What is the best approach to manage insomnia in an adult patient with no significant underlying medical conditions?

Management of Insomnia in Adults

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

All adults with chronic insomnia should receive Cognitive Behavioral Therapy for Insomnia (CBT-I) as the initial treatment before any pharmacological intervention. 1, 2, 3

CBT-I demonstrates superior long-term efficacy compared to medications, with sustained benefits after discontinuation and minimal adverse effects. 1, 3 The improvements are gradual but durable, with benefits maintained up to 2 years post-treatment, whereas medications provide only rapid symptom relief that disappears after discontinuation. 2, 3

Core Components of CBT-I to Implement

• Stimulus control therapy: Use the bed only for sleep, leave the bed if unable to sleep within approximately 20 minutes, and return only when drowsy. 2, 3
• Sleep restriction therapy: Limit time in bed to actual sleep time to consolidate sleep and increase sleep drive. 1, 4
• Cognitive restructuring: Address dysfunctional beliefs about sleep and catastrophic thinking about insomnia consequences. 3, 4
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or breathing exercises. 1, 5
• Sleep hygiene education: Wake at the same time daily, exercise regularly, avoid caffeine/nicotine before bedtime, keep bedroom quiet and temperature-regulated—though insufficient as monotherapy. 2, 6

Delivery Methods

CBT-I can be effectively delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all showing comparable efficacy. 1, 3 Brief behavioral therapy (BBT) may be appropriate when resources are limited, emphasizing behavioral components over 2-4 sessions. 1, 6

Pharmacotherapy: When and What to Prescribe

Pharmacotherapy should only supplement—never replace—CBT-I, and is reserved for situations where behavioral interventions alone are insufficient or while CBT-I is being implemented. 2, 6, 3

First-Line Pharmacological Options

The treatment algorithm follows this sequence: 6

For sleep onset insomnia:

• Zolpidem 10 mg (5 mg in elderly): Proven efficacy for reducing sleep latency with rapid absorption and sleep induction. 2, 6, 7
• Zaleplon 10 mg (5 mg in elderly): Effective for sleep onset with shortest half-life. 6
• Ramelteon 8 mg: Melatonin receptor agonist with minimal adverse effects and no dependence risk, particularly appropriate for patients with substance abuse history. 2, 6

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg: Addresses both sleep initiation and maintenance with 28-57 minute increase in total sleep time. 6
• Temazepam 15 mg: Effective for both onset and maintenance. 6
• Suvorexant (orexin receptor antagonist): Specifically recommended for sleep maintenance problems with 16-28 minute reduction in wake after sleep onset. 2, 6
• Low-dose doxepin 3-6 mg: Second-line agent with 22-23 minute reduction in wake after sleep onset, minimal anticholinergic burden at this dose. 6

Critical Prescribing Principles

• Use the lowest effective dose for the shortest duration possible, typically less than 4 weeks for acute insomnia. 2, 6, 3
• Elderly patients require dose adjustments: Zolpidem maximum 5 mg due to increased sensitivity, fall risk, and cognitive impairment. 2, 6
• Always combine pharmacotherapy with CBT-I implementation, as short-term hypnotic treatment must be supplemented with behavioral interventions. 2, 6, 3
• Monitor regularly after 1-2 weeks to evaluate efficacy on sleep latency, sleep maintenance, daytime functioning, and adverse effects including morning sedation and complex sleep behaviors. 6

Medications to Avoid

Strong recommendations against:

• Over-the-counter antihistamines (diphenhydramine): Lack of efficacy data, anticholinergic side effects, daytime sedation, and delirium risk especially in elderly patients. 2, 6, 3
• Antipsychotics: Problematic metabolic side effects and lack of evidence for insomnia. 2, 6
• Long-acting benzodiazepines (flurazepam): Extended half-life and increased fall risk. 2
• Trazodone: Not recommended for sleep onset or maintenance insomnia, with harms outweighing benefits. 6
• Herbal supplements (valerian) and melatonin: Insufficient evidence of efficacy. 6, 8

Special Population Considerations

Patients with comorbid depression/anxiety:

• Sedating antidepressants (mirtazapine, low-dose doxepin) are preferred as they simultaneously address both conditions. 6
• Mirtazapine requires nightly scheduled dosing (not PRN) due to 20-40 hour half-life and cannot provide immediate on-demand sedation. 6

Patients with dementia or cognitive impairment:

• Avoid benzodiazepines entirely due to unacceptable risk-benefit ratio with increased falls, cognitive impairment, and dependence. 2

Patients with substance abuse history:

• Avoid benzodiazepines; consider ramelteon or suvorexant instead. 6

Critical Safety Warnings

• All benzodiazepine receptor agonists carry risks: Daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, and cognitive impairment, particularly in elderly patients. 6, 7
• Stop medication immediately if patient discovers they performed activities while not fully awake. 6
• Observational studies link benzodiazepine use to increased risk of dementia, fractures, and major injury. 6
• Insomnia persisting beyond 7-10 days of treatment requires further evaluation for underlying sleep disorders like sleep apnea or restless legs syndrome. 6

Common Pitfalls to Avoid

• Starting with medications before attempting CBT-I violates guideline recommendations and deprives patients of more effective, durable therapy with superior long-term outcomes. 1, 3
• Relying on sleep hygiene education alone lacks efficacy as a single intervention and must be combined with other CBT-I components like stimulus control and sleep restriction. 2, 3
• Continuing pharmacotherapy long-term without periodic reassessment, as dependence and tolerance can develop. 2, 6
• Using doses appropriate for younger adults in older adults—zolpidem requires age-adjusted dosing (5 mg maximum in elderly). 2, 6
• Failing to match medication half-life to the patient's specific sleep complaint (onset versus maintenance). 2

Evidence Quality Note

The American College of Physicians guideline explicitly states there is insufficient evidence to determine the balance of benefits and harms of long-term pharmacologic treatments for chronic insomnia, with few studies evaluating medications for more than 4 weeks. 1 FDA labeling indicates pharmacologic treatments for insomnia are intended for short-term use, and patients should be discouraged from using these drugs for extended periods. 1