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. To manage insomnia, start by improving sleep hygiene: maintain a consistent sleep schedule, create a relaxing bedtime routine, keep your bedroom dark and cool, avoid screens before bed, limit caffeine and alcohol, and exercise regularly but not close to bedtime 1.
Behavioral Interventions
Some key behavioral interventions include:
- Stimulus control: associating the bed with sleep and removing distractions
- Sleep restriction: limiting time in bed to the amount of time spent sleeping
- Relaxation techniques: such as deep breathing, progressive muscle relaxation, or mindfulness meditation
- Sleep hygiene education: learning about healthy sleep habits and how to create a sleep-conducive environment
Medication Options
For short-term medication options, consider over-the-counter melatonin (0.5-5mg taken 1-2 hours before bedtime) or diphenhydramine (25-50mg) 1. If these aren't effective, prescription medications include non-benzodiazepines like zolpidem (5-10mg), eszopiclone (1-3mg), or zaleplon (5-20mg), which work by enhancing GABA effects in the brain. Benzodiazepines such as temazepam (15-30mg) may be used short-term but carry dependency risks. Doxepin (3-6mg) or trazodone (25-100mg) are alternatives with fewer dependency concerns 1.
Treatment Approach
Medications should generally be used for less than 2-4 weeks while addressing underlying causes and developing healthy sleep habits. Insomnia often stems from stress, anxiety, depression, or medical conditions, so treating these root causes is essential for long-term improvement. The American College of Physicians recommends psychological and behavioral interventions and supports short-term supplementary medication 1.
From the FDA Drug Label
Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.
- Indications for insomnia:
- Key difference: Zolpidem is specifically indicated for short-term use, while ramelteon has no explicit short-term limitation. The answer to the question about insomnia is that zolpidem and ramelteon are both used to treat insomnia, but zolpidem is limited to short-term use.
From the Research
Definition and Prevalence of Insomnia
- Insomnia is a major public health problem with a high prevalence, impacting daily life and co-morbid with other disorders 4.
- Approximately 6-10% of the population experiences chronic insomnia, which is a risk factor for multiple medical and psychiatric disorders 5.
- Sleep difficulties are an extremely prevalent health problem, with about 33% to 50% of adults reporting regular difficulty falling asleep or staying asleep 6.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
- CBT-I is a multi-component treatment for insomnia that targets difficulties with initiating and/or maintaining sleep 5.
- The primary focus of CBT-I is to address the perpetuating factors that contribute to the development of chronic insomnia 5.
- CBT-I is considered the first-line treatment for insomnia, with a large evidence base and recent recommendations supporting its use 5, 6, 7.
- The core components of CBT-I include sleep restriction therapy, stimulus control therapy, sleep hygiene, and cognitive therapy 5.
Efficacy of CBT-I
- CBT-I has been shown to be an effective treatment for adults with chronic insomnia, with clinically meaningful effect sizes 7, 4.
- Studies have demonstrated significant improvements in sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 7, 4.
- CBT-I has also been found to be effective in reducing insomnia severity and improving mental health in patients with comorbid mental disorders 8.
Comparison to Other Treatments
- CBT-I is considered a safe and highly effective treatment for insomnia, with no side effects and fewer episodes of relapse compared to sleep medication 6.
- Face-to-face treatments of at least four sessions seem to be more effective than self-help interventions or face-to-face interventions with fewer sessions 4.
Special Considerations
- CBT-I can be effective in patients with mental disorders and comorbid insomnia, including depression, post-traumatic stress disorder (PTSD), and alcohol dependency 8.
- CBT-I should be considered as a first-line treatment for patients with mental disorders and comorbid insomnia, given the many side effects of medication 8.