What is the first-line recommendation to help a generally healthy adult patient with primary insomnia fall asleep?

First-Line Treatment for Adult Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for adult patients with chronic insomnia, as it provides superior long-term efficacy compared to pharmacological options without the risks of tolerance, dependence, or adverse effects. 1, 2, 3

Strength of Recommendation

The American Academy of Sleep Medicine issues a STRONG recommendation that clinicians use multicomponent CBT-I for the treatment of chronic insomnia disorder in adults. 1 This is the only strong recommendation among all treatment modalities, with all other interventions receiving conditional recommendations. 1

Core Components of CBT-I

Multicomponent CBT-I must include at least three of the following elements: 2

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and improves sleep efficiency. 1, 2 Initial time in bed is restricted to average sleep duration (minimum 5 hours), then adjusted weekly based on sleep efficiency thresholds (>85-90% increase by 15-20 minutes; <80% decrease by 15-20 minutes). 1

• Stimulus control: Strengthens the association between bed/bedroom and sleep through specific instructions: go to bed only when sleepy, use bed only for sleep and sex, leave bed if unable to sleep within 20 minutes, maintain regular sleep-wake schedule, and avoid daytime napping. 1, 2

• Cognitive therapy: Targets maladaptive beliefs about sleep (e.g., "I can't sleep without medication," "My life will be ruined if I can't sleep") using structured psychoeducation, Socratic questioning, and behavioral experiments. 1, 2

• Sleep hygiene education: Serves as an adjunct component covering regular schedules, healthy diet, daytime exercise, quiet sleep environment, and avoiding caffeine, alcohol, and stimulating activities before bedtime. 1, 3 Sleep hygiene alone is ineffective as monotherapy and should never be used as a single-component treatment. 1, 2

Treatment Structure and Delivery

• Standard format: 4-8 sessions with a trained CBT-I specialist, using sleep diary data throughout treatment to monitor progress and guide adjustments. 2, 3

• Brief Behavioral Therapy for Insomnia (BBT-I): Abbreviated 1-4 session version emphasizing behavioral components (sleep restriction, stimulus control), appropriate when resources are limited or patients prefer shorter treatments. 2, 3

• Delivery method: In-person one-on-one delivery is most effective (incremental odds ratio 1.83), though telehealth and group formats can increase access. 2, 3

Clinical Outcomes

CBT-I produces clinically meaningful improvements in: 1, 2

• Reduced sleep onset latency
• Decreased wake time after sleep onset
• Improved sleep efficiency (>85%)
• Enhanced sleep quality
• Sustained benefits without tolerance or relapse
• Reduced need for pharmacologic therapy

Single-Component Alternatives (When CBT-I Unavailable)

If multicomponent CBT-I is not accessible, the American Academy of Sleep Medicine suggests these single-component therapies as conditional recommendations: 1

1. Stimulus control therapy (CONDITIONAL) 1
2. Sleep restriction therapy (CONDITIONAL) 1
3. Relaxation therapy (CONDITIONAL, including progressive muscle relaxation) 1

Critical Contraindications and Cautions

Sleep restriction therapy may be contraindicated in: 1, 2, 3

• High-risk occupations (heavy machinery operators, drivers)
• Predisposition to mania/hypomania
• Poorly controlled seizure disorders
• Excessive daytime sleepiness

Expected temporary side effects (typically resolve by end of treatment): 3

• Daytime fatigue and sleepiness during early treatment stages
• Mood impairment
• Cognitive difficulties

Common Pitfalls to Avoid

• Never offer medications as first-line treatment, as this undermines long-term outcomes and creates dependency risk. 2

• Avoid over-the-counter antihistamines, melatonin, or herbal supplements as these lack efficacy data and carry safety concerns. 2

• Do not use sleep hygiene education alone as it is ineffectual as monotherapy and may make patients less receptive to effective behavioral treatments. 1, 2

• Do not use benzodiazepines as first-line treatment, particularly in elderly patients, due to unacceptable risk-benefit ratio including falls, cognitive impairment, dependence, and daytime sedation. 4

Implementation and Monitoring

• Collect sleep diary data before and during treatment to monitor progress and guide adjustments. 2, 3

• Follow-up schedule: Regular assessment every 2-4 weeks during active treatment, then every 6 months thereafter. 4

• Pharmacotherapy consideration: Only after CBT-I has been unsuccessful should pharmacological options be considered, and even then, should be supplemented with behavioral therapy for optimal outcomes. 2, 4