What are the recommended treatments for insomnia in a general adult population?

Treatment of Insomnia in Adults

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

First-Line Treatment: CBT-I

All adults with chronic insomnia must receive CBT-I as initial therapy because it demonstrates superior long-term efficacy compared to medications, with sustained benefits after treatment ends and no risk of tolerance or adverse effects. 1, 2

Core Components of CBT-I

CBT-I is a multicomponent intervention that must include at least three of the following elements: 2

• Sleep restriction therapy: Limits time in bed to match actual sleep duration, creating mild sleep deprivation that strengthens homeostatic sleep drive. Initially restrict time in bed to average sleep duration, then gradually adjust based on sleep efficiency thresholds (>85% increase by 15-30 minutes; <80% decrease by 15-30 minutes). 2

• Stimulus control therapy: Strengthens the association between bed/bedroom and sleep by instructing patients to go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 15-20 minutes, and maintain consistent wake time. 1, 2

• Cognitive therapy: Targets maladaptive thoughts and beliefs about sleep using structured psychoeducation, Socratic questioning, thought records, and behavioral experiments to address dysfunctional beliefs that perpetuate insomnia. 2

• Relaxation techniques: Progressive muscle relaxation, guided imagery, or breathing exercises to reduce physiological and mental hyperarousal. 1, 3

• Sleep hygiene education: Avoid excessive caffeine (especially after early afternoon), evening alcohol, late exercise; optimize sleep environment for temperature, noise, and light. This is insufficient as monotherapy but essential as an adjunct. 1, 2, 3

Treatment Delivery and Structure

CBT-I is typically delivered over 4-8 sessions with a trained specialist, using sleep diary data throughout to monitor progress and guide adjustments. 2 Multiple delivery formats are effective, including individual therapy, group sessions, telephone-based programs, web-based modules, and self-help books. 2, 4

Brief Behavioral Therapy for Insomnia (BBT-I) is an abbreviated 1-4 session version emphasizing behavioral components (sleep restriction and stimulus control) that may be appropriate when resources are limited or patients prefer shorter treatment. 2

Efficacy of CBT-I

CBT-I produces clinically meaningful improvements: 5

• Sleep onset latency reduced by 19 minutes
• Wake after sleep onset reduced by 26 minutes
• Sleep efficiency improved by 9.91%
• Total sleep time increased by 7.6 minutes
• Benefits are sustained at long-term follow-up

Critical Contraindications for Sleep Restriction

Sleep restriction may be contraindicated in patients with: 2

• Seizure disorders (sleep deprivation can lower seizure threshold)
• Bipolar disorder (sleep deprivation may trigger mania/hypomania)
• High-risk occupations requiring alertness
• Poorly controlled medical conditions

Pharmacological Treatment

Pharmacotherapy should only be added if CBT-I is insufficient or unavailable, and must supplement—not replace—behavioral interventions. 2, 3

First-Line Pharmacological Options

When medication is necessary, the American Academy of Sleep Medicine recommends short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon: 3

For sleep onset insomnia:

• Zaleplon 10 mg (5 mg in elderly) 3
• Ramelteon 8 mg 3, 6
• Zolpidem 10 mg (5 mg in elderly) 3
• Triazolam 0.25 mg (associated with rebound anxiety, not preferred) 3

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 3
• Zolpidem 10 mg (5 mg in elderly) 3
• Temazepam 15 mg 3
• Doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes) 3
• Suvorexant (orexin receptor antagonist) 3

For combined sleep onset and maintenance:

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

Second-Line Pharmacological Options

Sedating antidepressants are appropriate when comorbid depression or anxiety is present: 3

• Doxepin 3-6 mg for sleep maintenance 3
• Mirtazapine (requires nightly scheduled dosing, not PRN; half-life 20-40 hours) 3
• Trazodone is explicitly NOT recommended by the American Academy of Sleep Medicine due to harms outweighing benefits 3

Medications NOT Recommended

The American Academy of Sleep Medicine explicitly recommends against: 3

• Over-the-counter antihistamines (diphenhydramine) - lack efficacy data, cause daytime sedation and delirium risk in elderly 3
• Melatonin - insufficient evidence for chronic insomnia 2
• Herbal supplements (valerian) - insufficient evidence 3
• Tiagabine - not effective 3
• Barbiturates and chloral hydrate - safety concerns 3
• Antipsychotics as first-line - problematic metabolic side effects 3

Critical Safety Considerations

All hypnotics carry significant risks: 3

• Complex sleep behaviors (sleep-driving, sleep-walking)
• Daytime impairment and driving risk
• Falls and fractures (especially in elderly)
• Cognitive impairment
• Potential associations with dementia (observational data)
• Dependence and withdrawal with prolonged use

Prescribing principles: 3

• Use lowest effective dose for shortest duration (typically <4 weeks for acute insomnia)
• Lower doses required in women and elderly (e.g., zolpidem maximum 5 mg in elderly)
• Monitor regularly for effectiveness and adverse effects
• Taper when discontinuing to prevent withdrawal
• Stop immediately if complex sleep behaviors occur

Treatment Algorithm

1. Initiate CBT-I first for all patients with chronic insomnia 1, 2

2. If CBT-I insufficient after 4-8 sessions, add pharmacotherapy while continuing behavioral interventions: 3

   • For sleep onset: zaleplon, ramelteon, or zolpidem
   • For sleep maintenance: eszopiclone, doxepin, or suvorexant
   • For comorbid depression/anxiety: sedating antidepressants

3. If first-line medication unsuccessful, try alternative agent in same class 3

4. If still insufficient, consider second-line options based on comorbidities 3

5. Reassess after 1-2 weeks of medication to evaluate efficacy and adverse effects 3

6. Plan for medication discontinuation with gradual taper while maintaining CBT-I techniques 3

Common Pitfalls to Avoid

• Never use sleep hygiene education alone as monotherapy—it is ineffective and may make patients less receptive to effective treatments 1, 2

• Never prescribe medications as first-line treatment without initiating CBT-I—this undermines long-term outcomes and creates dependency risk 2

• Never continue pharmacotherapy long-term without periodic reassessment—FDA labeling indicates short-term use only 3

• Never use traditional benzodiazepines (diazepam, lorazepam, clonazepam) as first-line agents—they have longer half-lives, greater fall risk, and cognitive impairment compared to approved BzRAs 3

• Never ignore underlying sleep disorders—if insomnia persists beyond 7-10 days of treatment, evaluate for sleep apnea, restless legs syndrome, or circadian rhythm disorders 3