What is the first line treatment for insomnia?

First-Line Treatment 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, 3

Why CBT-I is First-Line

• The American Academy of Sleep Medicine, American College of Physicians, and VA/DoD all recommend CBT-I as initial treatment due to its superior long-term efficacy and favorable benefit-to-risk ratio compared to medications. 1, 2
• CBT-I produces sustained benefits for up to 2 years without risk of tolerance, dependence, or adverse effects associated with pharmacotherapy. 1, 4
• Evidence demonstrates clinically meaningful improvements: sleep onset latency improves by 19 minutes, wake after sleep onset improves by 26 minutes, and sleep efficiency improves by nearly 10%. 4

Core Components of Effective CBT-I

CBT-I is a multicomponent behavioral intervention that must include at least three of the following elements 5, 6:

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 2, 3
• Stimulus control: Strengthens the association between bed/bedroom and sleep by going to bed only when sleepy, using bed only for sleep and sex, and leaving bed if unable to sleep within 15-20 minutes. 5, 2
• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep (such as catastrophizing about consequences of poor sleep) through structured psychoeducation and behavioral experiments. 2
• Sleep hygiene education: Addresses caffeine, alcohol, nicotine use, exercise timing, sleep environment, and sleep-wake regularity—but only as an adjunct, never as standalone treatment. 5, 3

Treatment Structure and Delivery

• Standard CBT-I is delivered over 4-8 sessions with a trained CBT-I specialist, using sleep diary data throughout to monitor progress and guide adjustments. 2, 3
• Brief Behavioral Therapy for Insomnia (BBT-I) is an abbreviated 1-4 session version emphasizing behavioral components (sleep restriction, stimulus control, sleep hygiene) when resources are limited. 5, 2, 3
• Digital CBT-I (dCBT) is a fully-automated, software-based delivery format that is safe, effective, and scalable for widespread dissemination. 7
• In-person one-on-one delivery is most effective (incremental odds ratio 1.83), though telehealth and group formats can increase access. 5, 3

When to Consider Pharmacotherapy (Second-Line Only)

Medications should only be considered when patients are unable to participate in CBT-I, still have symptoms despite CBT-I, or as a temporary adjunct to CBT-I. 1

If pharmacotherapy becomes necessary 1:

• Benzodiazepine receptor agonists (BzRAs) such as eszopiclone, zolpidem, zaleplon, triazolam, and temazepam may be used for sleep onset and maintenance insomnia.
• Ramelteon for sleep onset insomnia.
• Low-dose doxepin (3-6 mg) for sleep maintenance insomnia.
• Short-term use is preferred due to concerns about tolerance, dependence, and adverse effects with long-term use.

Critical Pitfalls to Avoid

• Never offer sleep hygiene education alone as treatment—it is ineffectual as monotherapy and may make patients less receptive to effective behavioral treatments like CBT-I. 5, 2
• Do not use over-the-counter antihistamines (diphenhydramine) due to lack of efficacy data, daytime sedation, anticholinergic effects, and delirium risk, especially in older adults. 1, 2
• Avoid trazodone—the American Academy of Sleep Medicine explicitly recommends against it due to insufficient efficacy data. 1
• Do not use antipsychotics as first-line treatment due to problematic metabolic side effects. 1
• Avoid benzodiazepines due to higher risk of tolerance, dependence, cognitive impairment, and complex sleep behaviors compared to newer agents. 1
• Do not prescribe medications as first-line treatment—this undermines long-term outcomes and creates dependency risk. 2

Special Considerations

• Sleep restriction may be contraindicated in patients working high-risk occupations (e.g., commercial drivers, heavy machinery operators), those predisposed to mania/hypomania, or those with poorly controlled seizure disorders. 2, 3
• Temporary daytime fatigue, sleepiness, mood impairment, and cognitive difficulties may occur during early CBT-I treatment stages but typically resolve by end of treatment. 3
• CBT-I is effective for insomnia comorbid with psychiatric disorders and medical conditions. 2
• For older adults, use extra caution with medications due to increased risk of falls, cognitive impairment, and adverse effects. 1