Insomnia Treatment
First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)
All adults with chronic insomnia should receive CBT-I as initial treatment before or alongside any pharmacotherapy, as it demonstrates superior long-term efficacy with sustained benefits after medication discontinuation. 1, 2
Core CBT-I Components
Stimulus control therapy restricts the bed to sleep and sex only, requires leaving the bedroom if unable to sleep within 15–20 minutes, and mandates a consistent wake time regardless of sleep duration 1, 3, 4
Sleep restriction therapy limits time in bed to match actual total sleep time plus 30 minutes, creating mild sleep deprivation that consolidates sleep, then gradually increases time in bed as sleep efficiency improves above 85% 1, 2, 4
Relaxation techniques include progressive muscle relaxation, guided imagery, diaphragmatic breathing, and biofeedback, all meeting criteria for empirically-supported treatments 3, 4
Cognitive restructuring addresses maladaptive beliefs about sleep (e.g., "I must get 8 hours or I'll be dysfunctional"), catastrophizing about consequences of poor sleep, and performance anxiety around sleep 1, 2
Sleep hygiene education alone is insufficient as monotherapy but should supplement other components: avoid caffeine after 2 PM, avoid alcohol within 3 hours of bedtime, exercise regularly but not within 3 hours of bedtime, keep bedroom dark/quiet/cool (60–67°F), and limit daytime naps to 30 minutes before 2 PM 1, 2
CBT-I Delivery Formats
Individual therapy, group sessions, telephone-based programs, web-based modules, and self-help books all demonstrate effectiveness, making CBT-I accessible even in resource-limited settings 1, 2
Between 70–80% of patients benefit from CBT-I, with reductions in sleep-onset latency and wake after sleep onset to below 30 minutes, plus a 30-minute increase in total sleep time 4
Pharmacotherapy: When Medication Is Necessary
Pharmacologic agents should only be added after initiating CBT-I and should supplement—not replace—behavioral interventions. 1, 2
First-Line Pharmacologic Options
For Sleep-Onset Insomnia
Zolpidem 10 mg (5 mg for adults ≥65 years) reduces sleep-onset latency by 25 minutes and increases total sleep time by 29 minutes; take within 30 minutes of bedtime with at least 7 hours remaining before planned awakening 1, 2, 5
Zaleplon 10 mg (5 mg for elderly) has a very short half-life (1 hour), providing rapid sleep initiation with minimal next-day sedation, making it suitable for middle-of-the-night dosing if at least 4 hours remain before awakening 2, 5
Ramelteon 8 mg is a melatonin-receptor agonist with zero abuse potential, no DEA scheduling, and no withdrawal symptoms, making it ideal for patients with substance-use history 1, 2, 5
For Sleep-Maintenance Insomnia
Low-dose doxepin 3–6 mg is the preferred first-line option, reducing wake after sleep onset by 22–23 minutes through selective H₁-histamine receptor antagonism with minimal anticholinergic effects at hypnotic doses and no abuse potential 1, 2, 5
Suvorexant 10 mg (orexin-receptor antagonist) reduces wake after sleep onset by 16–28 minutes via a mechanism distinct from benzodiazepine-type agents, with lower risk of cognitive and psychomotor impairment 1, 2, 5
Eszopiclone 2–3 mg addresses both sleep onset and maintenance, increasing total sleep time by 28–57 minutes with moderate-to-large improvement in sleep quality 1, 2, 5
Zolpidem extended-release 10 mg (5 mg for elderly) maintains higher concentrations over 6+ hours for sleep maintenance 5
Temazepam 15 mg is an intermediate-acting benzodiazepine for both sleep onset and maintenance, but carries higher risk of dependence, falls, and cognitive impairment compared to non-benzodiazepines 2, 5
Critical Dosing Adjustments
Elderly patients (≥65 years): Zolpidem maximum 5 mg, eszopiclone maximum 2 mg (start 1 mg), doxepin start 3 mg (maximum 6 mg) due to increased sensitivity and fall risk 1, 2, 5
Hepatic impairment: Eszopiclone maximum 2 mg (start 1 mg), zaleplon maximum 5 mg due to reduced clearance 2
Medications Explicitly NOT Recommended
Strong Recommendations Against
Trazodone provides only 10 minutes reduction in sleep latency and 8 minutes reduction in wake after sleep onset with no improvement in subjective sleep quality; adverse events occur in 75% of older adults (headache 30%, somnolence 23%), and harms outweigh minimal benefits 1, 2, 5
