What are the treatment options for insomnia?

Treatment of Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for all adults with chronic insomnia and must be initiated before or alongside any pharmacological intervention. 1, 2, 3

Initial Treatment Approach: CBT-I Components

CBT-I should include the following core components, delivered over 4-8 sessions:

Sleep Restriction Therapy

• Limit time in bed to match actual sleep duration (e.g., if sleeping 5 hours but in bed 8 hours, restrict to 5.5 hours initially). 2, 3
• Gradually increase time in bed by 15-30 minutes weekly if sleep efficiency exceeds 85%. 4
• This creates mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 3
• Caution: Contraindicated in patients with seizure disorders, bipolar disorder, or high-risk occupations due to daytime sleepiness risk. 2, 3

Stimulus Control Therapy

• Go to bed only when sleepy (not by clock time). 2, 3
• Use bed only for sleep and sex—no reading, TV, or phone use. 2, 3
• Leave bedroom if unable to fall asleep within 20 minutes; return only when sleepy. 3
• Maintain consistent wake time regardless of sleep quality. 3

Cognitive Therapy

• Address dysfunctional beliefs about sleep (e.g., "I must get 8 hours or I'll be sick"). 3, 4
• Use thought records and behavioral experiments to challenge catastrophic thinking. 3
• Provide psychoeducation about normal sleep variability. 3

Sleep Hygiene (Adjunct Only)

• Avoid caffeine after noon and alcohol within 3 hours of bedtime. 2, 4
• Optimize sleep environment (dark, quiet, cool). 2
• Sleep hygiene alone is insufficient as monotherapy and must be combined with other CBT-I components. 1, 3

CBT-I Delivery Formats

CBT-I can be delivered through multiple effective formats:

• Individual face-to-face therapy (gold standard). 1, 3
• Group therapy sessions. 1, 3
• Telephone-based programs. 1, 3
• Web-based digital CBT (dCBT) modules—fully automated and scalable. 1, 5
• Self-help books with therapist guidance. 1, 3

Brief Behavioral Therapy (BBT) may be used when resources are limited, emphasizing behavioral components over 2-4 sessions. 2, 3

Pharmacological Treatment Algorithm

Pharmacotherapy should supplement—never replace—CBT-I, and should be used at the lowest effective dose for the shortest duration possible. 1, 2, 4

First-Line Pharmacotherapy

When medication is necessary after or alongside CBT-I:

For Sleep Onset Insomnia:

• Zolpidem 10 mg (5 mg in elderly ≥65 years). 2, 6
• Zaleplon 10 mg. 2
• Ramelteon 8 mg (melatonin receptor agonist, no abuse potential). 2, 7
• Triazolam 0.25 mg (not preferred due to rebound anxiety). 2

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg (addresses both onset and maintenance). 2, 4
• Temazepam 15 mg. 2
• Low-dose doxepin 3-6 mg (FDA-approved, reduces wake after sleep onset by 22-23 minutes). 2, 4
• Suvorexant (orexin receptor antagonist, reduces wake after sleep onset by 16-28 minutes). 2, 4

Second-Line Options

If first-line agents fail:

• Alternative BzRA or ramelteon from different class. 1, 2
• Sedating antidepressants (preferred when comorbid depression/anxiety present):
  • Trazodone 25-100 mg (moderate evidence for SSRI-induced insomnia). 4
  • Mirtazapine (faster onset than SSRIs, improves sleep architecture). 4
  • Amitriptyline or doxepin at higher doses. 1, 2

Third-Line Options (Specialist Consultation)

• Combined BzRA/ramelteon plus sedating antidepressant. 1, 2
• Anticonvulsants (gabapentin, tiagabine—though tiagabine not recommended by AASM). 1, 2
• Atypical antipsychotics (quetiapine, olanzapine—use only when other options exhausted due to metabolic side effects). 1, 2

Medication Selection Factors

Choose specific agent based on:

