What are the causes and treatments of insomnia (difficulty initiating or maintaining sleep)?

From the Guidelines

Insomnia can be effectively managed through a combination of behavioral changes and, when necessary, medication, with Cognitive Behavioral Therapy for Insomnia (CBT-I) being the most effective long-term treatment, as supported by the American College of Physicians guideline 1. The management of insomnia involves improving sleep hygiene, which includes maintaining a consistent sleep schedule, creating a dark, quiet, and cool bedroom environment, avoiding screens 1-2 hours before bed, limiting caffeine and alcohol, and establishing a relaxing bedtime routine. Some key points to consider in managing insomnia include:

• Improving sleep environment and habits
• Utilizing CBT-I for long-term management
• Considering short-term medication use under the guidance of a healthcare provider
• Addressing underlying causes of insomnia, such as stress, anxiety, depression, or pain conditions
• Recognizing the importance of proper evaluation by a healthcare provider if insomnia persists, as it may indicate other underlying health conditions requiring specific treatment. The American College of Physicians recommends that all adult patients receive CBT-I as the initial treatment for chronic insomnia disorder, with a strong recommendation based on moderate-quality evidence 1. For short-term medication options, medications like zolpidem (Ambien, 5-10mg), eszopiclone (Lunesta, 1-3mg), or trazodone (50-100mg) may be considered, but their use should be limited to less than 2-4 weeks to avoid dependence, and the decision to use them should be made through a shared decision-making approach with a healthcare provider, taking into account the benefits, harms, and costs 1. Overall, the goal of treating insomnia is to improve sleep quality and alleviate the distress or dysfunction caused by the disorder, and this can be achieved through a combination of behavioral therapies, lifestyle changes, and, when necessary, medication, always prioritizing the patient's morbidity, mortality, and quality of life as outcomes.

From the FDA Drug Label

Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. BELSOMRA® (suvorexant) is indicated for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.

• Zolpidem is used for the short-term treatment of insomnia, specifically for difficulties with sleep initiation 2.
• Suvorexant is used for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance 3.
• Ramelteon is used for the treatment of insomnia characterized by difficulty with sleep onset 4.

From the Research

Definition and Classification of Insomnia

• Insomnia is a subjective complaint of poor sleep quality or quantity despite adequate time for sleep, resulting in daytime fatigue, irritability, and decreased concentration 5.
• Insomnia can be classified as idiopathic or comorbid, with comorbid insomnias associated with psychiatric disorders, medical disorders, substance abuse, and specific sleep disorders 5.
• The duration of insomnia symptoms can be acute (lasting from one night to a few weeks) or chronic (lasting at least three nights weekly for at least one month) 5.

Treatment Options for Insomnia

• Nonpharmacologic interventions for insomnia include sleep-hygiene education, stimulus-control therapy, relaxation therapy, and sleep-restriction therapy 5.
• Pharmacologic therapies for insomnia include benzodiazepines, benzodiazepine-receptor agonists, melatonin-receptor agonists, and antidepressants, with the choice of agent depending on patient-specific factors 5.
• Cognitive Behavioral Therapy for Insomnia (CBT-i) is a multi-component treatment that targets difficulties with initiating and/or maintaining sleep and is delivered over six to eight sessions 6.
• CBT-i has been shown to be an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes and no adverse outcomes reported 7.

Cognitive Behavioral Therapy for Insomnia (CBT-i)

• CBT-i is a safe and highly effective treatment for insomnia, producing results equivalent to sleep medication with no side effects and fewer episodes of relapse 8.
• The five key components of CBT-i are sleep consolidation, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques 8.
• CBT-i can be delivered through various methods, including face-to-face and multimodal approaches, and has been shown to be effective in adults with chronic insomnia, including older adults and adolescents 9.
• Despite its effectiveness, CBT-i is underutilized due to a shortage of trained practitioners and limited patient awareness of the treatment option 8.