What are the recommended treatment options for patients with insomnia, considering their medical history and lifestyle?

Treatment Recommendations for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all adults with chronic insomnia before considering any pharmacological intervention. 1, 2, 3

First-Line Treatment: CBT-I

CBT-I is the gold standard initial treatment with superior long-term efficacy compared to medications, producing clinically meaningful improvements sustained for up to 2 years without risk of tolerance or adverse effects. 3, 4 The benefits are durable beyond treatment end, unlike pharmacotherapy which shows degradation of benefit after discontinuation. 3

Core Components of CBT-I

CBT-I is a multimodal intervention delivered in 4-10 sessions that must include at least 3 of the following components: 1, 5, 4

• Sleep restriction therapy limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep 3
• Stimulus control therapy extinguishes the association between bed/bedroom and wakefulness, instructing patients to use bed only for sleep and sex 3, 5
• Cognitive therapy targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, and behavioral experiments 3, 5
• Relaxation training reduces physiological and mental hyperarousal 5, 4
• Sleep hygiene education includes avoiding excessive caffeine, evening alcohol, late exercise, and optimizing sleep environment—though insufficient as monotherapy 1, 2

Delivery Formats

CBT-I can be effectively delivered through multiple formats, all showing comparable effectiveness: 3, 6

• Individual face-to-face therapy 3
• Group therapy sessions 3
• Telephone-based programs 3
• Web-based digital modules (dCBT) 3, 6
• Self-help books 3

Digital CBT (dCBT) has emerged as a safe, effective, and scalable treatment delivery format that can be disseminated as readily as sleep medication, enabling universal access to guideline care. 6

Setting Realistic Expectations

Improvements from CBT-I are gradual, not immediate like pharmacological interventions, but benefits are durable beyond treatment end. 1, 2 Initial undesirable effects (sleepiness and fatigue) are typically mild and resolve quickly for most patients. 1 Treatment typically ranges from 4-8 visits, and patients may get discouraged if immediate results are not observed—providers must set realistic expectations before starting treatment. 1

Pharmacological Treatment: When and What to Use

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, and should supplement—not replace—behavioral interventions. 2, 3 Short-term hypnotic treatment must always be supplemented with behavioral and cognitive therapies. 1, 2

First-Line Pharmacotherapy Options

When medication is necessary, the following are recommended as first-line agents: 2

For sleep onset insomnia:

• Zaleplon 10 mg 2
• Ramelteon 8 mg (melatonin receptor agonist) 2
• Zolpidem 10 mg (5 mg in elderly) 2, 7
• Triazolam 0.25 mg (not first-line due to rebound anxiety risk) 2

For both sleep onset and sleep maintenance insomnia:

• Eszopiclone 2-3 mg 2, 8
• Zolpidem 10 mg (5 mg in elderly) 2, 7
• Temazepam 15 mg 2

For sleep maintenance insomnia specifically:

• Doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes) 2
• Suvorexant (orexin receptor antagonist) 2

Medication Selection Algorithm

1. Identify the primary sleep complaint: sleep onset difficulty versus sleep maintenance versus both 2
2. Consider patient-specific factors: age, comorbid conditions, history of substance abuse, medication interactions 2, 9
3. Use the lowest effective dose for the shortest duration possible 2
4. For patients with comorbid depression/anxiety: sedating antidepressants (e.g., mirtazapine) may be preferred as they simultaneously address both conditions 2, 3
5. For patients with history of substance abuse: avoid benzodiazepines; consider ramelteon or suvorexant 2

Agents NOT Recommended

The following should NOT be used for insomnia treatment: 2

• Over-the-counter antihistamines (e.g., diphenhydramine) due to lack of efficacy data, daytime sedation, and delirium risk especially in elderly 2
• Trazodone explicitly not recommended by guidelines despite widespread use 2
• Herbal supplements (e.g., valerian) and melatonin due to insufficient evidence 2
• Older hypnotics including barbiturates and chloral hydrate 2
• Sleep hygiene education alone as single-component therapy 1, 2

Special Population Considerations

Elderly Patients (Age 65+)

• Use lower doses: zolpidem maximum 5 mg (not 10 mg) due to increased sensitivity and fall risk 2
• Higher risk of adverse effects: falls, cognitive impairment, complex sleep behaviors (sleep-driving, sleep-walking) 2
• CBT-I remains first-line and is effective in older adults 3

Patients with Comorbid Medical Conditions

For patients with seizure disorder or bipolar disorder: exercise caution with sleep restriction therapy due to potential adverse effects of treatment-induced sleep deprivation 1, 2

For patients with congestive heart failure:

• CBT-I remains first-line treatment 10
• Screen for sleep-disordered breathing (sleep apnea), as CHF patients with sleep apnea have 2.7-fold greater mortality risk 10
• Consider CPAP therapy if obstructive sleep apnea is diagnosed, as it improves left ventricular ejection fraction and functional status 10
• Avoid benzodiazepines due to respiratory depression risk 10
• If medication needed: consider low-dose doxepin or ramelteon with minimal respiratory depression 10

Critical Safety Considerations

All hypnotics carry significant risks: 2

• Daytime impairment and morning sedation
• Complex sleep behaviors (sleep-driving, sleep-walking)
• Falls and fractures, particularly in elderly
• Cognitive impairment and anterograde amnesia
• Driving impairment
• Risk of dependence and withdrawal reactions

Monitor patients regularly, especially during initial treatment period, to assess effectiveness on sleep latency, sleep maintenance, daytime functioning, and adverse effects. 2

Insomnia persisting beyond 7-10 days of treatment requires further evaluation for underlying sleep disorders like sleep apnea, restless legs syndrome, or circadian rhythm disorders. 2

Common Pitfalls to Avoid

• Using pharmacotherapy as first-line treatment instead of CBT-I 1, 2, 3
• Prescribing sleep hygiene education alone as primary intervention—it is insufficient as monotherapy 1, 5
• Continuing pharmacotherapy long-term without periodic reassessment and attempts at tapering 2
• Failing to implement CBT-I alongside medication when pharmacotherapy is used 2
• Using doses appropriate for younger adults in elderly patients (e.g., zolpidem 10 mg instead of 5 mg) 2
• Prescribing over-the-counter antihistamines or herbal supplements with limited efficacy data 2
• Failing to screen for underlying sleep disorders when insomnia persists despite treatment 2