What is the initial intervention for an adult patient presenting with insomnia?

Initial Intervention for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for all adults with chronic insomnia disorder, and must be initiated before or alongside any pharmacological intervention. 1, 2

Why CBT-I Must Come First

The evidence is unequivocal: CBT-I demonstrates superior long-term efficacy compared to medications, with sustained benefits lasting up to 2 years after discontinuation, while medications lose effectiveness once stopped. 2, 3 Both the American Academy of Sleep Medicine (2021) and the American College of Physicians (2016) provide their strongest recommendations for CBT-I as initial treatment, with the ACP giving it a strong recommendation with moderate-quality evidence. 1

Core Components of CBT-I

CBT-I is a multicomponent intervention that should include the following elements:

Stimulus Control Therapy

• Use the bed only for sleep and sex—no reading, watching TV, or using phones in bed. 2, 3
• If unable to fall asleep within 20 minutes, leave the bed and engage in a relaxing activity in another room until drowsy, then return to bed. 2, 3
• Repeat this process as many times as necessary throughout the night. 3

Sleep Restriction Therapy

• Calculate total sleep time from a 2-week sleep diary (not time in bed, but actual sleep time). 2, 3
• Restrict time in bed to match actual sleep time, with a minimum floor of 5 hours. 3
• Adjust weekly based on achieving >85% sleep efficiency (total sleep time ÷ time in bed × 100%). 2, 3
• Critical contraindications: Do not use in patients with seizure disorders (sleep deprivation triggers seizures), bipolar disorder (can trigger mania), or high-risk occupations requiring alertness. 3

Relaxation Training

• Progressive muscle relaxation, guided imagery, or abdominal breathing exercises reduce somatic tension and cognitive arousal that perpetuate insomnia. 1, 2
• The American Academy of Sleep Medicine found clinically significant improvements in responder rate and sleep quality with relaxation therapy, though the overall quality of evidence was low. 1

Cognitive Therapy

• Address unhelpful beliefs about sleep such as "I must get 8 hours" or "My day is ruined if I don't sleep well" through structured psychoeducation, thought records, and behavioral experiments. 2, 3

Sleep Hygiene Education

• Sleep hygiene alone is explicitly NOT recommended as single-component therapy—it must be combined with other CBT-I components. 1, 2
• The American Academy of Sleep Medicine made a conditional recommendation against using sleep hygiene as the only treatment, as it was less effective than other interventions and may divert resources from more effective treatments. 1
• When included as part of multicomponent therapy, address: consistent wake time, avoiding caffeine/nicotine before bed, regular exercise (not close to bedtime), and optimizing bedroom environment (quiet, dark, cool temperature). 2

Delivery Methods for CBT-I

CBT-I can be effectively delivered through multiple formats—all show effectiveness: 1, 2

• In-person individual therapy (4-8 sessions over 6 weeks, preferred format). 3
• Group therapy sessions. 1
• Telephone-based programs. 1
• Web-based/digital platforms (Internet-based CBT-I showed significant improvements with Insomnia Severity Index scores dropping from 15.73 to 6.59, with 55% reduction in wake after sleep onset). 4
• Self-help books. 1

When to Consider Adding Pharmacotherapy

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

The American College of Physicians recommends using shared decision-making to discuss benefits, harms, and costs before adding short-term medication use in patients where CBT-I alone was unsuccessful (weak recommendation, low-quality evidence). 1

First-Line Medication Options

For sleep onset insomnia: 5, 2

• Zaleplon 10 mg (very short half-life, minimal residual sedation). 5
• Ramelteon 8 mg (melatonin receptor agonist, no dependence risk). 5
• Zolpidem 10 mg (5 mg in elderly). 5

For sleep maintenance insomnia: 5, 2

• Low-dose doxepin 3-6 mg (reduces wake after sleep onset by 22-23 minutes, minimal anticholinergic effects at this dose, no abuse potential). 5, 3
• Eszopiclone 2-3 mg (addresses both onset and maintenance, increases total sleep time by 28-57 minutes). 5, 2
• Suvorexant (orexin receptor antagonist, reduces wake after sleep onset by 16-28 minutes). 5

Critical dosing for elderly patients (≥65 years): 2

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

Medications Explicitly NOT Recommended

The American Academy of Sleep Medicine explicitly recommends against the following: 5, 2

• Trazodone (not recommended for sleep onset or maintenance—minimal benefit with harms outweighing benefits). 5
• Over-the-counter antihistamines like diphenhydramine/Benadryl (lack of efficacy data, strong anticholinergic effects, tolerance develops after 3-4 days). 5, 2
• Herbal supplements like valerian (insufficient evidence). 5
• Melatonin supplements (only 9-minute reduction in sleep latency, insufficient evidence). 5, 2
• Antipsychotics (problematic metabolic side effects, lack of evidence). 2
• Barbiturates and chloral hydrate (not recommended). 5

Critical Safety Warnings

All benzodiazepine receptor agonists carry risks that must be discussed with patients: 2, 3

• Complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating)—medication should be stopped immediately if these occur. 2
• Driving impairment and motor vehicle accidents the next day. 3
• Falls and fractures, especially in elderly patients. 2, 3
• Cognitive impairment. 3
• Observational studies suggest associations with dementia, fractures, and major injuries with long-term use. 3

Treatment Duration and Monitoring

• Use the lowest effective dose for the shortest duration possible, typically less than 4 weeks for acute insomnia. 2
• Reassess after 1-2 weeks to evaluate efficacy on sleep parameters and daytime functioning. 2
• Monitor for morning sedation, cognitive impairment, and complex sleep behaviors. 2
• Implement periodic reassessment—do not continue pharmacotherapy long-term without documented justification. 5, 2

Common Pitfalls to Avoid

• Failing to initiate CBT-I before or alongside pharmacotherapy—this is the most critical error, as medications alone provide inferior long-term outcomes. 2, 3
• Using sleep hygiene education as the only intervention—it must be part of multicomponent therapy. 1, 2
• Prescribing trazodone, diphenhydramine, or melatonin supplements despite clear guideline recommendations against these agents. 5, 2
• Using adult doses of hypnotics in elderly patients without appropriate dose reduction. 2
• Continuing pharmacotherapy beyond a few weeks without periodic reassessment and attempts at discontinuation. 5, 2
• Failing to screen for underlying sleep disorders (sleep apnea, restless legs syndrome, circadian rhythm disorders) that may present as insomnia. 3