What are the recommended treatments for insomnia?

Recommended Treatments for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated as first-line treatment for all adults with chronic insomnia before considering any pharmacological intervention. 1, 2

First-Line Treatment: CBT-I

• The American Academy of Sleep Medicine, American College of Physicians, and multiple international guidelines uniformly recommend CBT-I as the initial treatment due to its superior long-term efficacy (sustained benefits up to 2 years) and minimal risk of adverse effects compared to medications. 3, 1

• CBT-I is a multicomponent intervention that includes sleep restriction therapy, stimulus control, cognitive restructuring to address maladaptive thoughts about sleep, and sleep hygiene education—though sleep hygiene alone is insufficient as monotherapy. 3, 1, 2

• Multiple delivery formats are effective and should be offered based on patient access and preferences: in-person individual therapy (gold standard), group sessions, telephone-based programs, web-based modules, or self-help books. 3, 1

• Improvements from CBT-I are gradual but durable beyond treatment end, with initial side effects such as mild sleepiness and fatigue typically resolving quickly. 4

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—never as monotherapy without concurrent behavioral interventions. 2, 4

First-Line Medications (When Pharmacotherapy is Necessary)

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon are recommended as first-line pharmacotherapy. 1, 4

For sleep onset insomnia specifically: 1, 4

• Zaleplon 10 mg
• Zolpidem 10 mg (5 mg in elderly)
• Ramelteon 8 mg

For sleep maintenance insomnia specifically: 1, 4

• Eszopiclone 2-3 mg
• Zolpidem 10 mg
• Temazepam 15 mg

Second-Line Medications

• Low-dose doxepin (3-6 mg) for sleep maintenance insomnia 4
• Suvorexant (orexin receptor antagonist) for sleep maintenance insomnia 4
• Sedating antidepressants (e.g., mirtazapine, amitriptyline) when comorbid depression/anxiety is present 4

Critical Medications to AVOID

The American Academy of Sleep Medicine explicitly advises against the following due to lack of efficacy, safety concerns, or problematic side effects: 1, 2, 4

• Over-the-counter antihistamines (e.g., diphenhydramine)—lack efficacy data and cause daytime sedation and delirium, especially in elderly patients
• Antipsychotics as first-line treatment—problematic metabolic side effects
• Long-acting benzodiazepines—increased risks without clear benefit
• Herbal supplements (e.g., valerian) and melatonin—insufficient evidence of efficacy
• Trazodone—not recommended by AASM guidelines

Treatment Algorithm

Step 1: Initiate CBT-I as primary intervention for all patients 1, 2

Step 2: If CBT-I is insufficient, unavailable, or patient cannot participate, add short-term pharmacotherapy (typically less than 4 weeks) while continuing behavioral interventions 2, 4

Step 3: Select medication based on symptom pattern:

• Sleep onset difficulty → zaleplon, ramelteon, or zolpidem 4
• Sleep maintenance difficulty → eszopiclone, temazepam, doxepin, or suvorexant 4
• Comorbid depression/anxiety → sedating antidepressants 4

Step 4: Use lowest effective dose for shortest duration possible 4

Step 5: Regular follow-up to assess effectiveness, side effects, and need for medication adjustments 1, 4

Step 6: If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) 4

Critical Safety Considerations

• All hypnotics carry significant risks: daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls and fractures, dependence, withdrawal, and cognitive impairment—particularly in elderly patients. 1, 4

• Elderly patients require lower doses (e.g., zolpidem 5 mg maximum), should avoid benzodiazepines, and are at higher risk for falls and cognitive impairment. 4

• Combining multiple sedative medications significantly increases risks 4

• Caution with sleep restriction in patients with seizure disorder or bipolar disorder due to sleep deprivation effects 4

Common Pitfalls to Avoid

• Starting with medications before attempting CBT-I 1, 2
• Using sleep hygiene education alone as treatment—it is insufficient as monotherapy 3, 2
• Prescribing over-the-counter antihistamines or herbal supplements 1, 2
• Continuing pharmacotherapy long-term without periodic reassessment and concurrent behavioral interventions 2, 4
• Failing to consider drug interactions and contraindications 4
• Using sedating agents without matching them to specific sleep complaints (onset vs. maintenance) 4