Over-the-counter antihistamines (diphenhydramine, doxylamine) lack efficacy data, produce strong anticholinergic effects (confusion, urinary retention, falls), and develop tolerance after only 3–4 days of use 1, 2, 5
Antipsychotics (quetiapine, olanzapine) have weak evidence for insomnia benefit and significant risks including weight gain, metabolic dysregulation, extrapyramidal symptoms, and increased mortality in elderly with dementia 1, 2
Traditional benzodiazepines (lorazepam, clonazepam, diazepam) have half-lives longer than 24 hours, leading to drug accumulation, prolonged daytime sedation, higher risk of falls, cognitive impairment, respiratory depression, and associations with dementia and fractures 1, 2, 5
Melatonin supplements show only 9 minutes reduction in sleep latency with insufficient evidence of efficacy 1, 2
Herbal supplements (valerian, L-tryptophan) have insufficient evidence for efficacy 1, 2, 6, 7
Treatment Duration and Safety Monitoring
Duration Guidelines
FDA labeling indicates hypnotics are intended for short-term use (≤4 weeks) for acute insomnia; evidence is insufficient to support routine long-term use beyond 4 weeks 1, 2
Orexin-receptor antagonists (suvorexant, daridorexant) can be used for up to 3 months or longer in selected cases 7
Prolonged-release melatonin can be used for up to 3 months in patients ≥55 years 7
Mandatory Monitoring
Reassess after 1–2 weeks to evaluate efficacy on sleep-onset latency, total sleep time, nocturnal awakenings, and daytime functioning, and monitor for adverse effects including morning sedation, cognitive impairment, and complex sleep behaviors 1, 2, 5
Screen for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) at every visit; discontinue medication immediately if these occur 1, 2, 5
If insomnia persists beyond 7–10 days of appropriate treatment, reevaluate for comorbid sleep disorders (sleep apnea, restless-legs syndrome, periodic limb movement disorder, circadian-rhythm disorders) 1, 2, 5
Safety Warnings
All hypnotics carry risks including daytime impairment, driving impairment, falls, fractures, cognitive impairment, and observational data linking hypnotic use to dementia and major injuries 1, 2
Take medication only when at least 7–8 hours of sleep time is available, within 30 minutes of bedtime, and never after meals or with alcohol 2
Use the lowest effective dose for the shortest necessary duration, with periodic "drug holidays" to assess ongoing need and gradual tapering when discontinuing to avoid rebound insomnia 1, 2, 5
Treatment Algorithm
Step 1: Initiate CBT-I Immediately
- Start stimulus control, sleep restriction, relaxation techniques, and cognitive restructuring for all patients with chronic insomnia 1, 2, 3, 4
Step 2: Add First-Line Pharmacotherapy if CBT-I Insufficient After 4–8 Weeks
For sleep-onset difficulty: Zaleplon 10 mg, ramelteon 8 mg, or zolpidem 10 mg (5 mg if elderly) 1, 2, 5
For sleep-maintenance difficulty: Low-dose doxepin 3–6 mg or suvorexant 10 mg 1, 2, 5
For combined sleep-onset and maintenance: Eszopiclone 2–3 mg or zolpidem extended-release 10 mg (5 mg if elderly) 1, 2, 5
Step 3: If First-Line Agent Unsuccessful After 1–2 Weeks
- Switch to an alternative first-line agent within the same class (e.g., zaleplon → zolpidem for sleep onset; doxepin → suvorexant for sleep maintenance) 2
Step 4: If Multiple First-Line Agents Fail
- Consider sedating antidepressants (low-dose doxepin if not already tried) or orexin-receptor antagonists, especially when comorbid depression/anxiety is present 1, 2
Common Pitfalls to Avoid
Failing to initiate CBT-I before or alongside pharmacotherapy—behavioral interventions provide more sustained effects than medication alone 1, 2, 4
Using doses appropriate for younger adults in older adults—zolpidem requires age-adjusted dosing (5 mg maximum for ≥65 years) 1, 2, 5
Combining multiple sedative medications—significantly increases risks of respiratory depression, cognitive impairment, falls, and complex sleep behaviors 1, 2, 5
Continuing pharmacotherapy long-term without periodic reassessment—reevaluate every 2–4 weeks to assess effectiveness, side effects, and plan for medication tapering 1, 2, 5
Using sedating agents without considering their specific effects on sleep onset versus maintenance—zaleplon and ramelteon are primarily for sleep onset, not maintenance 2, 5
Prescribing trazodone, antihistamines, or antipsychotics for primary insomnia—these agents lack efficacy data and carry significant risks that outweigh any presumed benefits 1, 2, 5, 6, 7