1. Symptom pattern (onset vs. maintenance). 1, 2
2. Patient age (elderly require 50% dose reduction for zolpidem). 2, 4
3. Comorbid conditions (depression/anxiety favors sedating antidepressants). 1, 4
4. History of substance abuse (avoid benzodiazepines; use ramelteon or suvorexant). 2
5. Medication interactions and contraindications. 1, 2
6. Past treatment responses. 1, 2

Special Population Considerations

Elderly Patients (≥65 years)

• Maximum zolpidem dose is 5 mg (not 10 mg) due to increased sensitivity and fall risk. 2, 4
• Higher risk of cognitive impairment, complex sleep behaviors, and fractures with all hypnotics. 2, 4
• Avoid long-acting benzodiazepines entirely. 2, 4

Patients with Comorbid Depression/Anxiety

• Sedating antidepressants are preferred initial pharmacotherapy to simultaneously address mood and sleep. 1, 4
• Mirtazapine demonstrates faster onset than SSRIs with improved sleep architecture. 4
• SSRIs/SNRIs may worsen insomnia initially; consider adding low-dose trazodone or doxepin if this occurs. 4
• Always implement CBT-I alongside antidepressant therapy for most durable benefits. 4

Agents NOT Recommended

The following should NOT be used for insomnia treatment:

• Over-the-counter antihistamines (diphenhydramine, doxylamine)—lack efficacy data, cause daytime sedation and delirium risk in elderly. 2, 3, 4
• Melatonin supplements—insufficient evidence for chronic insomnia. 3, 4
• Herbal supplements (valerian)—insufficient evidence. 2
• Barbiturates and chloral hydrate—outdated with significant risks. 2
• Long-acting benzodiazepines (e.g., flurazepam)—increased fall and cognitive impairment risk without benefit. 2, 4
• Trazodone as monotherapy—not recommended by AASM for sleep onset or maintenance. 2
• Tiagabine—not recommended by AASM. 2

Monitoring and Follow-Up

• Collect sleep diary data before, during, and after treatment to objectively track progress. 1, 3
• Reassess every 1-2 weeks initially until insomnia stabilizes, then every 6 months (relapse rate is high). 1, 2
• Evaluate for occult sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment. 2
• Monitor for adverse effects: morning sedation, cognitive impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls. 2, 4
• Taper medications when conditions allow to prevent discontinuation symptoms. 2

Treatment Sequencing for Chronic Insomnia

1. Initiate CBT-I immediately (can be concurrent with medication if needed). 1, 3, 4
2. If CBT-I alone insufficient after 4-6 weeks, add first-line pharmacotherapy based on symptom pattern. 1, 2
3. If first-line medication ineffective after 2-4 weeks, switch to alternative first-line agent or add second-line option. 1, 2
4. If still ineffective, consider combined therapy or reevaluate for comorbid disorders. 1, 2
5. Reassess need for continued pharmacotherapy every 6 months; attempt taper when stable. 1, 2

Critical Pitfalls to Avoid

• Never prescribe hypnotics as first-line treatment without CBT-I—this undermines long-term outcomes and creates dependency risk. 1, 3, 4
• Never use sleep hygiene education alone—it is insufficient as monotherapy and must be combined with other CBT-I components. 1, 3
• Never use standard adult doses of hypnotics in elderly patients—zolpidem must be reduced to 5 mg maximum. 2, 4
• Never continue pharmacotherapy indefinitely without periodic reassessment—hypnotics should be time-limited with regular evaluation. 1, 2, 4
• Never combine multiple sedative medications—this significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures. 2
• Never ignore comorbid conditions—depression, anxiety, sleep apnea, and restless legs syndrome require specific management approaches. 1, 2, 4

Efficacy Data

• CBT-I produces clinically meaningful improvements: sleep onset latency reduced by 19 minutes, wake after sleep onset reduced by 26 minutes, sleep efficiency improved by 9.91%. 8
• CBT-I benefits are sustained long-term without tolerance or adverse effects, unlike pharmacotherapy. 1, 3, 8
• Zolpidem demonstrated superiority over placebo for sleep latency and efficiency for up to 35 days in controlled trials. 6
• Ramelteon is effective for sleep onset insomnia with trials up to 6 months duration. 7