What is the recommended first‑line management for insomnia in an 18‑year‑old?

First-Line Management of Insomnia in an 18-Year-Old

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for any 18-year-old with chronic insomnia, and it must be initiated before or alongside any pharmacologic intervention. 1, 2

Why CBT-I First

• CBT-I provides superior long-term efficacy compared to medications, with sustained benefits that persist after treatment ends, whereas medication effects disappear once the drug is stopped. 1, 2
• Between 70-80% of patients benefit from CBT-I, achieving reductions in sleep-onset latency and wake-after-sleep-onset to below 30 minutes, plus an additional 30 minutes of total sleep time. 3
• CBT-I can be delivered through multiple accessible formats—individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all showing comparable effectiveness. 1, 2

Core CBT-I Components to Implement

• Stimulus control therapy: Use the bed only for sleep; leave the bed if unable to fall asleep within 20 minutes; maintain consistent sleep and wake times every day (including weekends). 1, 2, 3
• Sleep restriction therapy: Limit time in bed to approximate actual sleep time plus 30 minutes (e.g., if sleeping 5 hours, allow only 5.5 hours in bed), then gradually increase as sleep efficiency improves. 1, 2, 3
• Relaxation techniques: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing to achieve a calm state at bedtime. 1, 2, 3
• Cognitive restructuring: Address negative beliefs about sleep (e.g., "I must get 8 hours or I'll fail tomorrow") and unrealistic expectations. 1, 2
• Sleep hygiene education: Avoid caffeine for ≥6 hours before bedtime, eliminate screens for ≥1 hour before bed, keep the bedroom cool/dark/quiet, avoid heavy exercise within 2 hours of bedtime, and maintain a fixed wake-time every morning. 1, 2

When to Add Pharmacotherapy

• Consider medication only if CBT-I alone is insufficient after 4-8 weeks, using shared decision-making to discuss risks, benefits, and the short-term nature of hypnotic use. 1, 2
• Pharmacotherapy should supplement—never replace—CBT-I, as behavioral interventions provide the foundation for durable improvement. 1, 2

First-Line Pharmacologic Options (If CBT-I Insufficient)

For Sleep-Onset Insomnia

• Zolpidem 10 mg (taken within 30 minutes of bedtime with ≥7 hours remaining before awakening) shortens sleep-onset latency by ~25 minutes and increases total sleep time by ~29 minutes. 1
• Zaleplon 10 mg has a very short half-life (~1 hour), providing rapid sleep initiation with minimal next-day sedation; suitable for middle-of-night dosing when ≥4 hours remain. 1
• Ramelteon 8 mg is a melatonin-receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms—appropriate for patients with any substance-use concerns. 1

For Sleep-Maintenance Insomnia

• Low-dose doxepin 3-6 mg reduces wake after sleep onset by 22-23 minutes via selective H₁-histamine antagonism, with minimal anticholinergic effects and no abuse potential. 1, 4
• Suvorexant 10 mg (orexin-receptor antagonist) reduces wake after sleep onset by 16-28 minutes and carries lower risk of cognitive/psychomotor impairment than benzodiazepine-type agents. 1

For Combined Sleep-Onset and Maintenance Insomnia

• Eszopiclone 2-3 mg improves both sleep onset and maintenance, increasing total sleep time by 28-57 minutes with moderate-to-large gains in perceived sleep quality. 1

Medications to Explicitly Avoid in an 18-Year-Old

• Benzodiazepines (lorazepam, clonazepam, diazepam): Long half-lives cause drug accumulation, daytime sedation, cognitive impairment, fall risk, and associations with dementia and fractures. 1
• Over-the-counter antihistamines (diphenhydramine, doxylamine): Lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, daytime sedation), and develop tolerance within 3-4 days. 1, 2
• Trazodone: Yields only ~10 minutes reduction in sleep latency with no improvement in subjective sleep quality; adverse events occur in ~75% of users. 1
• Antipsychotics (quetiapine, olanzapine): Weak evidence for insomnia benefit and significant risks including weight gain, metabolic dysregulation, and extrapyramidal symptoms. 1
• Melatonin supplements: Produce only ~9 minutes reduction in sleep latency with insufficient efficacy data. 1

Safety Monitoring and Duration

• Reassess after 1-2 weeks to evaluate effects on sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and to monitor for adverse effects (morning sedation, cognitive impairment, complex sleep behaviors). 1
• FDA labeling recommends hypnotics for short-term use (≤4 weeks) for acute insomnia; evidence does not support routine use beyond this period. 1
• Screen for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) at every visit; discontinue medication immediately if these occur. 1
• Use the lowest effective dose for the shortest necessary duration, integrating CBT-I to enable eventual tapering and avoid rebound insomnia. 1

Common Pitfalls to Avoid

• Starting medication without first implementing CBT-I leads to less durable benefit and missed opportunity for long-term improvement. 1, 2
• Using benzodiazepines as first-line treatment exposes young patients to unnecessary risks of dependence, cognitive impairment, and long-term harm. 1, 2
• Relying on sleep-hygiene education alone without structured CBT-I components (stimulus control, sleep restriction) fails to produce meaningful improvement. 1, 2
• Continuing hypnotic therapy beyond 4 weeks without reassessment violates FDA guidance and increases risk of dependence and adverse effects. 1
• Combining multiple sedative agents markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 1