From the Guidelines
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered the first-line treatment for adults with chronic insomnia disorder, as it has been shown to improve global outcomes, sleep outcomes, and quality of life without the risks associated with pharmacological interventions 1. To combat insomnia effectively, it is essential to establish a consistent sleep schedule, create a relaxing bedtime routine, and make the bedroom conducive to sleep. Limiting exposure to screens, avoiding caffeine and alcohol, and completing workouts earlier in the day can also promote better sleep. Some key strategies to improve sleep quality include:
- Establishing a consistent sleep schedule by going to bed and waking up at the same time every day, even on weekends
- Creating a relaxing bedtime routine that might include reading, taking a warm bath, or practicing meditation 30-60 minutes before sleep
- Making the bedroom conducive to sleep by keeping it dark, quiet, and cool (around 65°F or 18°C)
- Limiting exposure to screens at least one hour before bedtime as blue light suppresses melatonin production
- Avoiding caffeine after midday and limiting alcohol consumption, which may help you fall asleep initially but disrupts sleep quality later in the night
- Completing workouts at least 3-4 hours before bedtime, as regular exercise can promote better sleep If insomnia persists, CBT-I has been shown to be highly effective in improving sleep outcomes, including reduced sleep onset latency and wake after sleep onset, and improved sleep efficiency and sleep quality 1. Pharmacological interventions, such as eszopiclone, zolpidem, and doxepin, may be considered as a second-line treatment, but their use should be carefully weighed against the potential risks and benefits, and the American Academy of Sleep Medicine suggests that clinicians use these medications with caution, due to the limited evidence on their long-term efficacy and potential harms 1.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo. Ramelteon reduced sleep latency at each time point when compared to placebo The best ways to combat insomnia include taking ramelteon or zolpidem as they have been shown to decrease sleep latency in controlled clinical studies 2, 2, 3.
- Ramelteon has been evaluated for up to six months in duration and has been shown to reduce sleep latency in adults and elderly patients.
- Zolpidem has been shown to decrease sleep latency for up to 35 days in controlled clinical studies. Key points to consider when using these medications include:
- Dosage: Ramelteon 8 mg has been shown to be effective in reducing sleep latency, while the 16 mg dose conferred no additional benefit and was associated with higher incidences of fatigue, headache, and next-day somnolence.
- Duration of treatment: The clinical trials performed in support of efficacy were up to six months in duration for ramelteon and 4 to 5 weeks in duration for zolpidem.
From the Research
Combating Insomnia
To combat insomnia, several strategies can be employed, including:
- Cognitive Behavioral Therapy for Insomnia (CBT-I) 4, 5, 6, 7
- Improving sleep hygiene 8
- Managing psychological stressors 8
- Hypnotic treatment, such as zolpidem, although this should be used with caution due to potential side effects 8
- Pharmacological therapy, with consideration of the potential risks and benefits 8
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I has been shown to be an effective treatment for insomnia, with moderate to large effects on insomnia severity and mental health 4, 6, 7. CBT-I can be delivered through various methods, including self-management tools and provider-delivered therapy 5. The therapy encompasses several components, including:
- Sleep hygiene
- Stimulus control
- Sleep restriction
- Cognitive therapy
- Relaxation training 4
Pharmacological Therapy
Zolpidem is a commonly used hypnotic for the treatment of insomnia, but it has been associated with several adverse effects, including an increased risk of falls, hip fractures, and complex behaviors such as sleepwalking and hallucinations 8. The decision to prescribe zolpidem should be made on a case-by-case basis, considering the potential risks and benefits 8.
Long-term Effects of CBT-I
The effects of CBT-I have been shown to be sustained long-term, with clinically significant effects lasting up to a year after therapy 7. This suggests that CBT-I can be a effective treatment for insomnia in the long-term, with potential benefits for mental health and overall quality of life 6, 7.