First-Line Management of Adult Insomnia
Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated as the first-line treatment for all adults with chronic insomnia before or alongside any pharmacologic intervention, as it provides superior long-term efficacy with sustained benefits that persist after treatment ends. 1, 2, 3
Behavioral Interventions (First-Line)
Core CBT-I Components
CBT-I is the standard of care and should include all of the following evidence-based elements:
Sleep restriction therapy – Limit time in bed to match actual sleep duration (minimum 5 hours), creating mild sleep deprivation that strengthens homeostatic sleep drive and consolidates sleep. 1, 2, 3 Adjust weekly based on sleep efficiency (total sleep time ÷ time in bed × 100%). 3
Stimulus control therapy – Use the bed only for sleep and sex; leave the bed if unable to fall asleep within ~20 minutes and return only when drowsy. 1, 2, 3 This breaks the learned association between bed and wakefulness. 1
Cognitive restructuring – Identify and challenge maladaptive beliefs about sleep (e.g., "I can't function without 8 hours" or "I'll never sleep without medication") using Socratic questioning and behavioral experiments. 1, 2, 3
Relaxation techniques – Progressive muscle relaxation, guided imagery, or controlled breathing to reduce physiological hyperarousal. 1, 4, 5
Sleep hygiene education – Maintain consistent sleep-wake times, avoid caffeine ≥6 hours before bed, eliminate screens ≥1 hour before sleep, keep bedroom cool/dark/quiet. 1, 2 Sleep hygiene alone is insufficient as monotherapy and must be combined with other CBT-I components. 1, 2, 3
Delivery Formats
CBT-I can be delivered through individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books—all formats demonstrate comparable efficacy. 1, 2 Standard treatment is 4–8 sessions with a trained CBT-I specialist. 3, 5 Brief Behavioral Therapy for Insomnia (2–4 sessions emphasizing behavioral components) may be appropriate when resources are limited. 1, 2, 3
Efficacy and Duration
CBT-I produces clinically meaningful improvements: sleep-onset latency reduced by ≥20 minutes, wake after sleep onset reduced by ≥30 minutes, and total sleep time increased by ≥30 minutes. 2 Benefits persist for up to 2 years after treatment discontinuation, unlike medications whose effects cease when stopped. 1, 2, 3
Pharmacologic Options (Short-Term Adjunct)
Pharmacotherapy should only be added if CBT-I is insufficient, unavailable, or the patient cannot participate—never as monotherapy. 1, 2, 6 FDA labeling limits hypnotic use to ≤4 weeks for acute insomnia; evidence beyond this duration is insufficient. 1, 2, 6
First-Line Pharmacologic Agents
Match medication to insomnia phenotype:
For Sleep-Onset Insomnia
Zolpidem 10 mg (5 mg if age ≥65 years) – Reduces sleep-onset latency by ~25 minutes; take within 30 minutes of bedtime with ≥7 hours remaining before awakening. 1, 2, 6
Zaleplon 10 mg (5 mg if age ≥65 years) – Ultrashort half-life (~1 hour) provides rapid sleep initiation with minimal next-day sedation; suitable for middle-of-night dosing when ≥4 hours remain. 1, 2, 6
Ramelteon 8 mg – Melatonin-receptor agonist with no abuse potential, no DEA scheduling, and no withdrawal symptoms; preferred for patients with substance-use history. 1, 2, 6
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 at hypnotic doses and no abuse potential. 1, 2, 6 This is the preferred first-line option for sleep-maintenance problems. 2, 6
Suvorexant 10 mg – Orexin-receptor antagonist that reduces wake after sleep onset by 16–28 minutes; lower risk of cognitive/psychomotor impairment than benzodiazepine-type agents. 1, 2, 6
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 and improves subjective sleep quality; take within 30 minutes of bedtime with ≥7 hours remaining. 1, 2, 6
Dosing Adjustments for Older Adults
Age-adjusted dosing is mandatory for adults ≥65 years: zolpidem maximum 5 mg, eszopiclone maximum 2 mg, zaleplon maximum 5 mg. 1, 2, 6 Low-dose doxepin 3 mg and ramelteon 8 mg are the safest choices for older adults due to minimal fall risk and cognitive impairment. 2, 6
Medications Explicitly NOT Recommended
Trazodone – Yields only ~10 minutes reduction in sleep latency with no improvement in subjective sleep quality; adverse events occur in ~75% of older adults. 1, 2, 6, 7
Over-the-counter antihistamines (diphenhydramine, doxylamine) – Lack efficacy data, cause strong anticholinergic effects (confusion, urinary retention, falls, daytime sedation), and develop tolerance within 3–4 days. 1, 2, 6, 7
Traditional benzodiazepines (lorazepam, clonazepam, diazepam) – Long half-lives lead to drug accumulation, prolonged daytime sedation, higher fall and cognitive-impairment risk, and associations with dementia and fractures. 1, 2, 6
Antipsychotics (quetiapine, olanzapine) – Weak evidence for benefit and significant risks including weight gain, metabolic dysregulation, extrapyramidal symptoms, and increased mortality in elderly with dementia. 1, 2, 6, 7
Melatonin supplements – Produce only ~9 minutes reduction in sleep latency; insufficient evidence for chronic insomnia. 1, 2, 6, 7
Herbal supplements (valerian, L-tryptophan) – Insufficient evidence to support use for primary insomnia. 1, 2, 6, 7
Treatment Algorithm
Initiate CBT-I immediately for all patients with chronic insomnia, incorporating stimulus control, sleep restriction, relaxation, cognitive restructuring, and sleep-hygiene education. 1, 2, 3
Add first-line pharmacotherapy only if CBT-I is insufficient after 4–8 weeks:
Reassess after 1–2 weeks to evaluate sleep-onset latency, total sleep time, nocturnal awakenings, daytime functioning, and adverse effects. 1, 2, 6
If the first agent fails, switch to an alternative within the same class (e.g., zaleplon → zolpidem for onset; doxepin → suvorexant for maintenance). 2, 6
Taper medication after 3–6 months while maintaining CBT-I techniques to sustain sleep improvements. 2, 6
Safety Monitoring
All benzodiazepine-receptor agonists carry FDA warnings for complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating); discontinue immediately if these occur. 1, 2, 6
Avoid alcohol while using hypnotics, as it markedly increases risk of complex sleep behaviors and respiratory depression. 2, 6
Monitor for falls, fractures, and cognitive decline, especially in older adults. 1, 2, 6
If insomnia persists beyond 7–10 days despite treatment, evaluate for underlying sleep disorders (sleep apnea, restless-legs syndrome, circadian-rhythm disorders). 2, 6
Common Pitfalls to Avoid
Starting hypnotic therapy without first implementing CBT-I – Leads to less durable benefit and violates strong guideline recommendations. 1, 2, 3
Using adult dosing in older adults – Age-adjusted dosing (e.g., zolpidem ≤5 mg) is essential to reduce fall risk. 1, 2, 6
Combining multiple sedative agents – Markedly increases risk of respiratory depression, cognitive impairment, falls, and complex sleep behaviors. 2, 6
Continuing pharmacotherapy long-term without periodic reassessment – Reassess every 2–4 weeks; FDA labeling indicates short-term use only. 1, 2, 6
Prescribing trazodone, OTC antihistamines, or antipsychotics – These lack efficacy and carry significant safety concerns. 1, 2, 6, 7