What is the first-line therapy for insomnia?

First-Line Therapy for Insomnia

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

Why CBT-I is Superior to Medications

CBT-I produces clinically meaningful improvements that are sustained for up to 2 years, whereas pharmacotherapy shows degradation of benefit after discontinuation. 2 The VA/DoD and American Academy of Sleep Medicine explicitly state that sleep hygiene education and pharmacotherapy should not be considered first-line therapies. 3

CBT-I was found to be more effective than several pharmacotherapies, with equivalent short-term results (2-4 weeks) but superior long-term outcomes. 3 The potential benefits of CBT-I outweigh the potential harms and burden of pharmacotherapy given that there are fewer adverse effects. 3

Core Components That Must Be Included

The most efficacious CBT-I programs include these specific components:

• Cognitive restructuring to target maladaptive thoughts and beliefs about sleep (incremental odds ratio 1.68) 4
• Sleep restriction therapy limiting time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive (incremental odds ratio 1.49) 2, 4
• Stimulus control therapy to extinguish the association between bed/bedroom and wakefulness—go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 15-20 minutes (incremental odds ratio 1.43) 5, 4
• Third-wave components such as mindfulness and acceptance strategies (incremental odds ratio 1.49) 4

What NOT to Include

Sleep hygiene education alone is not only ineffectual but potentially harmful if patients believe they have received adequate treatment and become less receptive to referral for effective behavioral treatments like CBT-I. 3 Sleep hygiene was found to have no essential contribution (incremental odds ratio 1.01). 4

Relaxation procedures were found to be potentially counterproductive (incremental odds ratio 0.81) and should not be emphasized. 4

Treatment Structure and Delivery

• In-person therapist-led programs are most beneficial (incremental odds ratio 1.83) compared to other delivery formats. 4
• Standard CBT-I is typically delivered over 4-8 sessions with a trained CBT-I specialist. 2
• Brief Behavioral Therapy for Insomnia (BBT-I) can be offered when resources are limited, focusing on behavioral components only (sleep restriction, stimulus control). 5
• The evidence was insufficient to recommend for or against Internet-based or group delivery of CBT-I compared with face-to-face treatment. 3

Expected Outcomes

At posttreatment, CBT-I produces:

• Sleep onset latency improvement of 19 minutes 6
• Wake after sleep onset improvement of 26 minutes 6
• Sleep efficiency improvement of 9.91% 6
• Number needed to treat of 3.0 for remission 4

When Pharmacotherapy May Be Considered (Second-Line Only)

Medications should only be considered when:

• Patients are unable to participate in CBT-I 1
• Patients still have symptoms despite participation in CBT-I 1
• As a temporary adjunct to CBT-I 1

If medications are needed, short-intermediate acting benzodiazepine receptor agonists (eszopiclone, zolpidem, zaleplon) or ramelteon are first-line pharmacological options. 2 For older adults, use lower doses (e.g., zolpidem 5 mg instead of 10 mg) due to increased risk of falls and cognitive impairment. 2

Critical Pitfalls to Avoid

• Do not use over-the-counter antihistamines (diphenhydramine) due to lack of efficacy data, daytime sedation, anticholinergic effects, and delirium risk, especially in older patients. 1, 5
• Do not use trazodone for insomnia treatment due to insufficient efficacy data. 1
• Do not use antipsychotics as first-line treatment due to problematic metabolic side effects. 1
• Do not use melatonin for chronic insomnia due to insufficient evidence. 5
• Avoid benzodiazepines due to higher risk of tolerance, dependence, cognitive impairment, and complex sleep behaviors compared to newer agents. 1

Special Populations

For patients with comorbid psychiatric disorders or medical conditions, CBT-I remains first-line and is effective with moderate to large improvements in sleep parameters. 5, 2