What are the treatment options for sleep disorders?

Treatment Options for Sleep Disorders

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for chronic insomnia disorder, delivered over 4-8 sessions with a trained specialist, as it provides superior long-term efficacy with minimal side effects compared to pharmacological options. 1, 2

Primary Treatment Approach for Insomnia

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

CBT-I is recommended as first-line treatment by the American Academy of Sleep Medicine, American College of Physicians, Australian Sleep Association, and British Association for Psychopharmacology. 1

Core components of effective CBT-I include: 1, 2

• Stimulus control therapy: Go to bed only when sleepy, leave bed when unable to sleep, use bed only for sleep and sex, maintain consistent wake times, avoid daytime napping 1
• Sleep restriction therapy: Limit time in bed to match actual sleep duration (from sleep diaries), then adjust based on sleep efficiency thresholds 1
• Cognitive therapy: Identify and modify unhelpful beliefs about sleep through structured psychoeducation and behavioral experiments 1
• Relaxation training: Progressive muscle relaxation, abdominal breathing, guided imagery, or meditation to reduce somatic and cognitive arousal 1
• Sleep hygiene education: Adjunct component addressing lifestyle factors (exercise timing, caffeine/alcohol avoidance, bedroom environment) 1, 2

Treatment delivery options with proven efficacy: 1, 2

• In-person one-on-one: Most effective format (incremental odds ratio 1.83) 2
• Brief Therapies for Insomnia (BTIs): Abbreviated 1-4 session versions emphasizing behavioral components when resources are limited 1
• Internet-based CBT-I: Clinically significant improvements demonstrated in meta-analyses 1
• Group therapy, telephone delivery, and self-help formats: All show efficacy 1

Single-Component Therapies (When CBT-I Unavailable)

The following single-component therapies received conditional recommendations when multicomponent CBT-I is not available or appropriate: 1

• Stimulus control therapy alone: Standard recommendation with strongest single-component evidence 1, 3
• Relaxation therapy alone: Standard recommendation 1, 3
• Sleep restriction therapy alone: Guideline-level recommendation 1, 3

Important caveat: Sleep hygiene education alone is NOT recommended as single-component therapy due to lack of efficacy evidence, though it remains useful as part of comprehensive treatment. 1

Critical Implementation Considerations

Sleep diary monitoring is essential before and throughout treatment to guide adjustments. 2

Sleep restriction therapy may be contraindicated in: 2

• Patients in high-risk occupations (due to temporary increased sleepiness)
• Those predisposed to mania/hypomania
• Poorly controlled seizure disorders

Expected temporary side effects during early CBT-I treatment (typically resolve by treatment end): 1, 2

• Daytime fatigue and sleepiness
• Mood impairment
• Cognitive difficulties

Advantages over pharmacotherapy: 2

• Durable benefits beyond treatment completion 1
• Reduces need for pharmacologic therapy and associated adverse events 2
• No risk of dependence or complex sleep behaviors 4

Second-Line: Pharmacological Treatment

Pharmacotherapy should be considered second-line and for short-term use only. 1

Recommended Pharmacological Agents

Low-dose doxepin and nonbenzodiazepine receptor agonists (e.g., zolpidem) received weak favorable recommendations for short-term use. 1

Zolpidem efficacy data: 4

• Superior to placebo on sleep latency, sleep duration, and number of awakenings in transient insomnia
• 10 mg dose superior to placebo on sleep latency for 4 weeks and sleep efficiency for weeks 2 and 4 in chronic insomnia
• No rebound insomnia at recommended doses upon discontinuation

Critical Safety Warnings for Zolpidem

Discontinue immediately if complex sleep behaviors occur (sleep-driving, sleep-walking, preparing food, making phone calls, having sex while not fully awake). 4

Contraindications: 4

• History of complex sleep behaviors with zolpidem
• Concurrent alcohol use
• Allergy to zolpidem

Serious risks include: 4

• Complex sleep behaviors that have caused serious injury and death
• Next-day psychomotor impairment and impaired driving (especially with <7-8 hours sleep, higher doses, or concurrent CNS depressants)
• Severe anaphylactic reactions (angioedema involving tongue, glottis, larynx)
• Abnormal thinking and behavioral changes (hallucinations in <1% adults, 7% pediatric patients)
• Worsening depression and suicidal ideation in depressed patients

