What are the treatment options for insomnia?

From the Guidelines

Cognitive behavioral therapy for insomnia (CBT-I) is the most effective treatment for insomnia and should be considered the first-line treatment. This recommendation is based on the strongest and most recent evidence from the American Academy of Sleep Medicine clinical practice guideline 1. The guideline suggests that CBT-I is a multicomponent intervention that includes sleep restriction therapy, stimulus control, and cognitive therapy, and it has the most evidence available in the literature to support its effectiveness.

Key Components of CBT-I

• Sleep restriction therapy: limiting the amount of time spent in bed to improve sleep quality
• Stimulus control: associating the bed with sleep and removing distractions
• Cognitive therapy: addressing thoughts and behaviors that interfere with sleep

Benefits of CBT-I

• Improves global outcomes, including increased remission and treatment response
• Reduces sleep onset latency and wake after sleep onset
• Improves sleep efficiency and sleep quality
• Has minimal undesirable effects, such as sleepiness and fatigue, which are typically mild and resolve quickly

Delivery Modalities

CBT-I can be delivered in various formats, including in-person individual treatment, group treatment, and internet-based programs 1. Clinicians should discuss different delivery modalities with their patients and align the delivery modality based on availability, affordability, treatment format, duration, and the patient's preferences and values.

Other Treatment Options

Other treatments, such as behavioral therapy for insomnia (BTIs), sleep restriction therapy, stimulus control, and relaxation therapy, may also be useful interventions with minimal undesirable effects, but they received Conditional recommendations due to limited evidence 1. Medications, such as melatonin, zolpidem, eszopiclone, and trazodone, may be considered for short-term use, but they should be used with caution due to potential side effects and dependency risks 1.

From the FDA Drug Label

Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. The clinical trials performed in support of efficacy were 4 to 5 weeks in duration with the final formal assessments of sleep latency performed at the end of treatment. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia Zolpidem 10 mg was superior to placebo on a subjective measure of sleep latency for all 4 weeks, and on subjective measures of total sleep time, number of awakenings, and sleep quality for the first treatment week.

Treatment for insomnia: Zolpidem is indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation 2.

• Key findings:
  • Zolpidem 10 mg was superior to placebo on sleep latency and sleep efficiency in clinical trials 2.
  • The clinical trials performed in support of efficacy were 4 to 5 weeks in duration 2.
• Dosage: The recommended dose for zolpidem tartrate is 5 mg in the elderly and 10 mg in non-elderly adults 2.
• Clinical decision: Zolpidem can be used for the short-term treatment of insomnia, but it should be used with caution and at the recommended dose to minimize the risk of adverse effects 2, 2, 2.

From the Research

Treatment Options for Insomnia

• Non-pharmacologic approaches are preferred for treating insomnia due to the potential adverse effects of commonly used sleep-promoting drugs 3.
• Cognitive-behavioral therapy for insomnia (CBT-i) is a highly effective treatment for chronic insomnia, with clinically meaningful effect sizes and no reported adverse outcomes 4.
• CBT-i is often underutilized due to a shortage of trained practitioners and limited patient awareness, despite being a safe and effective treatment for insomnia 5.

Components of Cognitive-Behavioral Therapy for Insomnia

• The five key components of CBT-i are:
  • Sleep consolidation
  • Stimulus control
  • Cognitive restructuring
  • Sleep hygiene
  • Relaxation techniques 5
• These components help patients learn how to support and promote their body's natural sleep mechanism, leading to long-term improvements in sleep quality.

Other Non-Pharmacological Approaches

• Exercise and relaxation techniques are also effective in managing insomnia 3.
• Complementary and alternative approaches, such as light therapy, aromatherapy, music therapy, and herbal medicine, may be beneficial for some patients 3, 6.
• Behavioral approaches, including stimulus control, sleep restriction, and paradoxical intention, can be used to improve sleep quality 7.