What is the first line treatment for an adult patient with insomnia and no underlying medical conditions?

First-Line Treatment for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for all adults with chronic insomnia and must be initiated before any pharmacological intervention. 1, 2

Why CBT-I Must Come First

• CBT-I demonstrates sustained benefits lasting up to 2 years after treatment discontinuation, addressing the underlying mechanisms maintaining insomnia rather than just suppressing symptoms. 1, 3
• The American Academy of Sleep Medicine and American College of Physicians both explicitly recommend CBT-I as initial treatment due to its superior long-term efficacy and minimal risk of adverse effects compared to medications. 1, 2, 3
• While medications and CBT-I show similar acute effects, only CBT-I provides durable long-term effects after stopping treatment. 3

Core Components of Effective CBT-I

CBT-I must include these specific interventions (sleep hygiene education alone is insufficient): 1, 2

• Sleep restriction therapy - Limiting time in bed to actual sleep time to consolidate sleep 1, 2
• Stimulus control therapy - Reassociating the bed with sleep rather than wakefulness 1, 2
• Cognitive restructuring - Addressing maladaptive thoughts and anxiety about sleep 1, 2
• Sleep hygiene education - Avoiding caffeine, evening alcohol, late exercise, and optimizing sleep environment (necessary but insufficient as monotherapy) 1, 2

Delivery Options for CBT-I

• CBT-I can be effectively delivered through multiple formats: in-person individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books. 1, 2
• All delivery formats show effectiveness, addressing common barriers such as cost, geographic limitations, and provider availability. 1

When to Add Pharmacotherapy

Medications should only be considered in these specific scenarios: 2

• Patient is unable to participate in CBT-I
• Patient still has symptoms despite completing CBT-I
• As a temporary adjunct to CBT-I (not a replacement)

First-Line Medications (Only After CBT-I)

If pharmacotherapy becomes necessary, the American Academy of Sleep Medicine recommends short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon as first-line medications: 1, 4

For Sleep Onset Insomnia:

• Zaleplon 10 mg (5 mg in elderly) 1, 4
• Zolpidem 10 mg (5 mg in elderly) 1, 4, 5
• Ramelteon 8 mg (no abuse potential, safe for long-term use) 1, 4, 6

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg 1, 4
• Zolpidem 10 mg (5 mg in elderly) 1, 4
• Temazepam 15 mg 1, 4

For Both Sleep Onset and Maintenance:

• Eszopiclone 2-3 mg (approved for long-term use) 1, 4
• Zolpidem 10 mg (5 mg in elderly) 1, 4

Critical Medications to AVOID

The American Academy of Sleep Medicine explicitly advises against these as first-line treatments: 1, 2

• Over-the-counter antihistamines (e.g., diphenhydramine) - Lack efficacy data, cause daytime sedation, anticholinergic effects, and delirium risk in elderly 1, 2, 4
• Antipsychotics - Problematic metabolic side effects 2
• Long-acting benzodiazepines - Increased risks without clear benefit 1, 2
• Herbal supplements and melatonin - Insufficient evidence of efficacy 1, 4
• Trazodone - Explicitly not recommended due to insufficient efficacy data 2, 4

Treatment Algorithm

Follow this specific sequence: 1, 2

1. Initiate CBT-I immediately as primary intervention
2. Assess response after 4-6 weeks of CBT-I
3. If CBT-I insufficient, add short-term pharmacotherapy based on symptom pattern:
   • Sleep onset only → Zaleplon, ramelteon, or zolpidem
   • Sleep maintenance only → Eszopiclone, temazepam, or low-dose doxepin 3-6 mg
   • Both onset and maintenance → Eszopiclone or zolpidem
4. Continue CBT-I alongside any medication - Never replace behavioral therapy with drugs alone 1, 2
5. Reassess regularly (every 1-2 weeks initially) for effectiveness and side effects 1

Critical Safety Considerations

• All hypnotics carry significant risks: daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls and fractures, dependence, and withdrawal. 1, 4
• Elderly patients require lower doses: Zolpidem maximum 5 mg, avoid benzodiazepines entirely. 1, 2
• Use the lowest effective dose for the shortest duration possible. 2, 4
• If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders). 1

Common Pitfalls to Avoid

• Starting with medications before attempting CBT-I - This is the most common error and violates guideline recommendations 1, 2
• Using sleep hygiene education alone - Insufficient as monotherapy 1, 2
• Prescribing over-the-counter antihistamines or herbal supplements - No evidence of efficacy 1, 2
• Continuing pharmacotherapy long-term without reassessment - Increases risk of dependence and adverse effects 1, 2
• Failing to implement CBT-I alongside medication - Medications should supplement, not replace, behavioral interventions 1, 2, 7