Dosing requirements: 4

• Take only with 7-8 hours available for sleep
• Take on empty stomach (not with or after meals)
• One tablet per night maximum
• Avoid alcohol that evening or before bed

Agents NOT Generally Recommended

The VA/DOD guidelines recommend against (weak against): 1

• Benzodiazepines (differs from AASM guidelines due to harm concerns in military/veteran populations)
• Diphenhydramine
• Melatonin
• Chamomile
• Cranial electrical stimulation
• Kava (strong against recommendation) 1

Treatment for Specific Sleep Disorders Beyond Insomnia

Obstructive Sleep Apnea (OSA)

Screening and diagnosis: 1

• Use STOP questionnaire (Snoring, Tiredness, Observed apneas, high blood Pressure) as screening tool when excessive sleepiness is associated with observed apneas or snoring
• Confirm diagnosis with polysomnography or home sleep studies

Treatment approach: 1

• Continuous positive airway pressure (CPAP): Primary treatment
• Surgery or oral appliances: Alternative options
• Weight loss and exercise: Adjunctive recommendations
• Referral to sleep specialist

Restless Legs Syndrome (RLS)

Diagnostic approach: 1

• Check ferritin levels; levels <45-50 ng/mL indicate treatable cause

Treatment options: 1

• Dopamine agonists (meta-analyses show reduction in RLS symptoms and improved sleep)
• Benzodiazepines
• Gabapentin (calcium channel alpha-2-delta ligands effective per meta-analyses)
• Opioids
• Referral to sleep specialist

Narcolepsy

Consider when excessive sleepiness is accompanied by: 1

• Cataplexy
• Frequent short naps
• Vivid dreams
• Disrupted sleep
• Sleep paralysis

Diagnostic tools: 1

• Multiple Sleep Latency Tests (MSLTs)
• Polysomnography

Special Populations

Cancer Survivors

Psychosocial interventions are recommended: 1

• CBT shows improvement in sleep in multiple randomized controlled trials (58% breast cancer, 23% prostate cancer, 16% bowel cancer patients)
• Psychoeducational therapy
• Supportive expressive therapy

Physical activity interventions: 1

• Standardized yoga intervention showed greater improvements in global and subjective sleep quality, daytime functioning, sleep efficiency, and reduced sleep medication use (P≤.05)
• Exercise improved sleep at 12-week follow-up in meta-analysis

Patients with Mental Disorders and Comorbid Insomnia

CBT-I demonstrates significant efficacy in patients with comorbid mental disorders: 5

• Depression: Effect size 0.5 for insomnia reduction, 0.5 for depression symptom reduction
• PTSD: Effect size 1.5 for insomnia reduction, 1.3 for PTSD symptom reduction
• Alcohol dependency: Effect size 1.4 for insomnia reduction, 0.9 for alcohol dependency symptoms
• Psychosis/bipolar disorder: Effect size 1.2 for insomnia reduction

CBT-I should be considered first-line treatment in these populations given medication side effects and dual benefits on both insomnia and mental health symptoms. 5

Elderly Patients

Psychological and behavioral interventions are effective in older adults (Standard recommendation). 3

Zolpidem considerations: 4

• Recommended elderly dose is 5 mg (lower than standard 10 mg adult dose)
• Higher risk of falls due to drowsiness and decreased consciousness 4

Common Pitfalls to Avoid

Do not rely on sleep hygiene education alone - it lacks efficacy as single-component therapy despite being widely used by primary care providers. 1

Do not continue pharmacotherapy long-term - medications are recommended for short-term use only, whereas CBT-I provides durable long-term benefits. 1

Do not prescribe zolpidem without ensuring patients understand the requirement for 7-8 hours of sleep time - next-day impairment and complex sleep behaviors are significantly increased with insufficient sleep duration. 4

Do not overlook comorbid conditions - failure of insomnia to remit after 7-10 days of treatment indicates need to evaluate for primary psychiatric or medical illness. 4

Do not assume all insomnia is the same - differentiate between insomnia without comorbidities, insomnia with medical comorbidities, and insomnia with psychiatric comorbidities, as treatment efficacy varies. 1