How to Achieve Good Sleep: Evidence-Based Recommendations for Managing Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the gold standard first-line treatment for all adults with chronic insomnia and must be initiated before or alongside any medication. 1, 2
First-Line Treatment: CBT-I (Non-Pharmacologic)
CBT-I provides superior long-term efficacy compared to medications, with sustained benefits lasting up to 2 years after treatment ends, whereas medication effects cease when stopped. 1, 2
Core Components You Must Implement
Stimulus control therapy – Use your bed only for sleep (and sex); if you cannot fall asleep within 20 minutes, leave the bed and do a relaxing activity until drowsy, then return. 1, 2
Sleep restriction therapy – Limit time in bed to your actual sleep time plus 30 minutes (minimum 5 hours), adjusting weekly based on sleep efficiency (total sleep time ÷ time in bed × 100%). 1, 2
Cognitive restructuring – Challenge negative beliefs about sleep such as "I can't sleep without medication" or "My life will be ruined if I don't sleep." 1, 2
Relaxation techniques – Practice progressive muscle relaxation, guided imagery, or controlled breathing to reduce physiological arousal. 1, 2
Sleep hygiene education – Wake at the same time daily (including weekends), avoid caffeine for at least 6 hours before bed, eliminate screens 1 hour before sleep, exercise regularly (but not close to bedtime), and keep your bedroom quiet, dark, and cool. 1, 2
Delivery Options
CBT-I can be delivered through individual therapy, group sessions, telephone programs, web-based modules, or self-help books—all formats show comparable effectiveness. 1, 2
Expected Timeline
Improvements from CBT-I are gradual but durable, with 70-80% of patients benefiting from treatment; typical improvements include reducing sleep onset latency and wake time to below 30 minutes and increasing total sleep time by approximately 30 minutes. 3, 4
When to Add Pharmacotherapy
Medications should only supplement—never replace—CBT-I, and are reserved for situations where behavioral interventions alone are insufficient or while CBT-I is being implemented. 1, 5, 2
First-Line Medication Options
The American Academy of Sleep Medicine recommends short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or ramelteon as first-line pharmacotherapy when medication is necessary. 1, 5
For Sleep-Onset Insomnia:
- Zolpidem 10 mg (5 mg if age ≥65 years) – reduces sleep latency by ~25 minutes. 5, 2
- Zaleplon 10 mg (5 mg if age ≥65 years) – ultrashort half-life (~1 hour) for rapid sleep initiation with minimal next-day sedation. 5, 2
- Ramelteon 8 mg – melatonin receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms; ideal for patients with substance use history. 5, 2
For Sleep-Maintenance Insomnia:
- Low-dose doxepin 3-6 mg – reduces wake after sleep onset by 22-23 minutes with minimal anticholinergic effects and no abuse potential. 5, 2
- Suvorexant 10 mg – orexin receptor antagonist that reduces wake after sleep onset by 16-28 minutes with lower cognitive impairment risk than benzodiazepines. 5, 2
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. 5, 2
Critical Prescribing Principles
Use the lowest effective dose for the shortest duration possible, typically ≤4 weeks for acute insomnia, as FDA labeling indicates hypnotics are intended for short-term use. 1, 5, 2
Reassess after 1-2 weeks to evaluate sleep latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects. 5, 2
For elderly patients (≥65 years), reduce doses: zolpidem maximum 5 mg, eszopiclone maximum 2 mg, zaleplon maximum 5 mg. 5, 2
Medications to Explicitly Avoid
The following agents are not recommended for insomnia treatment based on guideline evidence:
Trazodone – produces only ~10 minute reduction in sleep latency with no improvement in subjective sleep quality; adverse events occur in ~75% of older adults. 1, 5
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, 5, 2
Antipsychotics (quetiapine, olanzapine) – weak evidence for benefit with significant risks including weight gain, metabolic syndrome, extrapyramidal symptoms, and increased mortality in elderly patients. 1, 5, 2
Traditional benzodiazepines (lorazepam, clonazepam, diazepam) – high risk of dependence, falls, cognitive impairment, respiratory depression, and associations with dementia and fractures. 5, 2
Melatonin supplements – produce only ~9 minute reduction in sleep latency with insufficient evidence for chronic insomnia. 5, 2
Herbal supplements (valerian, L-tryptophan) – insufficient evidence to support use for primary insomnia. 5, 2
Treatment Algorithm
Initiate CBT-I immediately for all patients with chronic insomnia, incorporating stimulus control, sleep restriction, relaxation, cognitive restructuring, and sleep hygiene. 1, 2
Add first-line pharmacotherapy if CBT-I alone is insufficient after 4-8 weeks:
If the chosen first-line agent fails after 1-2 weeks, switch to an alternative agent within the same class (e.g., zaleplon → zolpidem for onset; doxepin → suvorexant for maintenance). 5, 2
If multiple first-line agents are ineffective, consider sedating antidepressants (mirtazapine, low-dose doxepin at antidepressant doses) especially when comorbid depression or anxiety is present. 1, 5
Common Pitfalls to Avoid
Starting medications before attempting CBT-I – violates guideline recommendations and deprives you of more effective, durable therapy with superior long-term outcomes. 1, 2
Relying on sleep hygiene education alone – insufficient as single-component therapy and must be combined with other CBT-I components like stimulus control and sleep restriction. 1, 2
Using adult dosing in older adults – age-adjusted dosing is essential to reduce fall risk and cognitive impairment. 5, 2
Combining multiple sedating agents – markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 5, 2
Continuing pharmacotherapy long-term without periodic reassessment – hypnotics are intended for short-term use (≤4 weeks); evidence beyond this period is insufficient. 1, 5, 2
Prescribing trazodone, OTC antihistamines, or antipsychotics – these lack efficacy and carry significant safety concerns despite common off-label use. 1, 5, 2
Safety Warnings
All benzodiazepine receptor agonists carry FDA warnings for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating), daytime impairment, falls, fractures, and cognitive decline. 5, 2
Discontinue medication immediately if complex sleep behaviors occur, and avoid alcohol while using these agents. 5, 2
Observational data link hypnotic use to increased risk of dementia, fractures, and major injuries, though causality remains unproven. 1, 5