What are the treatment options for insomnia?

Treatment Options for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia and should be initiated before any pharmacological intervention. 1, 2, 3, 4

Initial Treatment Approach

CBT-I as Primary Intervention

• CBT-I must be offered first to all patients with chronic insomnia, regardless of age, including older adults and chronic hypnotic users. 1, 2, 3

• CBT-I produces clinically meaningful improvements in sleep parameters that are sustained for up to 2 years, unlike medications which show degradation of benefit after discontinuation. 2, 3

• CBT-I provides sustained benefits without risk of tolerance, dependence, or adverse effects inherent to medications. 2, 3, 4

Core Components of CBT-I (All Must Be Included)

Sleep Restriction Therapy:

• Limits time in bed to match actual sleep duration (based on sleep diary data), creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 2, 3, 4
• Time in bed is gradually increased or decreased based on sleep efficiency thresholds. 2
• Contraindicated in patients working high-risk occupations, those predisposed to mania/hypomania, or those with poorly controlled seizure disorders. 2

Stimulus Control Therapy:

• Breaks the association between bed/bedroom and wakefulness through specific instructions: go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes. 2, 3, 4

Cognitive Therapy:

• Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments. 2, 3, 4

Sleep Hygiene Education:

• Addresses environmental and behavioral factors, but is insufficient as monotherapy and must be combined with other components. 1, 2, 4

Treatment Structure

• CBT-I is typically delivered over 4-8 sessions with a trained CBT-I specialist. 2
• Brief Behavioral Therapy for Insomnia (abbreviated CBT-I emphasizing behavioral components) can be offered when resources are limited or patients prefer shorter treatment. 2, 3
• Sleep diary data must be collected before and during treatment to monitor progress and guide adjustments. 1, 2

Pharmacological Treatment (Second-Line Only)

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable. 2, 3, 4

Medication Sequence for Primary Insomnia

First-line medications (if pharmacotherapy is necessary):

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs): zolpidem, eszopiclone, zaleplon, temazepam. 1, 3
• Ramelteon (melatonin receptor agonist). 1, 3
• Zolpidem is indicated for short-term treatment of insomnia characterized by difficulties with sleep initiation, with efficacy demonstrated for up to 35 days. 5
• Ramelteon is indicated for insomnia characterized by difficulty with sleep onset, with efficacy demonstrated up to six months. 6

Second-line medications (if initial agents unsuccessful):

• Alternate short-intermediate acting BzRAs or ramelteon. 1
• Low-dose doxepin for sleep maintenance insomnia. 4

Third-line medications:

• Sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine), especially when treating comorbid depression/anxiety. 1, 3

Fourth-line medications:

• Combined BzRA or ramelteon with sedating antidepressant. 1

Fifth-line medications:

• Other sedating agents: anti-epilepsy medications (gabapentin, tiagabine) or atypical antipsychotics (quetiapine, olanzapine). 1

Special Considerations for Medications

Older adults:

• Use lower doses (e.g., zolpidem 5 mg instead of 10 mg) due to increased risk of cognitive impairment, falls, and fractures. 3
• BzRAs carry significant risks particularly in this population. 4

Medication selection factors:

• Symptom pattern (sleep onset vs. maintenance), treatment goals, past responses, patient preference, cost, comorbid conditions, contraindications, concurrent medications, and side effects. 1

What NOT to Use

The following are NOT recommended:

• Melatonin: Insufficient evidence for chronic insomnia treatment. 2, 4
• Over-the-counter antihistamines: Lack efficacy data and have safety concerns. 2, 4
• Herbal supplements: Lack efficacy data and carry safety concerns. 2
• Sleep hygiene education alone: Insufficient as stand-alone treatment. 1, 2

Monitoring and Follow-Up

• Clinical reassessment should occur every few weeks to monthly until insomnia stabilizes or resolves, then every 6 months, as relapse rate is high. 1, 2, 4
• Sleep diary data should be collected throughout treatment and at follow-up. 1, 2
• If single treatment or combination is ineffective, consider other behavioral therapies, different pharmacological therapies, combined therapies, or reevaluation for occult comorbid disorders. 1

Efficacy in Special Populations

• CBT-I is effective for insomnia comorbid with psychiatric disorders and medical conditions, with moderate to large improvements in sleep parameters. 2
• CBT-I remains first-line for pregnant women, with favorable benefit-to-risk ratio without medication exposure. 4