What are the treatment options for secondary insomnia?

From the Guidelines

Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment for adults with chronic insomnia disorder, including secondary insomnia, due to its strong evidence base and effectiveness in improving sleep outcomes and quality of life. The treatment of secondary insomnia focuses on addressing the underlying condition causing sleep difficulties rather than treating insomnia directly. The first step is to identify and treat the primary cause, which may include depression, anxiety, pain conditions, sleep apnea, or medication side effects. For depression or anxiety-related insomnia, CBT-I is highly effective, involving sleep restriction, stimulus control, and relaxation techniques practiced over 6-8 weekly sessions 1.

Some key points to consider when implementing CBT-I include:

• CBT-I is a multicomponent intervention that can be delivered in various formats, including in-person, group, or internet-based programs 1
• The treatment typically ranges from 4-8 visits and may require patients to adhere to treatment recommendations, which can be a challenge 1
• CBT-I has been shown to produce gradual improvements in insomnia symptoms, but the benefits are durable beyond the end of treatment 1
• Available evidence suggests that the initial undesirable effects of CBT-I are typically mild and resolve quickly for most patients 1

In addition to CBT-I, other behavioral therapies, such as behavioral therapy for insomnia (BTIs), sleep restriction therapy, stimulus control, and relaxation therapy, may also be useful interventions with minimal undesirable effects 1. However, CBT-I remains the treatment of choice for most patients due to its strong evidence base and effectiveness. Medications, such as low-dose antidepressants or sleep medications, may be considered for short-term use, but should generally be limited to 2-4 weeks to prevent dependence 1.

Overall, the goal of secondary insomnia treatment is to address the underlying condition causing sleep difficulties and improve sleep outcomes and quality of life. CBT-I should be considered the first-line treatment due to its strong evidence base and effectiveness, and other behavioral therapies and medications may be considered as adjunctive treatments or alternatives when CBT-I is not available or not desired by the patient.

From the FDA Drug Label

14.1 Transient Insomnia Normal adults experiencing transient insomnia (n=462) during the first night in a sleep laboratory were evaluated in a double-blind, parallel group, single-night trial comparing two doses of zolpidem (7. 5 and 10 mg) and placebo. 14. 2 Chronic Insomnia Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.

Secondary insomnia treatment is not directly addressed in the provided drug labels.

• The labels discuss primary insomnia and chronic insomnia, but do not provide information on secondary insomnia.
• Zolpidem and ramelteon are discussed as treatments for insomnia, but their use in secondary insomnia is not explicitly mentioned 2, 3, 3.

From the Research

Secondary Insomnia Treatment Approaches

• Cognitive-behavioral treatment has been shown to be an effective approach for secondary insomnia, despite traditional views that it should only be used for primary insomnia 4.
• Pharmacological treatment, including hypnotic medications, can be effective for secondary insomnia, but may have limitations and side effects 5, 6.
• Behavioral interventions, such as relaxation and stimulus control, may be a useful treatment approach for secondary insomnia, particularly in older adults 7, 8.

Considerations for Treatment

• Treatment of secondary insomnia should consider the underlying medical or psychiatric disorder, but may also require direct treatment of the insomnia symptoms 4, 5.
• The decision to treat secondary insomnia with pharmacotherapy or behavioral interventions should be individualized and take into account the patient's specific needs and circumstances 6, 8.
• Older adults with secondary insomnia may require special consideration due to age-related illnesses, changes in drug absorption and metabolism, and polypharmacy 7, 8.

Diagnostic Challenges

• Establishing an accompanying disorder as causal rather than comorbid can be difficult, even for experienced clinicians 8.
• Treatment of secondary insomnia may be complicated by the need to diagnose and treat the underlying disorder, as well as the insomnia symptoms themselves 4, 5.