What is the recommended combination therapy for insomnia?

From the Guidelines

Combination therapy for insomnia, including cognitive behavioral therapy for insomnia (CBT-I) and short-term medication use, is the most effective approach for improving sleep quality and reducing morbidity, mortality, and enhancing quality of life. The American College of Physicians guideline 1 recommends a multimodal approach, including psychological therapy, pharmacologic therapy, or a combination of both, to manage insomnia. For medications, the American Academy of Sleep Medicine clinical practice guideline 1 suggests using eszopiclone, zaleplon, or zolpidem as a treatment for sleep onset and sleep maintenance insomnia.

When selecting medications, consider the following options:

• Eszopiclone (2-3mg) for sleep onset and sleep maintenance insomnia 1
• Zaleplon (10mg) for sleep onset insomnia 1
• Zolpidem (10mg) for sleep onset and sleep maintenance insomnia 1 It is essential to limit benzodiazepine receptor agonists to 2-4 weeks to prevent dependence. Non-pharmacological interventions, such as sleep hygiene practices, stimulus control, sleep restriction, and relaxation techniques, should always accompany medication. Regular reassessment every 2-4 weeks is crucial to monitor efficacy and side effects, with the goal of tapering medications once sleep patterns improve.

Key considerations for combination therapy include:

• Starting with CBT-I as the foundation
• Adding short-term medication use as needed
• Selecting medications based on the patient's specific sleep needs and medical history
• Monitoring for efficacy and side effects regularly
• Tapering medications once sleep patterns improve By prioritizing a multimodal approach and regularly reassessing treatment efficacy, clinicians can provide effective combination therapy for insomnia, ultimately improving patient outcomes and quality of life.

From the Research

Combination Therapy for Insomnia

• Combination therapy for insomnia involves the use of cognitive behavioral therapy (CBT) and medication, such as zolpidem, to treat insomnia 2.
• Studies have shown that CBT alone or in combination with zolpidem can produce significant improvements in sleep latency, time awake after sleep onset, and sleep efficiency 2.
• The addition of medication to CBT can produce added benefits during acute therapy, but long-term outcome is optimized when medication is discontinued during maintenance CBT 2.

Cognitive Behavioral Therapy (CBT) for Insomnia

• CBT is a multimodal intervention that targets difficulties with initiating and/or maintaining sleep and is delivered over the course of six to eight sessions 3.
• CBT-I is considered the standard of care for chronic insomnia and is efficacious when implemented alone or in combination with a pharmacologic agent 4.
• Core components of CBT-I include Sleep Restriction Therapy, Stimulus Control Therapy, Sleep Hygiene, and Cognitive Therapy 3.

Pharmacological Management of Insomnia

• Pharmacotherapy for insomnia is common, and hypnotic agents are among the most frequently prescribed medications in the United States 5.
• Newer hypnotics have been shown to have a better safety profile and longer term efficacy compared to older medications 5.
• The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations 5.

Efficacy of Combination Therapy

• Studies have shown that combination therapy can produce higher remission rates compared to CBT alone or medication alone 2, 6.
• The best long-term outcome is obtained with patients treated with combined therapy initially, followed by CBT alone 2.
• The results of combination therapy studies will inform clinical and policy decisions regarding the benefits and harm of combination therapy for patients with insomnia 6.