What are the causes and treatments of insomnia (difficulty initiating or maintaining sleep)?

From the Guidelines

Insomnia should be treated with cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment, as it has been shown to be highly effective in improving sleep outcomes and reducing symptoms of insomnia, as recommended by the American College of Physicians 1.

Key Points to Consider

• Insomnia is a common sleep disorder characterized by difficulty falling asleep, staying asleep, or getting restorative sleep, affecting approximately 6% to 10% of adults 1.
• The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, defines insomnia disorder as a predominant symptom of difficulty with sleep initiation, difficulty maintaining sleep, or early-morning waking with inability to return to sleep causing clinically significant distress or impairment in activities, occurring at least 3 nights per week for 3 months or more 1.
• Treatment goals include improving quality and quantity of sleep and associated impairments, with a focus on global outcomes measuring sleep and associated distress and dysfunction 1.
• Non-medication approaches, such as maintaining a consistent sleep schedule, creating a relaxing bedtime routine, avoiding screens before bed, keeping your bedroom dark and cool, and limiting caffeine and alcohol, should be tried first [@Example@].
• If these measures don't help, short-term medication options, such as over-the-counter sleep aids or prescription medications like benzodiazepines, non-benzodiazepine "Z-drugs", melatonin receptor agonists, or sedating antidepressants, may be considered, but their use should be carefully weighed against potential risks and side effects 1.
• Cognitive behavioral therapy for insomnia (CBT-I) is a highly effective treatment for insomnia and should be considered before or alongside medications, as it addresses both physiological and psychological factors contributing to insomnia 1.

Recommendations

• Start with CBT-I as the initial treatment for chronic insomnia disorder, as recommended by the American College of Physicians 1.
• Consider non-medication approaches and lifestyle modifications to improve sleep hygiene.
• Use short-term medication options judiciously, weighing potential benefits against risks and side effects.
• Monitor symptoms and adjust treatment plans as needed to achieve optimal outcomes.

From the FDA Drug Label

1 INDICATIONS AND USAGE BELSOMRA® (suvorexant) is indicated for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance.

1. Indications and Usage Section 1 INDICATIONS AND USAGE Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.

• Suvorexant, zolpidem, and ramelteon are all indicated for the treatment of insomnia.
• The specific characteristics of insomnia treated by these medications include:
  • Sleep onset difficulties (suvorexant, zolpidem, ramelteon)
  • Sleep maintenance difficulties (suvorexant) 2, 3, 4

From the Research

Definition and Prevalence of Insomnia

• Insomnia is a leading cause of disability, occurring in approximately 6-10% of the population 5.
• It is a risk factor for multiple medical and psychiatric disorders 5.
• Insomnia disorder is present in as much as 30% of the general adult population 6.

Cognitive Behavioral Therapy for Insomnia (CBT-i)

• CBT-i is a multi-component treatment for insomnia that targets difficulties with initiating and/or maintaining sleep 5.
• It is delivered over the course of six to eight sessions 5.
• CBT-i is now commonly recommended as first-line treatment for chronic insomnia 7.
• The primary focus of CBT-i is to address the perpetuating factors that contribute to the development of chronic insomnia 5.

Components of CBT-i

• Sleep Restriction Therapy 5, 8
• Stimulus Control Therapy 5, 8
• Sleep Hygiene 5, 8
• Cognitive Therapy 5, 8
• Relaxation training 6

Efficacy of CBT-i

• CBT-i is an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes 7.
• It improves sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 7.
• CBT-i is superior to sleep hygiene education in treating menopause-related insomnia disorder 9.
• Response to CBT-i is similar to sleep restriction therapy, but CBT-i outperforms sleep restriction therapy in improving sleep maintenance 9.