What are the recommended treatment options for a patient with insomnia, considering their medical history and potential underlying mental health conditions?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: January 8, 2026View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

Insomnia Treatment

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

All patients with chronic insomnia should receive CBT-I as the initial treatment before any pharmacological intervention. 1, 2, 3

Why CBT-I First

  • CBT-I produces clinically meaningful improvements in sleep parameters that are sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation 2, 4
  • CBT-I provides sustained benefits without risk of tolerance, dependence, or adverse effects associated with medications 2, 4
  • The American College of Physicians provides a strong recommendation (moderate-quality evidence) that CBT-I be used as initial treatment for all adults with chronic insomnia 3
  • CBT-I is effective across all age groups, including older adults and chronic hypnotic users 2

Core Components of CBT-I

CBT-I is a multimodal intervention delivered over 4-8 sessions that includes: 2, 5

  • 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
  • Stimulus control therapy: Extinguishes the association between bed/bedroom and wakefulness by establishing consistent sleep-wake schedules and removing wakeful activities from the bedroom 1, 2
  • Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 2
  • Relaxation techniques: Reduces physiological and mental hyperarousal 1, 5
  • Sleep hygiene education: Addresses environmental and behavioral factors, though insufficient as monotherapy 1, 5

Delivery Modalities

  • In-person, therapist-led programs are most beneficial, but digital CBT-I is an effective and scalable alternative when in-person therapy is unavailable 3
  • CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all showing effectiveness 1, 2

Pharmacological Treatment: When and What to Prescribe

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, and should supplement—not replace—behavioral interventions. 1, 6, 3

First-Line Pharmacotherapy Options

For sleep onset insomnia: 6

  • Zaleplon 10 mg 6
  • Ramelteon 8 mg (melatonin receptor agonist) 6
  • Zolpidem 10 mg (5 mg in elderly) 6
  • Triazolam 0.25 mg (associated with rebound anxiety, not preferred first-line) 6

For sleep maintenance insomnia: 6

  • Eszopiclone 2-3 mg 6
  • Zolpidem 10 mg (5 mg in elderly) 6
  • Temazepam 15 mg 6
  • Doxepin 3-6 mg (low-dose, second-line option) 6
  • Suvorexant (orexin receptor antagonist) 6, 7

For both sleep onset and maintenance: 6

  • Eszopiclone 2-3 mg 6
  • Zolpidem 10 mg (5 mg in elderly) 6
  • Temazepam 15 mg 6

Second-Line and Alternative Options

  • Doxepin 3-6 mg: Specifically recommended for sleep maintenance insomnia with moderate-quality evidence showing reduction in wake after sleep onset by 22-23 minutes 6
  • Sedating antidepressants (e.g., mirtazapine, amitriptyline): Consider when comorbid depression/anxiety is present 6, 2
  • Suvorexant: Orexin receptor antagonist for sleep maintenance, with moderate-quality evidence showing reduction in wake after sleep onset by 16-28 minutes 6, 7

Agents NOT Recommended

Do not prescribe the following: 6

  • Trazodone: Explicitly not recommended by AASM for sleep onset or maintenance insomnia; harms outweigh benefits 6
  • Over-the-counter antihistamines (e.g., diphenhydramine): Lack efficacy data, cause daytime sedation, and increase delirium risk especially in elderly 6
  • Herbal supplements (e.g., valerian) and melatonin: Insufficient evidence of efficacy 6
  • Tiagabine (anticonvulsant): Not recommended 6
  • Barbiturates and chloral hydrate: Not recommended 6

Special Population Considerations

Elderly Patients (Age 65+)

Use lower doses of all hypnotics in older adults due to increased sensitivity and fall risk: 6, 2

  • Zolpidem maximum 5 mg (not 10 mg) 6, 2
  • Elderly patients are at higher risk for falls, cognitive impairment, complex sleep behaviors, and daytime sedation 6, 7
  • Monitor closely for morning sedation and cognitive changes 6

Patients with Comorbid Depression/Anxiety

Sedating antidepressants are the preferred initial pharmacological choice when comorbid depression/anxiety is present, as they simultaneously address both conditions: 6, 2

  • Consider mirtazapine or amitriptyline 6
  • CBT-I remains first-line even in this population 2
  • Monitor for worsening depression or suicidal ideation, particularly with hypnotics like suvorexant which showed dose-dependent increase in suicidal ideation in clinical studies 7

Patients with Medical Comorbidities

  • Assess for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) if insomnia persists beyond 7-10 days of treatment 6, 7
  • Suvorexant has not been studied in patients with severe obstructive sleep apnea or severe COPD; use caution in compromised respiratory function 7

