What is the recommended evaluation and first‑line management of insomnia in adults, including non‑pharmacologic measures, cognitive‑behavioral therapy for insomnia (CBT‑I), and appropriate pharmacologic options?

Management of Insomnia in Adults

All adults with chronic insomnia should receive Cognitive Behavioral Therapy for Insomnia (CBT-I) as the initial treatment before or alongside any pharmacotherapy, as it demonstrates superior long-term efficacy with sustained benefits after medication discontinuation. 1, 2, 3

Initial Evaluation

Before initiating treatment, conduct a focused assessment to identify contributing factors and rule out secondary causes:

• Obtain a detailed sleep history including sleep-onset latency, wake after sleep onset, total sleep time, number of awakenings, daytime impairment (fatigue, concentration difficulties, mood changes), and duration of symptoms (acute <3 weeks vs. chronic ≥3 nights/week for ≥1 month). 1, 4

• Review all medications and substances that may cause or worsen insomnia: β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs, caffeine, nicotine, and alcohol. 5, 6

• Screen for comorbid conditions including depression, anxiety, chronic pain, sleep apnea, restless legs syndrome, periodic limb movement disorder, and circadian rhythm disorders—if insomnia persists beyond 7–10 days of treatment, formal evaluation for these disorders is warranted. 1, 2, 7

• Collect a 2-week sleep diary documenting bedtime, wake time, sleep latency, nocturnal awakenings, total sleep time, daytime napping, caffeine/alcohol intake, and perceived sleep quality. 2, 3

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is the standard of care for chronic insomnia and must be initiated before or concurrently with any pharmacotherapy. 1, 2, 3

Core Components of CBT-I

• Stimulus control therapy: Use the bedroom only for sleep and sex; leave the bedroom if unable to fall asleep within 15–20 minutes; return only when sleepy; maintain consistent wake times 7 days/week. 2, 3, 5, 8

• Sleep restriction therapy: Limit time in bed to match actual total sleep time plus 30 minutes (e.g., if sleeping 5 hours, allow 5.5 hours in bed); gradually increase by 15–30 minutes weekly as sleep efficiency improves to ≥85%. Caution: avoid in patients with seizure disorder or bipolar disorder due to sleep deprivation effects. 2, 3, 5, 8

• Cognitive restructuring: Address maladaptive beliefs about sleep (e.g., "I must get 8 hours or I'll be dysfunctional"), catastrophic thinking about insomnia consequences, and performance anxiety around sleep. 2, 3, 8

• Relaxation techniques: Progressive muscle relaxation, diaphragmatic breathing, guided imagery, or mindfulness meditation to reduce psychophysiological arousal at bedtime. 2, 3, 5, 8

• Sleep hygiene education (insufficient as monotherapy but essential as part of comprehensive treatment): Avoid caffeine after 2 PM, nicotine, and alcohol within 3 hours of bedtime; avoid heavy exercise within 2 hours of bedtime; keep the bedroom cool (60–67°F), dark, and quiet; avoid screens 1 hour before bed; avoid heavy meals within 3 hours of bedtime. 2, 3, 5

Delivery Formats

CBT-I can be delivered through individual therapy (6–8 sessions), group sessions, telephone-based programs, web-based modules, or self-help books—all formats demonstrate effectiveness. 1, 2, 3

Expected Timeline

Improvements from CBT-I are gradual, typically requiring 4–8 weeks for full effect, but benefits are durable and persist beyond treatment discontinuation, unlike pharmacotherapy. 1, 2, 3

Second-Line Treatment: Pharmacotherapy

Medications should be added only when CBT-I alone is insufficient after an adequate 4–8 week trial, or in select cases as a temporary adjunct to CBT-I. 1, 2

Treatment Algorithm Based on Insomnia Phenotype

For Sleep-Onset Insomnia (Difficulty Falling Asleep)

First-line options:

• Zolpidem 10 mg (5 mg for adults ≥65 years or women): Reduces sleep-onset latency by ~25 minutes and increases total sleep time by ~29 minutes; take within 30 minutes of bedtime with ≥7 hours remaining before planned awakening. 1, 2, 3

• Zaleplon 10 mg (5 mg for adults ≥65 years): Very short half-life (~1 hour) with minimal next-day sedation; suitable for middle-of-the-night dosing when ≥4 hours remain before awakening. 1, 2, 3

• Ramelteon 8 mg: Melatonin-receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms; particularly appropriate for patients with substance use history. 1, 2

For Sleep-Maintenance Insomnia (Frequent Awakenings or Early Morning Awakening)

First-line options:

• Low-dose doxepin 3–6 mg: Reduces wake after sleep onset by 22–23 minutes via selective H₁-histamine antagonism; minimal anticholinergic effects at hypnotic doses; no abuse potential; safest option for older adults. Start 3 mg; increase to 6 mg after 1–2 weeks if insufficient response. 1, 2, 3, 5

• Suvorexant 10 mg: Orexin-receptor antagonist that reduces wake after sleep onset by 16–28 minutes; lower risk of cognitive and psychomotor impairment than benzodiazepine-type agents; may be continued for up to 3 months or longer in selected patients. 1, 2, 3

