What is the recommended first-line treatment for chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) or a sleep study?

CBT-I is First-Line Treatment for Chronic Insomnia, Not Sleep Study

Cognitive behavioral therapy for insomnia (CBT-I) should be offered as the initial treatment for all adults with chronic insomnia disorder—a sleep study (polysomnography) is not indicated for uncomplicated chronic insomnia and should be reserved only for cases where other sleep disorders like obstructive sleep apnea are suspected. 1, 2

Why CBT-I Over Sleep Study

Sleep Studies Are Not Diagnostic Tools for Uncomplicated Insomnia

• Polysomnography is not indicated as initial management for uncomplicated chronic insomnia 2
• Sleep studies should only be ordered when you suspect comorbid sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, or REM sleep behavior disorder 2
• The diagnosis of chronic insomnia is clinical, based on patient-reported difficulty falling asleep, staying asleep, early morning awakening, and daytime impairment lasting ≥3 months 2

CBT-I Has the Strongest Evidence Base

• The American College of Physicians, American Academy of Sleep Medicine, and VA/DoD all recommend CBT-I as first-line treatment with strong recommendations based on moderate-quality evidence 1, 2
• CBT-I produces clinically meaningful improvements: sleep onset latency reduces by 19 minutes, wake after sleep onset improves by 26 minutes, and sleep efficiency increases by 9.91% 3
• These benefits are sustained for up to 2 years, unlike pharmacotherapy which loses efficacy and creates dependency risk 4, 3

How to Implement CBT-I

Core Components That Must Be Included

The most effective CBT-I packages include these critical components:

• Sleep restriction therapy: Limit time in bed to match actual sleep duration (from sleep diary), creating mild sleep deprivation that strengthens homeostatic sleep drive, then gradually adjust based on sleep efficiency thresholds of 85-90% 2, 5
• Stimulus control: Go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 15-20 minutes, maintain consistent wake time 1, 2
• Cognitive restructuring: Target dysfunctional beliefs about sleep using Socratic questioning, thought records, and behavioral experiments 2, 5
• Sleep hygiene education: Avoid caffeine after noon, alcohol within 4 hours of bedtime, late evening exercise, and excessive time in bed—but this alone is insufficient as monotherapy 1

Treatment Structure

• Standard CBT-I is delivered over 4-8 sessions with a trained specialist 2, 6
• Brief behavioral therapy for insomnia (1-4 sessions) emphasizing behavioral components can be offered when resources are limited 1, 6
• In-person one-on-one delivery is most effective (incremental odds ratio 1.83) compared to group or internet-based formats 6, 5
• Collect sleep diary data before and throughout treatment to monitor progress and guide adjustments 2, 6

When Pharmacotherapy May Be Considered (Second-Line Only)

Medications should only be used when:

• Patients cannot participate in CBT-I 4
• Symptoms persist despite completing CBT-I 4
• As a temporary adjunct during CBT-I (not as monotherapy) 4

Medication Options If Needed

• Low-dose doxepin 3-6 mg for sleep maintenance insomnia 1, 4
• Nonbenzodiazepine benzodiazepine receptor agonists (eszopiclone, zolpidem, zaleplon) for short-term use only 1, 4
• Avoid benzodiazepines due to higher risk of tolerance, dependence, cognitive impairment, and falls 4

Critical Pitfalls to Avoid

Do Not Use These Approaches

• Sleep hygiene education alone is insufficient as stand-alone treatment and may be harmful if patients believe effective treatments like CBT-I will also be ineffectual 1, 2
• Over-the-counter antihistamines (diphenhydramine) lack efficacy data and cause daytime sedation, anticholinergic effects, and delirium risk in older adults 2, 4
• Melatonin is not recommended for chronic insomnia due to insufficient evidence 1, 2
• Herbal supplements (valerian, chamomile) should not be used 1, 2
• Ordering sleep studies for uncomplicated insomnia wastes resources and delays effective treatment 2

Contraindications for Sleep Restriction

Sleep restriction therapy may be contraindicated in:

• Patients working in high-risk occupations (commercial drivers, heavy machinery operators) 2, 6
• Those predisposed to mania/hypomania 2, 6
• Patients with poorly controlled seizure disorders 2, 6

Special Populations

Older Adults

• CBT-I is effective and preferred in older adults, with low- to moderate-quality evidence showing improved sleep efficiency, reduced sleep onset latency, and improved insomnia severity scores 1
• Extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects 4

Comorbid Psychiatric or Medical Conditions

• CBT-I is effective for insomnia comorbid with psychiatric disorders and medical conditions, with moderate to large improvements in sleep parameters 2
• Treat the insomnia directly with CBT-I rather than assuming it will resolve when the comorbid condition improves 2

Monitoring and Follow-Up

• Follow-up regularly until insomnia stabilizes or resolves, then every 6 months 2
• Monitor for temporary daytime fatigue, sleepiness, mood impairment during early treatment stages—these typically resolve by end of treatment 6
• If pharmacotherapy is used, periodic reassessment is mandatory with concurrent behavioral interventions 4