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

Management of Insomnia in Adults

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be the initial treatment for all adults with chronic insomnia before considering any medication. 1, 2, 3

First-Line Treatment: CBT-I

CBT-I is the gold standard and produces sustained improvements for up to 2 years, unlike medications which lose effectiveness after discontinuation. 2, 3

Core CBT-I Components to Implement

Stimulus Control Therapy 1, 2, 3:

• Use the bed only for sleep—no reading, TV, or phone use in bed 2
• Go to bed only when sleepy, not at a predetermined time 2
• If unable to fall asleep within approximately 20 minutes, leave the bed and engage in a relaxing activity until drowsy, then return 2, 3
• Repeat this process as many times as necessary throughout the night 2
• Wake up at the same time every day regardless of sleep quality 3

Sleep Restriction Therapy 1, 2, 3:

• Calculate the patient's current total sleep time from a 2-week sleep diary 2
• Restrict time in bed to match actual sleep time, with a minimum of 5 hours 2
• Set consistent bedtime and wake time to achieve >85% sleep efficiency 2
• Adjust time in bed weekly based on sleep efficiency—increase by 15-30 minutes if efficiency >85%, decrease if <80% 2

Cognitive Restructuring 1, 2:

• Address catastrophic thinking about sleep consequences 1
• Challenge beliefs like "I must get 8 hours or I'll be dysfunctional" 1
• Reduce performance anxiety around sleep 1

Sleep Hygiene Education (necessary but insufficient alone) 1, 2:

• Avoid caffeine after 2 PM and nicotine before bedtime 3
• Avoid alcohol in the evening 3
• Exercise regularly but not within 3 hours of bedtime 3
• Keep bedroom quiet, dark, and cool 3

CBT-I Delivery Methods

In-person, therapist-led CBT-I is most beneficial, but digital CBT-I is effective when in-person is unavailable. 1, 2 Treatment typically requires 4-8 sessions over 6 weeks. 2

Expected Timeline and Counseling

Counsel patients that improvements are gradual but sustained—initial mild sleepiness and fatigue from sleep restriction typically resolve within 1-2 weeks. 2 Unlike medications, CBT-I benefits persist long after treatment ends. 3, 4, 5

When to Add Pharmacotherapy

Only after CBT-I has been attempted or when CBT-I is unavailable should pharmacotherapy be considered, and it must always supplement—never replace—behavioral interventions. 1, 2, 6, 3

First-Line Medication Options

For Sleep Onset Insomnia 6, 3:

• Zolpidem 10 mg (5 mg in elderly or women): Reduces sleep latency by 25 minutes, rapid absorption 6, 3, 7
• Zaleplon 10 mg (5 mg in elderly): Very short half-life, minimal residual sedation, specifically for sleep onset 6
• Ramelteon 8 mg: Melatonin receptor agonist, no dependence risk, minimal adverse effects 2, 6, 8

For Sleep Maintenance Insomnia 2, 6, 3:

• Low-dose doxepin 3-6 mg: Reduces wake after sleep onset by 22-23 minutes, minimal anticholinergic effects at this dose, no abuse potential 2, 6
• Suvorexant 10 mg: Orexin receptor antagonist, reduces wake after sleep onset by 16-28 minutes 1, 6

For Combined Sleep Onset and Maintenance 2, 6, 3:

• Eszopiclone 2-3 mg: Increases total sleep time by 28-57 minutes, addresses both initiation and maintenance 1, 6, 3
• Zolpidem 10 mg (5 mg in elderly): Effective for both onset and maintenance 6, 7
• Temazepam 15 mg: Short-intermediate acting benzodiazepine receptor agonist 6

Critical Prescribing Principles

Use the lowest effective dose for the shortest duration possible—FDA approval is for short-term use (4-5 weeks). 1, 3 There is insufficient evidence to determine the balance of benefits and harms of long-term pharmacologic treatment. 1, 3

Elderly patients require mandatory dose reductions: 1, 3

• Zolpidem maximum 5 mg (not 10 mg) 6, 3, 7
• Eszopiclone maximum 2 mg (start with 1 mg) 6
• Ramelteon 8 mg or low-dose doxepin 3 mg are safest choices due to minimal fall risk 3

Medications to AVOID

Do NOT use these agents—they are explicitly not recommended: 2, 6, 3

• Diphenhydramine (Benadryl) and antihistamines: Lack efficacy data, strong anticholinergic effects, tolerance develops after 3-4 days, increased delirium risk in elderly 2, 6, 3
• Trazodone: Only 10 minutes reduction in sleep latency with no improvement in subjective sleep quality, harms outweigh benefits 2, 6
• Melatonin supplements: Only 9 minutes reduction in sleep latency, insufficient evidence 6
• Valerian and herbal supplements: Insufficient evidence of efficacy 6
• Antipsychotics (quetiapine, olanzapine): Problematic metabolic side effects, no evidence for insomnia 2
• Long-acting benzodiazepines: Increased risks without clear benefit, drug accumulation, prolonged daytime sedation 6

Critical Safety Warnings

All hypnotics carry serious risks: 1, 2, 3

• Daytime impairment and driving accidents (FDA black box warning) 1, 3
• Complex sleep behaviors: sleep-driving, sleep-walking, sleep-eating 1, 3
• Falls and fractures, particularly in elderly 1, 2, 3
• Cognitive impairment 1, 3
• Observational studies suggest associations with dementia (though causality not established) 1

Stop medication immediately if patient discovers they performed activities while not fully awake. 3

Benzodiazepines carry additional risks: 2, 6

• Dependence and withdrawal reactions 2
• Rebound insomnia upon discontinuation 6
• Should be avoided when possible, especially in elderly and those with cognitive impairment 2, 3

Special Population Considerations

Patients with Comorbid Depression/Anxiety 6, 3:

• Consider sedating antidepressants as first-line: mirtazapine or low-dose doxepin 3-6 mg 6, 3
• These simultaneously address both mood disorder and sleep disturbance 6

Patients with Substance Abuse History 2:

• Avoid benzodiazepines entirely 2
• Consider ramelteon 8 mg or suvorexant 10 mg (no abuse potential) 2

Patients with Hepatic Impairment 6:

• Reduce doses significantly (e.g., zaleplon to 5 mg maximum) 6
• Avoid medications with extensive hepatic metabolism 6

Assessment Before Treatment

Screen for underlying sleep disorders that require different management: 2

• Sleep apnea (snoring, witnessed apneas, excessive daytime sleepiness) 2
• Restless legs syndrome (uncomfortable leg sensations relieved by movement) 2
• Circadian rhythm disorders (delayed sleep phase, shift work disorder) 2

If insomnia persists beyond 7-10 days of treatment, further evaluation is required. 2

Common Pitfalls to Avoid

Do NOT prescribe medications before attempting CBT-I—this is the most common error in insomnia management. 2 Medications provide only temporary relief while CBT-I produces durable, long-term improvements. 3, 4, 5

Do NOT rely on sleep hygiene education alone—it lacks efficacy as a single intervention. 1, 2 It must be combined with stimulus control and sleep restriction. 1, 2

Do NOT let patients stay in bed "trying to sleep" for hours—this worsens conditioned arousal and perpetuates insomnia. 1, 2 The 20-minute rule is critical. 2, 3

Do NOT continue pharmacotherapy long-term without periodic reassessment and attempts at discontinuation. 2, 6 The best long-term outcome occurs when medication is discontinued during maintenance CBT. 5

Do NOT use higher doses in elderly patients—this significantly increases fall risk, cognitive impairment, and complex sleep behaviors. 1, 3