Treatment Selection Algorithm

Step 1: Initiate CBT-I 1, 2, 3

  • All patients should receive CBT-I as first-line treatment
  • Deliver over 4-8 sessions using in-person or digital modalities

Step 2: If CBT-I insufficient or unavailable, add pharmacotherapy 1, 6

  • Identify primary sleep complaint (onset vs. maintenance vs. both)
  • Consider patient-specific factors: age, comorbidities, substance abuse history, medication interactions

Step 3: Select medication based on sleep pattern 6

  • Sleep onset only: Zaleplon 10 mg, ramelteon 8 mg, or zolpidem 10 mg (5 mg elderly)
  • Sleep maintenance only: Doxepin 3-6 mg, suvorexant, or eszopiclone 2-3 mg
  • Both onset and maintenance: Eszopiclone 2-3 mg, zolpidem 10 mg (5 mg elderly), or temazepam 15 mg
  • Comorbid depression/anxiety: Sedating antidepressants (mirtazapine, amitriptyline)

Step 4: Use lowest effective dose for shortest duration 6

  • Prescribe short-term use only (typically less than 4 weeks for acute insomnia) 6
  • Reassess after 1-2 weeks to evaluate efficacy and adverse effects 6

Step 5: If first-line medication fails 6

  • Try alternative agent in same class
  • Consider switching to different mechanism (e.g., BzRA to orexin antagonist)
  • Reassess for underlying psychiatric or medical disorders 7

Critical Safety Considerations

All Hypnotics Carry Risks

Counsel patients about the following risks before prescribing any hypnotic: 6, 7

  • Complex sleep behaviors: Sleep-walking, sleep-driving, eating, making phone calls while not fully awake—can occur after first dose or any subsequent use 7
  • Daytime impairment: Driving impairment, cognitive and behavioral changes 6, 7
  • Falls and fractures: Particularly in elderly patients 6, 7
  • Worsening depression/suicidal ideation: Immediately evaluate any new behavioral signs or symptoms 7
  • Anterograde amnesia: Particularly with doses above 10 mg zolpidem 8

Discontinue Immediately If:

  • Patient experiences complex sleep behavior 7
  • New suicidal ideation or behavioral changes emerge 7
  • Insomnia fails to remit after 7-10 days, suggesting underlying psychiatric or medical disorder 7

Drug-Specific Warnings

Suvorexant (Belsomra): 7

  • Dose-dependent increase in suicidal ideation observed in clinical studies
  • Can cause sleep paralysis, hypnagogic/hypnopompic hallucinations, and cataplexy-like symptoms (leg weakness)
  • Prescribe lowest number of tablets feasible at one time in patients with depression

Zolpidem: 8

  • Use 5 mg maximum in elderly (not 10 mg)
  • Statistically significant decrease in next-day performance on cognitive testing
  • Anterograde amnesia can occur, especially at doses ≥10 mg

Common Pitfalls to Avoid

  • Do not prescribe hypnotics as first-line treatment without attempting CBT-I—this violates guideline recommendations and deprives patients of more effective, durable therapy 1, 3
  • Do not rely on sleep hygiene education alone—it lacks efficacy as a single intervention and must be combined with other CBT-I components 1, 5
  • Do not use doses appropriate for younger adults in elderly patients—zolpidem requires age-adjusted dosing (5 mg maximum in elderly) 6, 2
  • Do not continue pharmacotherapy long-term without periodic reassessment—medications should be used short-term with regular monitoring 6
  • Do not prescribe trazodone for insomnia—AASM explicitly recommends against it 6
  • Do not recommend over-the-counter antihistamines or herbal supplements—they lack efficacy data and carry safety concerns 6
  • Do not fail to assess for underlying sleep disorders—if insomnia persists beyond 7-10 days of treatment, evaluate for sleep apnea, restless legs syndrome, or other primary sleep disorders 6, 7
  • Do not combine multiple sedative medications—this significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures 6

Patient Education Requirements

Before prescribing any sleep medication, educate patients about: 6

  • Treatment goals and realistic expectations
  • Safety concerns and potential side effects
  • Importance of behavioral treatments (CBT-I) alongside or instead of medication
  • Risk of complex sleep behaviors and need to discontinue if they occur
  • Caution against driving or hazardous activities until response is known
  • Need for regular follow-up and reassessment

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Guideline

Cognitive Behavioral Therapy for Insomnia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Guideline

Cognitive Behavioral Therapy for Insomnia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

Research

Cognitive-behavioral therapy for chronic insomnia.

Current treatment options in neurology, 2014

Guideline

Pharmacotherapy of Insomnia

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.