What is the first‑line treatment for an adult patient presenting with both insomnia and anxiety?

First-Line Treatment for Insomnia and Anxiety

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for adults presenting with both insomnia and anxiety, and it should be initiated immediately before or alongside any pharmacotherapy. 1, 2

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Why CBT-I First for Both Conditions

• CBT-I effectively reduces both insomnia and anxiety symptoms simultaneously, making it uniquely suited for patients with comorbid presentations. 2, 3
• A randomized controlled trial demonstrated that internet-based CBT-I was more effective than internet-based CBT for anxiety in reducing insomnia symptoms, while being equally effective in reducing anxiety symptoms in patients with both conditions. 3
• CBT-I provides superior long-term efficacy compared to medications, with sustained benefits after treatment discontinuation, whereas medication effects cease when stopped. 1, 2, 4
• The treatment produces clinically meaningful improvements: 19-minute reduction in sleep onset latency, 26-minute reduction in wake after sleep onset, and 9.91% improvement in sleep efficiency. 4

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Core CBT-I Components (Implement All)

Sleep Restriction Therapy

• Limit time in bed to match actual total sleep time (calculated from sleep diary), then adjust weekly based on sleep efficiency. 2, 5
• This component shows the strongest evidence (d = -0.45) for reducing insomnia severity among all CBT-I elements. 5

Stimulus Control Therapy

• Use the bed only for sleep and sex; leave the bed if unable to fall asleep within 20 minutes. 2, 6
• Maintain a consistent wake time every morning (including weekends), regardless of sleep quality. 1, 2
• Avoid daytime napping to consolidate sleep drive. 1

Cognitive Restructuring

• Address catastrophic beliefs about sleep (e.g., "I must get 8 hours or I'll be dysfunctional"). 2, 7
• Challenge unhelpful thoughts that perpetuate both insomnia and anxiety. 2

Relaxation Training

• Implement progressive muscle relaxation or guided imagery to reduce somatic and cognitive arousal. 1, 2

Sleep Hygiene Education

• Avoid caffeine for at least 6 hours before bedtime; eliminate nicotine and limit alcohol. 2, 6
• Keep the bedroom dark, quiet, and cool; remove screens at least 1 hour before bed. 6
• Sleep hygiene alone is insufficient as monotherapy and must be combined with other CBT-I components. 1, 7

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Delivery Formats (All Equally Effective)

• CBT-I can be delivered via individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats demonstrate comparable efficacy. 1, 2, 8
• Treatment typically consists of 4–8 weekly or biweekly sessions. 1, 7

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When to Add Pharmacotherapy

• Consider adding medication only if CBT-I is insufficient after 2–4 weeks, never as a replacement for behavioral therapy. 2, 6
• Pharmacotherapy should always supplement—not replace—CBT-I, as medication alone provides less durable benefits. 1, 2

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

For Combined Sleep Onset and Maintenance:

• Eszopiclone 2–3 mg (1 mg if age ≥65 years) increases total sleep time by 28–57 minutes with moderate-to-large improvements in sleep quality. 9, 2
• Zolpidem 10 mg (5 mg if age ≥65 years) reduces sleep onset latency by ~25 minutes. 9, 2

For Sleep Maintenance Only:

• Low-dose doxepin 3–6 mg reduces wake after sleep onset by 22–23 minutes with minimal anticholinergic effects and no abuse potential. 9, 2
• Suvorexant 10–20 mg (orexin receptor antagonist) reduces wake after sleep onset by 16–28 minutes. 9, 2

For Sleep Onset Only:

• Zaleplon 10 mg (5 mg if elderly) has an ultrashort half-life with minimal next-day sedation. 9, 2
• Ramelteon 8 mg (melatonin receptor agonist) has no abuse potential and is appropriate for patients with substance use history. 9, 2

If Comorbid Depression:

• Sedating antidepressants such as mirtazapine 15–30 mg or trazodone 150–300 mg can address both depression and insomnia. 2

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Medications to Explicitly Avoid

• Benzodiazepines (lorazepam, clonazepam) carry higher risk of dependence, cognitive impairment, falls, and respiratory depression. 9, 2
• Over-the-counter antihistamines (diphenhydramine) lack efficacy data, cause strong anticholinergic effects (confusion, falls, delirium), and develop tolerance within 3–4 days. 9, 2
• Antipsychotics (quetiapine, olanzapam) have weak evidence for insomnia benefit and significant risks including weight gain, metabolic dysregulation, and extrapyramidal symptoms. 9, 2
• Melatonin supplements produce only ~9 minutes reduction in sleep latency with insufficient evidence. 9, 2
• Trazodone yields only ~10 minutes reduction in sleep latency with no improvement in subjective sleep quality; harms outweigh benefits. 1, 2

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Critical Safety Considerations

• All hypnotics carry risks of complex sleep behaviors (sleep-driving, sleep-walking), next-day impairment, falls, and fractures, particularly in elderly patients. 2
• Elderly patients require dose adjustments: zolpidem maximum 5 mg, eszopiclone maximum 2 mg. 9, 2
• Use the lowest effective dose for the shortest duration (typically ≤4 weeks for acute insomnia). 9, 2
• Reassess after 1–2 weeks to evaluate efficacy, side effects, and plan for medication taper. 2

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Treatment Algorithm Summary

1. Initiate CBT-I immediately for all patients with anxiety and insomnia, incorporating all five core components (sleep restriction, stimulus control, cognitive restructuring, relaxation, sleep hygiene). 2

2. Deliver CBT-I for 4–8 sessions via the most accessible format (individual, group, telephone, web-based, or self-help). 2, 8

3. Add medication only if CBT-I is insufficient after 2–4 weeks, selecting based on sleep pattern:

   • Combined onset/maintenance → eszopiclone 2–3 mg or zolpidem 10 mg (5 mg if elderly) 2
   • Maintenance only → low-dose doxepin 3–6 mg or suvorexant 10–20 mg 2
   • Onset only → zaleplon 10 mg or ramelteon 8 mg 2

4. Reassess after 1–2 weeks of medication and plan for taper, using the lowest effective dose for the shortest duration. 2

5. Continue CBT-I throughout medication use and tapering to maintain long-term benefits. 7

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Common Pitfalls to Avoid

• Prescribing sleep medications without concurrent CBT-I leads to dependence without addressing underlying sleep architecture problems. 2, 6
• Using adult dosing in elderly patients increases fall risk; always use age-adjusted dosing. 2
• Combining multiple sedative agents markedly increases risk of respiratory depression, cognitive impairment, and falls. 2
• Failing to screen for underlying causes such as sleep apnea, restless legs syndrome, or medication side effects before assuming primary insomnia. 6
• Relying on sleep hygiene education alone without structured CBT-I fails to produce durable improvement. 1, 7