What treatment options are available for an adult patient with insomnia?

Treatment Options for Adult Insomnia

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment before any medication, and if pharmacotherapy is needed, use short-intermediate acting benzodiazepine receptor agonists (BzRAs) like zolpidem, eszopiclone, or zaleplon, or ramelteon as initial options. 1, 2

First-Line Treatment: CBT-I (Always Start Here)

CBT-I must be initiated before or alongside any pharmacotherapy because it provides superior long-term outcomes with sustained benefits after discontinuation and minimal adverse effects compared to medications. 1, 2, 3

Core CBT-I Components to Implement:

• Stimulus control therapy: Go to bed only when sleepy, maintain a regular wake time, avoid naps, use bed only for sleep, and leave the bedroom if unable to sleep within 20 minutes—repeat as necessary. 1, 4

• Sleep restriction therapy: Track total sleep time via sleep log for 1-2 weeks, then limit time in bed to match actual sleep time (minimum 5 hours), adjusting weekly based on sleep efficiency (>85% = increase by 15-20 minutes; <80% = decrease by 15-20 minutes). 1, 4

• Cognitive restructuring: Address distorted beliefs like "I can't sleep without medication," "My life will be ruined if I can't sleep," and "I have a chemical imbalance." 1, 2

• Relaxation training: Progressive muscle relaxation involving methodical tensing and relaxing different muscle groups. 1, 4

• Sleep hygiene: Wake at same time daily, avoid caffeine after early afternoon, eliminate evening alcohol, avoid late exercise, keep bedroom quiet and temperature-regulated. 3, 4

CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats show effectiveness. 2, 3

Pharmacotherapy Algorithm (Only After CBT-I Initiated)

Step 1: First-Line Medications

Select based on primary sleep complaint pattern:

For sleep onset insomnia:

• Zaleplon 10 mg (5 mg in elderly) 2
• Ramelteon 8 mg 2
• Zolpidem 10 mg (5 mg in elderly) 2
• Triazolam 0.25 mg (not first-line due to rebound anxiety risk) 1, 2

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 2
• Temazepam 15 mg (7.5 mg in elderly/debilitated) 2, 5
• Zolpidem 10 mg (5 mg in elderly) 2
• Low-dose doxepin 3-6 mg 2
• Suvorexant 2

For combined sleep onset and maintenance:

• Eszopiclone 2-3 mg (increases total sleep time by 28-57 minutes) 2
• Zolpidem 10 mg (5 mg in elderly) 2
• Temazepam 15 mg 2, 5

Step 2: If First-Line Agent Fails

Switch to an alternative BzRA within the same class based on previous response and symptom pattern. 1, 2

Step 3: If BzRAs Fail or Are Contraindicated

Consider sedating antidepressants, particularly if comorbid depression/anxiety:

• Low-dose doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes) 2
• Mirtazapine (must be taken nightly, not PRN; half-life 20-40 hours) 2
• Amitriptyline (significant anticholinergic burden) 2

Do NOT use trazodone—explicitly not recommended due to harms outweighing benefits despite modest sleep parameter improvements. 2

Special Patient Populations:

Patients with substance use history:

• Prefer ramelteon or suvorexant over BzRAs to avoid DEA-scheduled drugs and abuse potential. 1, 2, 3

Elderly patients (≥65 years):

• Zolpidem maximum 5 mg 2
• Temazepam 7.5 mg initially 5
• Ramelteon 8 mg or low-dose doxepin 3 mg (safest choices with minimal fall/cognitive impairment risk) 2

Critical Safety Warnings

All BzRAs and hypnotics carry serious risks:

• Complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) 1, 2
• Daytime impairment and driving risk 1, 2
• Falls and fractures, especially in elderly 1, 2
• Cognitive and behavioral changes 1, 2
• Dependence, withdrawal reactions, and abuse potential 5

Stop medication immediately if patient discovers they performed activities while not fully awake. 5

FDA labeling indicates pharmacologic treatments are intended for short-term use (7-10 days for acute insomnia, generally not beyond 4 weeks). 1, 5 Few studies evaluated medications beyond 4 weeks, so long-term adverse effects remain unknown. 1

When discontinuing, use gradual taper to reduce withdrawal risk—do not stop abruptly as this can cause seizures, severe mental changes, depression, hallucinations, and suicidal thoughts. 5

Medications to Avoid

Never recommend these agents:

• Over-the-counter antihistamines (diphenhydramine)—lack efficacy data, cause daytime sedation and delirium risk in elderly 2, 3
• Herbal supplements (valerian) and melatonin—insufficient efficacy evidence 2
• Trazodone—explicitly not recommended 2
• Antipsychotics (quetiapine, olanzapine)—problematic metabolic side effects, lack of evidence 2
• Barbiturates and chloral hydrate—not recommended 2, 4
• Long-acting benzodiazepines (diazepam, clonazepam as first-line)—increased risks without clear benefit 2

Monitoring and Follow-Up

• Reassess after 1-2 weeks to evaluate efficacy on sleep latency, sleep maintenance, daytime functioning, and adverse effects (morning sedation, cognitive impairment, complex sleep behaviors). 2
• Continue CBT-I alongside any pharmacotherapy—never use medication in isolation. 1, 2, 4
• Attempt medication tapering when conditions allow, facilitated by concurrent CBT-I. 2, 4
• Use lowest effective dose for shortest duration possible. 1, 3

Common Pitfalls to Avoid

• Failing to initiate CBT-I before or alongside pharmacotherapy—this is the most critical error as behavioral interventions provide more sustained effects than medication alone. 1, 2, 3
• Using doses appropriate for younger adults in elderly patients—requires age-adjusted dosing (e.g., zolpidem 5 mg maximum in elderly). 2
• Continuing pharmacotherapy long-term without periodic reassessment. 2, 4
• Combining multiple sedative medications—significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures. 2
• Using sedating agents without considering their specific effects on sleep onset versus maintenance. 2