antidepressant doses (not low-dose sedation) 3
3. Add short-term hypnotic (zolpidem, eszopiclone) only if CBT-I plus appropriate antidepressant is insufficient 3

Critical pitfall: Do not use low-dose sedating antidepressants (trazodone 50 mg, mirtazapine 7.5 mg) as monotherapy—this undertreats the depression 3.

Elderly Patients

Older adults are more likely to report sleep maintenance problems rather than sleep onset difficulties 1. They require lower medication doses (zolpidem 5 mg maximum) and are at higher risk for falls, cognitive impairment, and complex sleep behaviors 5, 3.

Monitoring and Follow-Up

• Collect sleep diary data before and during treatment 1, 2
• Clinical reassessment should occur every few weeks until insomnia stabilizes, then every 6 months (relapse rate is high) 1, 2
• If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders such as sleep apnea, restless legs syndrome, or circadian rhythm disorders 2, 3
• When single treatment is ineffective, consider other behavioral therapies, alternative pharmacological agents, combined therapies, or reevaluation for occult comorbid disorders 1

Common Pitfalls to Avoid

• Using medications as first-line treatment undermines long-term outcomes and creates dependency risk 2
• Prescribing hypnotics long-term without periodic reassessment and concurrent behavioral interventions 5, 3
• Using sleep hygiene education alone as stand-alone treatment—it must be combined with other CBT-I components 1, 2
• Failing to implement CBT-I when adding or switching medications 5, 3
• Prescribing SSRIs/SNRIs without addressing their sleep-disrupting effects 3