What is the recommended treatment for an adult patient with insomnia (difficulty falling asleep, staying asleep, or non‑restorative sleep) without an obvious acute medical or psychiatric cause?

Treatment for Poor Sleep in Adults with Insomnia

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

Initiate CBT-I immediately as the primary intervention before considering any medication. 1, 2, 3

• CBT-I provides superior long-term efficacy compared to pharmacotherapy, with sustained benefits for up to 2 years after treatment ends, whereas medication effects cease when stopped. 1, 2, 3
• This is a strong recommendation from the American Academy of Sleep Medicine, American College of Physicians, and VA/DoD guidelines. 1, 2, 3

Core Components of Effective CBT-I

• Sleep restriction therapy – Limit time in bed to match actual sleep duration (typically 5–6 hours initially), then gradually increase by 15–30 minutes weekly if sleep efficiency exceeds 85%. 3
• Stimulus control – Go to bed only when sleepy; use bed only for sleep and sex; leave bed if unable to fall asleep within 20 minutes; maintain consistent wake time every day including weekends. 1, 3, 4
• Cognitive restructuring – Address dysfunctional beliefs about sleep (e.g., "I must get 8 hours or I'll be sick") through Socratic questioning and behavioral experiments. 3
• Relaxation techniques – Progressive muscle relaxation, guided imagery, or breathing exercises. 1, 4
• Sleep hygiene education – Avoid caffeine ≥6 hours before bed, eliminate screens 1 hour before bed, maintain consistent sleep schedule, optimize bedroom environment (cool, dark, quiet). 1, 3

Treatment Structure

• Deliver CBT-I over 4–8 sessions with a trained specialist, using sleep diary data throughout to monitor progress. 3
• Brief Behavioral Therapy for Insomnia (2–4 sessions emphasizing behavioral components) may be appropriate when resources are limited. 2, 3
• CBT-I can be delivered via individual therapy, group sessions, telephone, web-based modules, or self-help books—all formats show comparable efficacy. 1, 3

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Second-Line Treatment: Pharmacotherapy (Only After CBT-I Initiation)

Medications should supplement—not replace—CBT-I, and are indicated only when CBT-I alone is insufficient after 4–8 weeks or when patients cannot participate in behavioral therapy. 1, 2

For Sleep-Onset Insomnia

• Zolpidem 10 mg (5 mg if age ≥65 years) – Reduces sleep latency by ~25 minutes; take within 30 minutes of bedtime with ≥7 hours remaining before awakening. 1, 5
• Zaleplon 10 mg (5 mg if age ≥65 years) – Ultra-short half-life (~1 hour); suitable for middle-of-night dosing when ≥4 hours remain before awakening. 1, 2
• Ramelteon 8 mg – Melatonin receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal; preferred for patients with substance-use history. 1, 2

For Sleep-Maintenance Insomnia

• Low-dose doxepin 3–6 mg – Reduces wake after sleep onset by 22–23 minutes via selective H₁-histamine antagonism; minimal anticholinergic effects and no abuse potential. 1, 2
• Suvorexant 10 mg – Orexin receptor antagonist; reduces wake after sleep onset by 16–28 minutes with lower cognitive/psychomotor impairment risk than benzodiazepine-type agents. 1, 2

For Combined Sleep-Onset and Maintenance Insomnia

• Eszopiclone 2–3 mg (1 mg if age ≥65 years or hepatic impairment) – Increases total sleep time by 28–57 minutes; moderate-to-large improvement in subjective sleep quality. 1, 2
• Take within 30 minutes of bedtime with ≥7 hours remaining before awakening. 1

Duration and Monitoring

• FDA labeling limits hypnotics to ≤4 weeks for acute insomnia; evidence beyond 4 weeks is insufficient. 1, 5
• Reassess after 1–2 weeks for changes in sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects. 1
• Use the lowest effective dose for the shortest duration; taper gradually when discontinuing to avoid rebound insomnia. 1, 2

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Medications Explicitly NOT Recommended

• Trazodone – Yields only ~10 minutes reduction in sleep latency with no improvement in subjective sleep quality; harms outweigh minimal benefits. 1, 2
• Over-the-counter antihistamines (diphenhydramine, doxylamine) – Lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation), and tolerance develops within 3–4 days. 1, 2
• Traditional benzodiazepines (lorazepam, clonazepam, diazepam) – Long half-lives lead to drug accumulation, prolonged daytime sedation, higher fall/cognitive-impairment risk, and associations with dementia and fractures. 1
• Antipsychotics (quetiapine, olanzapine) – Weak evidence for insomnia benefit; significant risks including weight gain, metabolic dysregulation, extrapyramidal symptoms. 1, 2
• Melatonin supplements – Produce only ~9 minutes reduction in sleep latency; insufficient evidence. 1, 2
• Herbal supplements (valerian, L-tryptophan) – Insufficient evidence to support use. 1, 6

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Critical Safety Warnings

• Complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating) are FDA-warned adverse effects of all benzodiazepine receptor agonists; discontinue immediately if these occur. 1, 5
• Avoid alcohol while using hypnotics; it markedly increases risk of complex sleep behaviors and respiratory depression. 1
• Next-day impairment – Patients often do not perceive psychomotor and memory deficits; avoid driving or operating machinery until fully awake. 1, 5
• Falls, fractures, and cognitive decline are increased with all hypnotics, especially in adults ≥65 years. 1
• Observational data suggest possible association between hypnotic use and higher dementia risk. 1

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Common Pitfalls to Avoid

• Initiating pharmacotherapy without first implementing CBT-I – Leads to less durable benefit and contravenes guideline recommendations. 1, 2, 3
• Using adult dosing in older adults – Age-adjusted dosing (e.g., zolpidem ≤5 mg, eszopiclone ≤2 mg for ≥65 years) is essential to reduce fall risk. 1
• Combining multiple sedative agents – Markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 1
• Failing to reassess pharmacotherapy regularly – Efficacy, side effects, and continued need should be evaluated every 2–4 weeks. 1
• Continuing hypnotic therapy long-term without periodic reassessment – FDA labeling indicates short-term use; routine use beyond 4 weeks is not supported by evidence. 1, 5
• Prescribing agents without matching pharmacologic profile to insomnia phenotype – Use zaleplon for sleep-onset only, doxepin for sleep-maintenance only, and eszopiclone for combined symptoms. 1