For Combined Sleep-Onset and Maintenance Insomnia

First-line options:

• Eszopiclone 2–3 mg (1 mg starting dose for adults ≥65 years, maximum 2 mg): Increases total sleep time by 28–57 minutes; moderate-to-large improvement in sleep quality; take within 30 minutes of bedtime with ≥7 hours remaining. 1, 2, 3

• Temazepam 15 mg: Intermediate-acting benzodiazepine; effective for both onset and maintenance but carries higher risk of dependence, falls, and cognitive impairment than non-benzodiazepine options. 1, 2

Dosing Adjustments for Special Populations

• Adults ≥65 years: Zolpidem maximum 5 mg, eszopiclone maximum 2 mg (start 1 mg), doxepin maximum 6 mg (start 3 mg), zaleplon maximum 5 mg. 1, 2, 3, 5

• Hepatic impairment: Eszopiclone maximum 2 mg, zaleplon maximum 5 mg due to reduced drug clearance. 1, 2

• Women: FDA recommends lower doses of zolpidem (5 mg) and eszopiclone due to slower drug metabolism. 2

Duration and Monitoring

• FDA labeling recommends hypnotics for short-term use (≤4 weeks) for acute insomnia; evidence does not support routine use beyond this period. 1, 2, 3

• Reassess after 1–2 weeks to evaluate effects on sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and to monitor adverse effects (morning sedation, cognitive impairment, complex sleep behaviors). 1, 2, 3

• Use the lowest effective dose for the shortest necessary duration; consider periodic "drug holidays" to assess ongoing need; taper gradually to avoid rebound insomnia, using CBT-I to facilitate discontinuation. 1, 2, 3

• Screen for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) at every visit; discontinue medication immediately if these occur. 1, 2, 3

Medications Explicitly NOT Recommended

• Trazodone: Yields 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, somnolence); harms outweigh minimal benefits. 1, 2, 3

• Over-the-counter antihistamines (diphenhydramine, doxylamine): Lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, falls), develop tolerance within 3–4 days, and carry high risk of delirium in older adults. 1, 2, 3

• Traditional benzodiazepines (lorazepam, clonazepam, diazepam): Long half-lives lead to drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, and observational data link them to dementia and fractures. 1, 2, 3

• Antipsychotics (quetiapine, olanzapine): Weak evidence for insomnia benefit; significant risks including weight gain, metabolic disturbance, extrapyramidal symptoms, and increased mortality in elderly patients with dementia. 1, 2, 3

• Melatonin supplements: Produce only ~9 minutes reduction in sleep latency with insufficient efficacy data. 1, 2

• Herbal supplements (valerian, L-tryptophan): Insufficient evidence to support use for primary insomnia. 1, 2

Special Considerations for Comorbid Conditions

Insomnia with Comorbid Depression or Anxiety

• Sedating antidepressants may be considered as second- or third-line agents when comorbid depression/anxiety is present: mirtazapine (also aids sleep), low-dose doxepin 3–6 mg (for sleep maintenance), or sertraline (preferred SSRI due to lower QTc prolongation risk, though it may worsen insomnia initially). 1, 2, 3

• Continue CBT-I alongside antidepressant therapy to address both the mood disorder and insomnia simultaneously. 2, 3

Insomnia with Substance Use History

• Avoid benzodiazepines and benzodiazepine-receptor agonists due to high abuse potential. 2, 3, 6

• Consider ramelteon 8 mg or suvorexant 10 mg as non-controlled alternatives with no abuse liability. 1, 2, 6

• Sobriety remains the necessary first-line treatment for insomnia in alcohol use disorder; most patients will have some improvement with abstinence alone. 6

Insomnia in Older Adults (≥65 Years)

• Low-dose doxepin 3 mg and ramelteon 8 mg are the safest first-line choices due to minimal fall risk and cognitive impairment. 2, 5, 9

• Avoid benzodiazepines due to higher risk of falls, cognitive impairment, dependence, and possible acceleration of dementia. 5, 9

• Start all medications at the lowest available dose due to reduced drug clearance and increased sensitivity to peak effects. 5, 9

Common Pitfalls to Avoid

• Initiating pharmacotherapy without first employing CBT-I, which provides more durable benefits than medication alone. 1, 2, 3

• Using adult dosing in older adults; age-adjusted dosing (e.g., zolpidem ≤5 mg for ≥65 years) is essential to reduce fall risk. 2, 5

• Combining multiple sedative agents, which markedly increases the risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 1, 2

• Failing to reassess pharmacotherapy regularly (every 2–4 weeks) to evaluate efficacy, side effects, and to plan tapering. 1, 2, 3

• Prescribing agents without matching their pharmacologic profile to the specific insomnia phenotype (e.g., using zaleplon for maintenance rather than onset). 1, 2

• Using trazodone, OTC antihistamines, antipsychotics, or traditional benzodiazepines for primary insomnia despite lack of efficacy and significant safety concerns. 1, 2, 3

• Continuing pharmacotherapy long-term without periodic reassessment and attempts at tapering with CBT-I support. 1, 2, 3