From the Guidelines
The evaluation and treatment of insomnia should begin with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, as recommended by the American Academy of Sleep Medicine 1. This approach includes sleep hygiene education, stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring. The goal of CBT-I is to address underlying sleep habits and behaviors that contribute to insomnia, and it has been shown to be effective in improving sleep quality and reducing symptoms of insomnia. Some key components of CBT-I include:
- Sleep hygiene: maintaining consistent sleep schedules, creating a comfortable sleep environment, avoiding stimulants like caffeine before bedtime, limiting screen time, and exercising regularly but not close to bedtime
- Stimulus control: associating the bed with sleep and relaxation, and avoiding activities that can interfere with sleep
- Sleep restriction: limiting the amount of time spent in bed to improve sleep efficiency
- Relaxation techniques: using techniques such as deep breathing, progressive muscle relaxation, or mindfulness meditation to reduce stress and promote relaxation
- Cognitive restructuring: identifying and challenging negative thoughts and beliefs that contribute to insomnia
For medication therapy, short-term options may be considered, but should be used with caution and under the guidance of a healthcare professional. Some options include:
- Over-the-counter supplements like melatonin (0.5-5mg taken 1-2 hours before bedtime)
- Prescription medications such as non-benzodiazepine hypnotics (zolpidem 5-10mg, eszopiclone 1-3mg, or zaleplon 5-10mg at bedtime), traditional benzodiazepines, sedating antidepressants like trazodone (25-100mg at bedtime), or orexin receptor antagonists like suvorexant (10-20mg at bedtime) Medications should generally be used for short periods (2-4 weeks) with the lowest effective dose to avoid dependence and tolerance. Chronic insomnia often requires a combination approach, addressing underlying conditions while implementing behavioral strategies and judicious use of medications when necessary, as recommended by the American College of Physicians 1 and the American Academy of Sleep Medicine 1.
From the FDA Drug Label
Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, treatment of insomnia should be initiated only after careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated Worsening of insomnia or the emergence of new cognitive or behavioral abnormalities may be the result of an unrecognized underlying psychiatric or physical disorder and can emerge during the course of treatment with hypnotic drugs such as BELSOMRA Since sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient
The approach to evaluation and treatment for insomnia involves:
- Careful evaluation of the patient to rule out underlying physical or psychiatric disorders
- Initiation of treatment only after careful evaluation
- Monitoring for worsening of insomnia or emergence of new cognitive or behavioral abnormalities
- Re-evaluation of the patient if insomnia does not remit after 7 to 10 days of treatment or if new symptoms emerge 2 3 Key considerations include:
- Ruling out underlying physical or psychiatric disorders
- Monitoring for adverse reactions and complex sleep behaviors
- Adjusting treatment as needed based on patient response and emergence of new symptoms
From the Research
Approach to Evaluation and Treatment for Insomnia
The approach to evaluation and treatment for insomnia involves a non-pharmacologic approach, which is preferred in most cases due to the possible adverse effects of commonly used drugs to promote sleep 4.
Non-Pharmacologic Treatment
The non-pharmacologic treatment of insomnia includes:
- Cognitive-behavioral therapy for insomnia (CBT-i), which is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep 5
- Exercise and relaxation techniques 4
- Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine 4
- Sleep restriction therapy, stimulus control therapy, sleep hygiene, and cognitive therapy, which are core components of CBT-i 5
Cognitive Behavioral Therapy for Insomnia (CBT-i)
CBT-i is a brief and structured therapeutic intervention aimed at changing maladaptive sleep habits and unhelpful sleep-related beliefs and attitudes that perpetuate insomnia 6.
- CBT-i has been found to be an effective alternative to pharmacotherapy in individuals with insomnia, with clinically meaningful effect sizes 7
- CBT-i encompasses sleep hygiene, stimulus control, sleep restriction, cognitive therapy, and relaxation training 8
- CBT-i can be delivered through various methods, including face-to-face and multimodal approaches 7, 8
Treatment Outcomes
The treatment outcomes for CBT-i include:
- Improvement in sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 7
- Clinically meaningful and durable changes in sleep and associated insomnia symptoms 6
- Remission, sleep quality, and sleep onset latency in adults with insomnia, including older adults and adolescents 8